Harm reduction professionals Amber Sheldon, left, and William Buehlman discuss supply inventories at Glide in San Francisco, with dog Daydream.

SAN FRANCISCO — Ever since the powerful synthetic opioid fentanyl started showing up in the U.S. illicit drug supply eight years ago, experts have surmised that drug traffickers were using the inexpensive white powder to boost the potency of heroin, sometimes adding too much and inadvertently killing their customers.

In a series of interviews with heroin users in Rhode Island in 2017, Brown University researchers reported that users “described fentanyl as unpleasant, potentially deadly, and to be avoided.” They concluded that demand for the deadly contaminant was low and that its presence in the drug supply was “generating user interest in effective risk mitigation strategies, including treatment.”

But in San Francisco’s gritty Tenderloin district, where fentanyl was only rarely seen until last year, drug users tell a starkly different story. For many of them, fentanyl is a high-value drug that, if used carefully, can prevent dope sickness and deliver a strong high for a fraction of the price of heroin.

More than half of San Francisco Bay Area drug users purposely seek fentanyl, despite its dangers, according to harm reduction workers who talk to hundreds of drug users every day. Fifty times stronger than heroin and 100 times stronger than morphine, the synthetic opioid was rarely detected in U.S. illicit drug markets or in the bodies of fatal overdose victims just a decade ago. Now it has become the biggest killer in the nation’s raging drug overdose epidemic.

To be sure, many other drug-using San Franciscans say they try to avoid the deadly white powder, and some reported overdosing after unwittingly consuming a wide variety of fentanyl-laced drugs, including methamphetamines, cocaine and counterfeit Xanax and Vicodin pills.

Still, an increasing number of drug users there say they are opting for fentanyl when it’s available. And despite its powerful potency, fentanyl isn’t killing nearly as many people there as it is on the East Coast and in Appalachia.

In San Francisco, the consumer preference for fentanyl and the relatively low death rate likely stem in large part from the way the drug is marketed by dealers, said Phillip Coffin, director of substance use research at the city’s public health department.

Fentanyl that is sold there is clearly labeled. It’s rarely disguised as heroin, as it is elsewhere. As a result, users who buy fentanyl know what they’re getting and, in most cases, take the necessary precautions, Coffin said.

It’s still a much more dangerous drug than heroin, which is typically sold as black tar in California and tends to be inconsistent in potency and quality, he added.


Amber Sheldon, right, greets a frequent client at the harm reduction program at Glide in San Francisco. The program offers clean syringes, drug test strips and other supplies to frequent drug users. Sheldon and others in the city’s harm reduction community help drug users learn how to protect themselves and others from fatal overdoses.

Fentanyl seen early in NH

In New Hampshire, synthetic fentanyl has been the street drug of choice for years. By 2015, two-thirds of the 439 overdose deaths involved fentanyl, according to the Office of the Chief Medical Examiner.

That same year, the Drug Enforcement Administration issued a nationwide alert about fentanyl, calling it “a threat to health and public safety.”

A DEA spokesman told the New Hampshire Sunday News that agents here were encountering drug users who were specifically asking for “China White,” the street name for fentanyl at the time. “They’re seeking out the potency of that, which is scary,” Special Agent Timothy Desmond told the Sunday News in January 2016. “They don’t want the heroin; they want the more potent stuff.”

The heroin epidemic had become a fentanyl epidemic.

S.F. focus: Harm reduction

Another reason for San Francisco’s relatively low death rate from fentanyl is the city’s entrenched and well-funded harm reduction community, Coffin said. After the first fentanyl outbreak in the city in 2015, public health and harm reduction groups joined forces to sharply increase the amount of the overdose-reversal drug Narcan distributed to all drug users and intensify outreach programs.

The biggest concentration of intentional fentanyl users is in the Tenderloin, said Kristen Marshall, who runs a drug testing program for the Harm Reduction Coalition, a national organization that provides training and supplies to harm reduction groups.

But an increasing number of drug users in other San Francisco neighborhoods are also starting to opt for the powerful powder, she said.

With the help of harm reduction workers who supply Narcan and drug test strips, many fentanyl users have developed ways of protecting themselves from overdoses. And despite the drug’s short-lived euphoria, they say they plan to continue using fentanyl, albeit carefully, primarily because of its value, Marshall said.

“For drug users, it’s just like you or I making decisions about the products we choose when we grocery shop,” she said. “Fentanyl is stronger, you need less of it, and it’s cheaper. So why wouldn’t I, as somebody with limited funds, want to spend my money on something that’s a better value and therefore a better product?”

As fentanyl started seeping into the city four years ago, Marshall said, the public health and harm reduction communities revamped their message to drug users. “It was clear people were going to use it, so we decided not to scare people by saying that fentanyl will definitely cause an overdose. Instead, we said they should use it with caution.

“Use less of it, use it slower, use it with other people, and keep Narcan with you,” Marshall said. “It’s also important to test your drugs. Even if you know you’re getting fentanyl, you need to run additional tests to see what else might be in the mix.”

In the past decade, as the opioid overdose epidemic ravaged much of the rest of the country, San Francisco and most of California seemed immune. Fentanyl started to be noticed in California only in 2015, and its death toll was limited. Appalachian and New England states were seeing fentanyl in 2011, and by 2013 it was killing people by the dozens in a single day.

