San Francisco’s Response to Fentanyl and Fentanyl-Involved Overdose

The SFDPH-funded Drug Overdose Prevention and Education (DOPE) Project has been managing the multi- sectoral, coordinated response to the gradually increasing presence of fentanyl in San Francisco since 2015. The DOPE Project distributes materials through all collaborative partner programs and has developed targeted messaging around fentanyl. Collaborative partner programs include; San Francisco AIDS Foundation Syringe Access Services, Glide Harm Reduction Services, Homeless Youth Alliance, SF Drug Users Union, St. James Infirmary, San Francisco County Jail Health Services, San Francisco Community Health Center, SF HOT, UCSF’s UFO/VIP/Hero Studies, Mission Neighborhood Resource Center, Martin De Porres, Shanti HIV Services, At the Crossroads and SFDPH Community Health Response Team and Substance Use Research Unit.

In 2017, The DOPE Project distributed nearly 20,000 doses of naloxone primarily to people who use drugs and service providers in San Francisco and documented 1,266 overdose reversals.

Figure 2: DOPE Project Interventions: Naloxone, Fentanyl Test Strips and Fentanyl Comic

Fentanyl Test Strips

Part of The DOPE Project’s coordinated response has been to introduce point-of-use fentanyl drug testing for people who use drugs to identify whether fentanyl or a fentanyl analog is present in their drug supply. In early 2017, The DOPE Project partnered with the Syringe Access Collaborative (SAC) to pilot the distribution of fentanyl test strips. The SAC includes the San Francisco AIDS Foundation’s Syringe Access Services, Glide Harm Reduction Services, St. James Infirmary, SF Drug Users Union and the Homeless Youth Alliance — all of which are DOPE Project naloxone distribution sites in addition to syringe access service providers. In August 2017, the strips became available to syringe access programs through the California Supply Clearinghouse, supported by the California Department of Public Health.

All five syringe access programs in San Francisco who are participating in this initiative (coordinated by DOPE and financially supported by the California Department of Public Health) are distributing the test strips to people who use drugs and completing surveys that they return to The DOPE Project monthly. The DOPE Project analyzes the results of the surveys, and issues quarterly reports to all SAC programs.

SAC programs are reporting that a significant proportion of their drugs are testing positive for fentanyl, including white powders, black tar heroin, methamphetamine, crack and powder cocaine and some pills. Participants tend to report positive test results to SAC programs more frequently than negative results, so it is difficult to determine accurately what percentage of the San Francisco drug supply contains fentanyl from these surveys alone.

In response to the presence of fentanyl in the San Francisco drug supply, The DOPE Project’s messaging has focused on Universal Precautions, and encouraging an overall change in the way that people are approaching using drugs in a market where fentanyl is inconsistently present. We have found that if we focus too heavily on intermittent alerts when there is a cluster of overdoses, people start to believe that during the “in between” times, there is less fentanyl. We want people to begin to cultivate an awareness about the constant possibility of fentanyl in their drugs, and to change the way they approach drug-taking in the era of fentanyl. We work with our collaborative partners in San Francisco to help PWUD develop strategies for identifying, anticipating and using fentanyl in the face of a drug supply that is inconsistent and constantly changing.

Harm Reduction Strategies Developed by PWUD and Disseminated by DOPE Partners Include:

Adjusting dosage,
Staggering use when in groups so someone is alert enough to react if there is an overdose,
Switching mode of administration (i.e. from injecting to smoking),
Learning how to anticipate and recognize fentanyl based on sensation, taste and appearance, and,
Making sure that at least one person in any group has naloxone and understands that they need to use it immediately if people go into rapid respiratory depression.