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The rise of fentanyl is no accident, and it’s not going away

Illustration | Leo Cooperband

By Douglas Russell

As Omicron fades and San Francisco opens back up, the city can now turn its attention to another long-running publichealth epidemic: the cheap and increasingly available drug known as fentanyl. A synthetic opioid developed to be 50 times more potent than morphine, fentanyl has changed the street drugs marketplace and taken the opioid crisis to new levels. 

The heartbreaking deaths of three people in a Mission apartment in early March were only the latest in a long string of overdoses, which have claimed more lives in this city than Covid has, some 1,300 in all since March 2020. Amid the anger and frustration at this loss of life, though, is an unfortunate tendency to rely on stereotyping “addicts” and plenty of misinformation about the role that fentanyl (aka fenny or fenty) now plays in the cultural makeup in the lives of all drug users, be they occasional partiers or long-term daily users. Fentanyl is now the Big Drug on Campus.

Its emergence as the go-to painkiller du jour flies in the face of the stories that are typically told of this synthetic opioid, which has existed for more than 40 years. Yes, it has popped up in the lurid autopsies of Prince, baseballer Tyler Skaggs, Vine app creator Colin Kroll and true-crime author Michelle McNamara. But fentanyl has a number of established medical uses, too. It’s quickly effective as an anesthetic when mixed with a muscle relaxer, making it a no-brainer when it comes to palliative care. Studies show that fentanyl remains the go-to painkiller during surgery in spite of “more potent, safer, faster-onset, and both shorter- and longer-lasting” alternatives. It is still the world’s most popular opioid.

Chemically, fentanyl is highly lipid-soluble, making transdermal patches the go-to choice when a patient has lost the ability to swallow. Tampering with those patches and recrystallizing the fentanyl inside them initially caused the drug to leap from hospital settings to the street. Now mass-produced overseas—China and Mexico are the primary sources, according to the DEA—the drug is remarkable for its efficacy in impressively small amounts, making it a convenient ingredient to cut lackluster heroin or pressed pills and/or boosting legal painkillers to their maximum impact. 

As with ketamine, another drug that’s consumed both medically and recreationally, a war on drugs-style campaign to eradicate it is essentially impossible. Fentanyl guarantees results. It changed pain-management medicine, and now it has irrevocably altered the street-drug marketplace. 

Alison Heller, FentCheck co-founder, describes how to test drugs for fentanyl using FentCheck test strips outside The Sycamore on Nov. 17, 2021. | Camille Cohen

Left unconsidered with the deaths of many casual users is the new reality that fentanyl is a major player in drug adulteration, showing up in other substances in amounts that can have immediate, potentially lethal, effects. It can no longer be considered temporary or disregarded as too niche; fentanyl is our new reality.

In the case of the three Mission deaths, the unsuspecting partygoers ingested fentanyl-laced cocaine, quite likely in amounts that the non-user would find immediately overwhelming. A single survivor had passed out alongside the other three, but this individual did not succumb to the drug’s effects. They awoke and called parademics to no avail, although they were spared from witnessing their three friends fall eerily silent as the powerful narcotic shut down their muscle control, eventually stopping their lungs from drawing air. 

But the public consensus that fentanyl’s presence in other street drugs has to be a horrible mistake is misguided. It might defy common sense that such a potent narcotic would be deliberately mixed into cocaine and methamphetamine, which are strong stimulants, but it appears to be happening. One theory holds that its potency makes the user immediately aware that the drug they are taking is effective. Street cocaine is often cut with non-reactive fillers, such as aspirin or creatine, but now a dealer can adulterate it with something just as cheap that will also produce a fast result, albeit one that risks the lives of the clients. In that sense, fentanyl is no aberration.

Perversely, it is occasional drug users who may now be at higher risk. Because fentanyl’s potential for overdose is so great, and because it now shows up in drugs sold or marketed as other substances, daily users are increasingly vigilant about its dangers. The people caught off-guard are the ones buying drugs outside a club or on a whim, or thinking that the amount that they used to use in college is the same amount that they need today.  

Luckily, there’s naloxone, popularly known as Narcan, an emergency anti-overdose treatment that attaches to the brain’s opioid receptors, effectively shoving fentanyl out of the way. It was carefully designed to be user-friendly and non-reactive to anything but opioids. In California, The Dope Project lets people find where they can access free Narcan and be trained to use it. 

Fentanyl has become enough of an issue that willful ignorance to this shift in drug culture is potentially deadly. If a consumer buys any drug off of the streets, it must be assumed to be adulterated in some fashion, and therefore the casual drug user must be more engaged and informed about current drug trends than ever before. 

Now that fentanyl is so prevalent, its public users, bobbing and weaving like zombies, rival the specter of the aggressive meth user as the biggest scourge of the Tenderloin and Civic Center.  And there will be more cases of fentanyl overdoses, and more of it will show up in other drugs. It is imperative that the conversation include fentanyl as an accepted fact, not as an apparition or fluke. Fentanyl is here to stay.

Douglas Russell is a harm-reduction counselor who lives and works with the drug-using population in the Tenderloin.

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