They died in parks, cars, motels, alleyways, bus stops, bathrooms and tents. Some collapsed on busy city streets, others in remote desert terrain. The oldest victim was 81. The youngest was one day old.
A new analysis by the Guardian reveals that fentanyl claimed the lives of more than 2,100 people living on the streets of Los Angeles county and in homeless shelters between 2014 to 2023.
Last year, the LA county medical examiner for the first time logged more than 1,000 drug-related deaths of unhoused people, including a record-high of 728 overdoses linked to fentanyl.
The figures illustrate the staggering toll as fentanyl wreaks havoc on unhoused communities in LA, an emergency fueled by a growing housing crisis and the worst overdose epidemic in US history, which in recent years has seen the powerful synthetic opioid rapidly infiltrate communities on the west coast.
Los Angeles, the nation’s most populous county, is home to more than 75,000 unhoused people. The majority of those people live on the streets. More than six unhoused people now die every day, and homelessness and treatment programs have failed to meet the scale of the needs.
The analysis of medical examiner autopsy records reveals:
From 2022 to 2023, there was a 15% increase in deaths of unhoused people in which fentanyl was ruled to be one of the primary causes.
The number of fentanyl deaths has surged over the last five years, with 633 fatalities among the unhoused in 2022, 255 in 2020 and 30 in 2018.
Black Angelenos make up only 9% of the county’s overall population, but accounted for 27% of all fentanyl deaths of unhoused people in the last decade.
The data is considered preliminary and incomplete, as the medical examiner only investigates deaths considered sudden, violent or unusual, and where the deceased had not recently been seen by a doctor. But experts say the records provide a representative snapshot of the increasing losses.
The county’s public health department does its own, more comprehensive tracking of deaths of unhoused people, with more rigorous inquiries into victims’ housing status, but hasn’t released 2023 figures. In its latest report, that department said there were some signs that the rate of all overdose fatalities among the homeless population had plateaued between 2021 and 2022, meaning the share of unhoused people suffering drug deaths did not rise. But it also reported that fentanyl was showing up in more of these deaths, and that the overdose mortality rate among the unhoused was 40.5 times greater than the general LA population.
“I’ve seen the destruction of fentanyl, and I hate it, I hate it. It is a family and individual destroyer,” said Ronald Paul Hams, a 38-year-old veteran. Hams lives in a tent in Van Nuys, just north of the city. Since fentanyl began devastating unhoused communities, Hams says, he has rescued dozens of people suffering overdoses by quickly deploying Narcan, the nasal spray that can reverse the effects of opioids and restore someone’s breathing.
Down the street from Hams’ camping spot along a lightly traveled bike path sat a vacant tent adorned with piles of bouquets and stuffed animals. The memorial was set up in honor of a 25-year-old woman who had lived there and died two weeks earlier. Hams was nearby when he learned she was unresponsive, but it was too late, he said: “My whole soul was completely crushed. She had a whole life ahead of her.” Hams suspects it was fentanyl, but the cause hasn’t yet been determined.
As fentanyl overdoses escalate, under-resourced street medics, harm reduction teams, volunteers and unhoused people like Hams have been fighting to stem the tide of preventable deaths.
‘The pain will never go away’
Hams became unhoused in 2014, when grief over the death of his older brother unraveled his life. He lost a warehouse job and has been on the streets since. He is now known locally as a Narcan expert adept at saving lives.
“I’ve had people say: ‘I only use when I’m around you, because you have a good track record,’” Hams said. He considers it a compliment, though he says the work takes its toll. “People don’t know it, but I actually go back to my spot and cry every time, because I think about what could’ve happened.”
Still, he accepts the responsibility: “I’m a part of harm reduction. Someone has to be there.”
Fentanyl is 50 times more potent than heroin and cheap to illicitly manufacture. The drug’s flow into California has dramatically escalated in recent years; state authorities seized roughly 62,000lbs (28,000kg) of fentanyl in 2023, according to the governor’s office, “enough to potentially kill the global population” and 11 times the volume from two years prior.
The drug comes in the form of counterfeit pills, but over the last decade, traffickers have increasingly laced other street drugs with fentanyl, making their supplies stronger, more addictive and more dangerous. Unhoused people have long suffered high rates of substance use disorders, and advocates in LA say the crisis on the streets became significantly more deadly as fentanyl has become mixed into the methamphetamine supply and people unknowingly ingest lethal doses.
The overdose data indicates fentanyl victims frequently were found with a combination of drugs in their systems.
Hams knows how hard it is to stop using fentanyl. He witnessed first-hand the debilitating withdrawal “sickness”, recounting the suffering of a former girlfriend while she was attempting to get clean: “Her skin and whole body hurt. It was unimaginable agony for days.”
There are other factors contributing to the drug’s lethality, he said. Many users fear arrest if they call 911, despite good samaritan laws meant to protect those callers from prosecution. He also emphasizes the dangers of isolation – when people use alone and “can’t administer Narcan on themselves”. The city’s sweeps and shutdowns of his encampment community, on an industrial road called Aetna Street, have scattered people to more hidden corners and motel where the risk of overdosing alone can be greater, he said.
That appeared to be the case with Michael Flores, 55, who had lived in a tent on Aetna Street, but last year was placed in a motel room through a homelessness program. On 28 November, he overdosed on fentanyl there.
“The pain will never go away,” said his mother, Irma Hayward, 79. Flores, who went by Mike Flo, was her second son to fatally overdose.
