Stimulants and Other Drugs Containing Fentanyl
As San Francisco’s experience with fentanyl has evolved over the last three years, we have seen changes in how it is sold and made available to PWUD in the drug supply. When fentanyl first arrived in San Francisco in 2015, it was sold as a white powder that PWUD referred to as “china white,” or pressed into counterfeit Xanax and Norco pills. We continue to see intermittent waves of fentanyl sold in counterfeit pill form and showing up in stimulants and other drugs like methamphetamine, cocaine and ketamine. Since 2017, fentanyl has been available in powder and solid form, sold as fentanyl to individuals intentionally purchasing it (Figure 3).
Figure 3: Photos of Powder and Solid Form Fentanyl Sold in San Francisco as Fentanyl, Obtained by The DOPE Project, 2017
Recent Fentanyl & Overdose Clusters in San Francisco:
Since 2015 San Francisco has experienced several clusters of overdose related to fentanyl and an uptick in fentanyl contamination. The emergence of fentanyl in non-opioid drug supplies (cocaine, methamphetamine) and the intermittent presence of counterfeit pills that contain fentanyl has generated concern and questions about how to promote overdose prevention among non-opioid users, non-injectors and others who may not be accessing harm reduction services in San Francisco.
As discussed above, the first wave of fentanyl came to San Francisco in early spring of 2015 in the form of white powder sold as “china white,” and later in the fall of that year, pressed into counterfeit Xanax. San Francisco’s community response was swift and effective, driven largely by The DOPE Project and partner agencies serving PWUD (Rowe, C. Ibid.). It was apparent however, that harm reduction programs had an easier time reaching PWUD who were purchasing and using the “china white”, who were largely injecting and accessing harm reduction services. When the counterfeit pills emerged in the fall, harm reduction programs expressed challenges reaching the pill-using population with information.
In April 2017, San Francisco experienced a wave of 9 non-fatal overdoses and one fatal overdose from crack cocaine contaminated with fentanyl. Toxicology on the one decedent from OCME and results of samples tested by the toxicology lab at Zuckerberg San Francisco General Hospital (ZSFGH) confirmed that the crack cocaine was contaminated by fentanyl. Upon receipt of toxicological confirmation, the DOPE Project and SDPH launched a coordinated response to the overdoses and there were no further incidents after the initial several days. The response included targeted outreach by DOPE partners with naloxone to people using crack and SFDPH alerts to all SUD treatment and public health programs. It is believed by DOPE Project and our partners that this was an accidental contamination, and that once the supplier and using community realized that it was causing overdoses, the situation was corrected.
In late 2017, the fentanyl test strip pilot began showing a high percentage of stimulants testing positive for fentanyl. Surveys collected from SAC partners between August and December 2017 showed 78 percent of the speed/crystal meth samples tested came back positive, as did 67 percent of the crack cocaine samples. However, aside from the contaminated crack in April, we have not seen significant numbers of deaths among non-opioid using methamphetamine and cocaine users. This indicates that those drugs were not necessarily cut with a substantial amount of fentanyl, but possibly contaminated, or containing small amounts of the drug that are posing minimal or insignificant risk to people using them.
In February 2018, there was a tragic incident in the Haight Ashbury district of San Francisco where three non- opioid using young people overdosed simultaneously overnight and were found deceased in a doorway in the morning. Samples of drugs and paraphernalia found at the scene were tested immediately by OCME, and data from these samples revealed methamphetamine, ketamine, fentanyl and acetyl fentanyl. From discussions with their peers in the Haight, it was determined that the three individuals ingested the drug thinking it was ketamine, and it caused the fatal overdoses.
The DOPE Project and our community partners responded immediately, along with alerts issued by SFDPH and media coverage. The information disseminated about the three overdoses raised awareness about the possibility of contaminated stimulants city-wide, and throughout California. Despite the earlier outbreak of crack cocaine containing fentanyl in April 2017, this incident caused significantly more alarm and there was more media coverage. As a result, large numbers of PWUD who had not been accessing harm reduction services in San Francisco had more widespread awareness of the possibility of fentanyl in other drugs other than opioids.
In April 2018, DOPE was alerted by our partners at the ZSFGH toxicology lab that we were possibly receiving false positives with the fentanyl test strips when testing MDMA and methamphetamine. In collaboration with the lab, we developed a new testing procedure with the strips to include the proper dilution of drug residue to avoid false positives and communicated with all SAC partners distributing test strips. This indicates that while there are certainly drugs contaminated with fentanyl (evidenced by the fentanyl/crack overdoses and the three Haight methamphetamine/ketamine/fentanyl overdoses), the amount of methamphetamine that was contaminated with fentanyl was likely highly overestimated.
Current Efforts to Address Stimulants and Other Drugs Contaminated with Fentanyl
In addition to the efforts described above including monitoring data, disseminating education materials, naloxone and fentanyl test strips, the DOPE Project and partner programs have also been conducting focused outreach to non-opioid users to increase awareness about fentanyl and naloxone. SFDPH has issued several alerts to Substance Use Disorder (SUD) programs and SFDPH safety net clinics in San Francisco to encourage them to include information about naloxone and overdose with anyone engaging in SUD programming. BAART Market and Turk, Fort Help, Bayview Hunter’s Point Foundation, the Latino Commission, and Health Right 360’s medical detox began distributing naloxone to opioid agonist and SUD treatment patients in spring 2018. The CBHS Pharmacy at 1380 Howard has been providing naloxone directly without prescription to individuals who are not accessing Syringe Access Services and other DOPE sites.
DOPE Project has been working with the Entertainment Commission to reach clubs, bars and entertainment venues in San Francisco with information about naloxone and possible fentanyl contamination of stimulants and other drugs and are equipping these businesses with a supply of naloxone for emergency use. To date, DOPE has conducted 18 separate trainings, reaching over 100 bartenders and entertainment services workers in San Francisco who can now respond to an overdose if one should occur in their establishment.