“Here in California, we felt lucky we weren’t seeing the same kind of devastation from the opioid epidemic that was occurring on the other side of the country,” said Kelly Pfeifer, a physician and addiction expert at the California Health Care Foundation.

Fentanyl showed up in San Francisco early compared to the rest of the state. It was rarely seen in other parts of California until last year.

In April, that changed: Three people died in downtown Los Angeles after snorting fentanyl-laced cocaine, and public health officials reported the substance had been found in methamphetamines as well.

A month later, state law enforcement officials began meeting with researchers, medical examiners and public health leaders to develop better ways to detect the deadly illicit opioid in the drug supply, alert users and distribute more Narcan — similar to San Francisco’s 2015 response.


A photo of bags of fentanyl that were seized in a drug bust.

NH harm-reduction steps

At the same time, Daniel Ciccarone, a family physician and researcher at the University of California, San Francisco, was preparing to publish a paper on the fentanyl scourge that was killing thousands of drug users elsewhere in the country.

His conclusion: The vast majority of drug users don’t want fentanyl. The third and deadliest wave of the opioid epidemic, Ciccarone and other researchers said, was driven by drug traffickers, not by user demand. The powerful white powder was mostly killing people who were unaware of its presence.

The fentanyl epidemic, Ciccarone said, is a supply problem. But since the war on drugs has proven unsuccessful, the solution is to address the demand side by making addiction treatment and harm reduction more available, he said.

Pfeifer agrees that better prevention and access to treatment is the solution to the epidemic, suggesting that part of the reason California has one of the lowest overdose death rates in the country is that the state expanded Medicaid to low-income adults in 2010, four years earlier than most other states, and has since built substantial treatment infrastructure in many parts of the state.In response to the opioid epidemic, New Hampshire lawmakers finally passed legislation allowing community health organizations to distribute clean syringes to intravenous drug users.

There are currently two “safe syringe programs” (SSPs) operating in the state, in Nashua and on the Seacoast. Advocates say the clean syringes and Narcan they provide free of charge — and the used needles they collect — are important, but just as critical is the education they provide users about safer drug use, HIV and Hepatitis C testing and treatment options.

Dean LeMire was one of the founders of the Hand-Up SSP on the Seacoast, a program of the New Hampshire Harm Reduction Coalition. He said program volunteers recently began giving out fentanyl test strips so that IV drug users can confirm the presence of the drug before using.

LeMire said once a drug user confirms the presence of fentanyl, harm reduction advocates suggest taking a tiny test dose first to judge the potency. Another tip is to inject the drug slowly, waiting to see the effect before injecting the entire syringe, he said.

Another harm reduction practice, LeMire said, is to make sure there are other people around and “stagger” the drug use. “In other words, one person uses while the others observe and are ready to respond if they overdose. If that person is safe after a few minutes, then the other person goes. And that way, hopefully at most one person would overdose and then they would know, OK, we’ve got something really strong here.”

Like other harm reduction measures, fentanyl test strips offer a way to engage drug users in conversations about safety and treatment, LeMire said. He said a recent survey found that drug users who used the test strips were more likely to reduce the amount of the drug they used and less likely to overdose.

LeMire, who recently moved to Austin, Texas, said fentanyl caught on more quickly in New Hampshire because, like heroin, it comes in powder form but is cheaper and more difficult to detect. “So it packs a bigger punch.”

The drug has also found its way into the cocaine supply here, something LeMire attributes to “dealer error,” as drug-sellers don’t clean surfaces or equipment they use to process different drugs for street sales.

“And that’s dangerous,” he said. “If fentanyl gets into a dealer’s cocaine supply, if somebody doesn’t have a tolerance for opioids, then they can immediately overdose on cocaine that’s laced with a tiny bit of fentanyl.”

Of the 41 drug overdose deaths in New Hampshire in 2018 involving cocaine, 36 involved cocaine and opioids, according to the Office of the Chief Medical Examiner. Just three were from cocaine alone, and two involved cocaine and other, non-opioid drugs. It’s been a familiar pattern over the past seven years.

In 2018, 282 of the 330 fatal overdoses in New Hampshire involved fentanyl, according to the latest data from the medical examiner’s office. There were still 83 cases pending toxicology results.

A moving target

San Francisco is unique in its method of drug surveillance and user education, said Daniel Raymond, policy director of the national Harm Reduction Coalition.

“More than any other place I’ve seen,” he said, “San Francisco’s harm reduction community systematically talks to drug users about their preferences and experiences and continuously feeds that information to the San Francisco Department of Health, which uses that intelligence to inform its message and overdose prevention strategies.”

Through that feedback network, Daniel Ciccarone, a family physician and researcher at the University of California, San Francisco, said he had recently heard that some users in San Francisco were actively choosing fentanyl. And though the dynamics of the local drug culture appear to be starkly different from what he encountered in Maryland, Massachusetts and West Virginia, where he conducted most of his research, Ciccarone said he wasn’t surprised.

“Fentanyl, like the rest of the illicit drug market, is a moving target,” he said. “You can’t generalize from one region to another, and what may be true today may not be tomorrow.”

He maintained that the nationwide fentanyl epidemic has been primarily supply driven. But for unknown reasons, the cartels decided not to push fentanyl in California until recently, he said. “If fentanyl is starting to become a demand issue here in California, that could be really bad news.”

Shawne K. Wickham contributed to this report. Her ongoing series, Beyond the Stigma, focuses on addiction and mental health in New Hampshire.