Flores had long struggled with addiction and mental health challenges. He participated in high school athletics, including wrestling and football, and his mother later worried those activities had damaged his brain. He frequently suffered severe headaches and back pain, and had delusional thoughts. He was in and out of homelessness most his life, battling alcoholism and unable to maintain steady office jobs.
He sometimes stayed with his mother, but it often didn’t last. He also struggled with the rules of shelter programs. She got him a van to sleep in, but it fell into disrepair. He found a community on Aetna Street, she said: “It was safer than other areas. They took care of each other.” She said he didn’t know he had used fentanyl, but added he may have done it to “numb his pain”, and he needed mental health treatment.
Treating patients on the street
City and county leaders have been working to rapidly expand public health services to address the fentanyl crisis, but have struggled to keep up with the demands.
LA city council member Eunisses Hernandez last year secured funding for a street medicine team from the University of Southern California to operate in her district, which includes MacArthur Park. The park’s considered the epicenter of LA’s overdoses crisis – Hernandez says she sometimes hears of as many as four overdoses in one day.
The initiative, the only full-time street medicine team dedicated to a single district in the city, is now serving roughly 100 people a month.
“They’ve been making life-changing impacts, preventing crises from happening in the first place and responding when crises occur, but it’s one team for a district of 22 neighborhoods and 264,000 people. It’s definitely not enough,” Hernandez said. She recently advocated that settlement funds from opioid manufacturers be appropriated to support the creation of a “respite center” in MacArthur Park, where people struggling with addiction can rest and access support and services.
Brett Feldman, the director and co-founder of the USC street medicine team, has been treating unhoused patients in LA since 2018 and has four other teams that travel throughout the city. One morning in March, he and other clinicians tracked down one of their regular patients on a street lined with warehouses south of Skid Row. Diana Farias, 34, showed them a solar contraption she’d rigged for her encampment. “You’ve gotta learn to adapt and evolve or you get left behind,” she said.
While Feldman examined Farias’s worsening toothache, she explained how she stays away from hospitals and traditional medical facilities as much as possible given past experiences of feeling ostracized and disrespected due to her housing status: “I have PTSD from the emergency room so I avoid it, and I get more sick,” she said.
In the last year, Farias has also been trying hard to avoid fentanyl, but she once accidentally ingested it when it was mixed into something else: “I almost died,” she said, without elaborating. “I don’t want it anywhere near me, ever.” She counted six people she’s known who have died from likely fentanyl overdoses. “I just live day to day,” she sighed, as her own three dogs and two cats ran in circles around her. “There is no planning two days ahead, because you just don’t know if you’ll make it to two days.”
Feldman said his team in previous years only gave Narcan to people who used opioids – now they give the medication and fentanyl test strips to everyone.
A few streets away, under an overpass, Feldman’s 47-year-old patient Betty Bautista, who has been unhoused for six years, said she recently used Narcan on a neighbor. “We have to help each other, because it can happen anytime,” she said. Even after surviving near-death overdoses, people quickly start using again, she said. “They accept it might happen to them. We’re all aware and accept it.”
One man collapsed and died in a nearby tent, she said, but he wasn’t found for days.
‘How do you change a life trajectory?’
LA has rolled out other strategies. Since 2017, the county’s substance abuse prevention and control bureau has expanded investments in harm reduction services by 500% and treatment programs by 275%, including a surge in residential treatment and recovery beds, said Dr Gary Tsai, the bureau’s director. The recent plateauing of the rate of overdose deaths coincided with a two-and-a-half-fold increase in the distribution of Narcan, his department found. “It has been scaled to a degree that is very promising. These are real lives saved,” Tsai said.
LA county’s division of housing for health has its own mobile clinics. Dr Absalon Galat, the program’s medical director, described the challenges of treating addiction in the field. Some of his patients with substance use disorders do enter treatment programs, but the progress often isn’t sustainable without housing and stability in other parts of their lives, he said. “You get clean temporarily, but is that really going to change your life trajectory?’ he asked. “After rehab, you’re back on the streets in the same environment.”
Some return with lower tolerances and overdose, Galat added. Instead of preaching abstinence, he focuses on lowering barriers to care by meeting people at their tents, and reducing risks by getting people on addiction medications. He also connects patients to benefits like social security, which can get them closer to stability.
But Galat has to deal with political resistance, including from some municipalities within the county and businesses that don’t want mobile clinics for the unhoused in their areas. He pointed to a new “no trespassing” sign with a sheriff’s phone number that appeared by his regular patients in a vacant plot of Lancaster desert; if the patients are pushed elsewhere, he’ll have trouble finding them and getting them their meds. “The mobile clinics show how people should be treated and taken care of, but some people don’t like that, and we get boxed out,” he said.
Political concerns have repeatedly blocked another harm reduction strategy that some providers and county officials say would save lives: safe consumption sites, where people can use drugs under supervision. In 2022, Governor Gavin Newsom vetoed a bill that would have allowed pilot sites in LA, saying he supported “cutting-edge harm reduction strategies”, but feared “unintended consequences”.
By the Aetna Street tents, a cardboard memorial honors 20 unhoused people who have died in the area, including Mike Flores. His mother, who sometimes brings burritos and sandwiches to the residents, said she wanted her son to be remembered for more than his addiction.
He loved cooking, dancing and rapping, and had a compassion for others, once helping rescue people during an earthquake. Even amid his worsening struggles, Flores did his best to take care of his mother, taking her shopping and on beach trips and buying her jewelry. He and his friends recently helped her move into a mobile home.
The last time she saw her son’s face was in a video he sent to her from his motel room, telling her he’d soon help her fix up her new home.
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