San Francisco is facing its deadliest year ever for drug overdoses, a trend blamed on the surge of powerful synthetic fentanyl in the US’s illicit drug supply.
In the first nine months of 2023, the northern California city saw 692 people die of overdoses, more than in the entire year of 2022, according to new data reported by the city’s medical examiner. The city is on track to see more than 800 deaths this year, topping its highest year ever, 2020, when it saw 720.
August was the deadliest month on record – with an overdose death every nine hours.
“It’s going to be an almost 25% increase over last year – that’s crazy and unfortunate,” said Dr Daniel Ciccarone, a professor at the University of California, San Francisco, who specializes in addiction medicine.
The deaths in San Francisco come despite a blitzkrieg of policies aimed at stemming the crisis. And experts warn that a new and troubling trend is emerging: more and more victims are found to have consumed both fentanyl and methamphetamine.
Only a handful of jurisdictions across the US release overdose statistics quickly enough to track trends in real time. But a number of those that did show that other metro areas – particularly on the west coast – have also seen their overdose numbers climb in 2023. The state of Oregon, and Santa Clara county, California, both reported increases in overdose deaths this year. Washington state, one of the latest to see a surge in fentanyl overdoses, now is showing the biggest increases in the US – with overdose deaths jumping 39% in the 12 months ending in June 2023. In the midwest, Cleveland, Ohio, also reported a rise in deaths, and so did Washington DC on the east coast.
Federal officials and addiction experts had been hopeful that the fentanyl crisis would recede after the Covid-19 pandemic eased, but national statistics show that 110,000 people died of drug overdoses in the 12 months ending in June 2023 – a climb of 2.6% over the prior year.
“I had predicted the epidemic would start to burn out,” said Ciccarone. “But it is unbelievably resilient and horribly durable.”
Several east coast states, where fentanyl first hit and began ravishing the drug-using population around 2013, have started to show small decreases in deaths. But on the West Coast, where the deadly synthetic didn’t saturate the market until around 2019, the numbers are still climbing rapidly.
“California has now surpassed the national average and it’s becoming the single most important place for overdose intervention in terms of sheer numbers,” said Joseph Friedman, an addiction researcher at the University of California, Los Angeles.
Using meth to counteract fentanyl
Ciccarone and Friedman, through their separate research, have described how the opioid epidemic has moved across the US in a series of deadly waves. First, in the early 2000s, millions of people became addicted to prescription opioids that were marketed by drug companies and readily handed out by doctors. Then, as providers cracked down on prescriptions around 2010, millions of drug consumers turned to heroin on the streets. In the third wave, cheap, super-powerful fentanyl flooded the illegal market beginning around 2013. Eventually it largely replaced heroin and killed thousands of drug users in its wake. The drug is so strong that just a few extra grains of powder can send someone into a life-threatening overdose.
Now, Ciccarone, Friedman and others have identified a new, hugely troubling fourth wave, as more and more deaths involve users who have mixed methamphetamine with their fentanyl use.
A study by Friedman and UCLA epidemiologist Chelsea Shover found that the number of overdose deaths involving both stimulants, like meth, and fentanyl has increased 50-fold since 2010.
Users are adding meth to their drug use to counteract fentanyl side effects that they don’t like, Friedman said: “Fentanyl took over the illicit opioid market not because the consumers like it, but because the distributors like it. It’s massively profitable.”
But fentanyl consumers “are finding that they’re withdrawing really soon and they can’t sleep through the night anymore”, he said. “So with the rise of really, really pure methamphetamine, basically available everywhere in the western US, it’s become a natural thing for people to use that to offset the negative aspects of fentanyl.”
While it’s still an open question whether mixing meth with fentanyl use is more deadly in the short term, the fact that people are combining the drugs raises a host of thorny problems for healthcare providers. There are medicines, such as buprenorphine, proven to help people break addiction to opioids, but there are no FDA-approved drugs to counter meth dependence.
Meth use is also believed to increase risks of a number of severe mental health symptoms, including paranoia, delusions and hallucinations.
‘Our policy options are not working’
In San Francisco, city officials have tried a yo-yoing assortment of tactics to stop the deaths, from declaring a state of emergency to creating, and later closing, a facility where users could use drugs under supervision, and then flooding the streets with police.
In an emailed statement, the San Francisco department of public health said it recognized the impact of the crisis, and is working to expand substance use treatment options and overdose prevention efforts.
Ciccarone noted that the city’s latest tack towards arresting people has not helped save lives. “Clearly the city has not done well enough. If our North Star is reducing deaths, our policy options are not working.”
In King county, which includes Seattle, half of overdose deaths now involve both fentanyl and meth, said Brad Finegood, who leads overdose prevention efforts for the county’s public health department.
“The lethality of drugs is up – they are much more potent and powerful,” he said. “Now that the drug market has gone synthetic, [formulas] can be changed in production. We don’t always know what is being cooked up. Drugs are also low-cost and high-availability.”
Ciccarone said despite the troubling developments, the fact that many east coast states are starting to see slight downturns in the number of overdose deaths makes him optimistic that interventions, such as increased availability of addiction treatment and the life-saving drug Narcan, are starting to reverse the tide.
Finegood, who lost his own brother to a multi-substance overdose 19 years ago, said it is important to have hope and to break down the stigma drug users face.
“The more that we stigmatize people who use drugs, the more that we’re pushing them further into the fringes,” he said. “I’m cognizant that every single person who dies out there is somebody’s kid. And also every single person out there struggling is capable of recovery. We just have to continue to keep our arms wide open and keep engaging people.”
