The coffee table sat on an Eighth Street sidewalk.
The sun had set and there were no working streetlights in that part of downtown San Diego, so during one Thursday last fall you could barely see the four people huddled around its edges.
Heather Newhart walked up and introduced herself. Newhart, a substance abuse counselor who spends much of her time in encampments, spotted a white pill near one of the men. Street drugs aren’t always what they appear to be and she asked if he was willing to test it.
The man said he was confident about what kind of opioid was inside. But he agreed to check.
***
Overdoses in San Diego County are both highly visible and deceptively hidden.
Drug use in public, particularly among people living outside, is an obvious reminder of how the crisis intersects with homelessness. Downtown San Diego sometimes features people standing at seemingly impossible angles, knees bent and arms loose, in what one fire captain described as the “fentanyl fold.”
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Yet that’s only part of the picture. Last year, calls about more than 13,700 potential overdoses took the San Diego Fire and Rescue Department to almost every corner of the city.
There are hopeful signs. While fentanyl, a strikingly powerful synthetic opioid, remains a leading cause of accidental deaths countywide, the total number of fatal drug and alcohol overdoses dropped last year by more than 7 percent, the first significant dip after a long stretch of increases. A recent three-year period in San Diego and Imperial counties showed the amount of drugs seized by U.S. Customs and Border Protection decreasing by about 25 percent.
The landscape, however, is in constant flux. During interviews and ride-alongs with paramedics, ambulance workers, harm reduction specialists, police officers and medical experts around the state, as well as conversations with people struggling with addiction, two points often came up.
First, drugs on the street are increasingly hard to fight.
One of the best tools for combating opioid overdoses is naloxone, which is often offered under the brand name Narcan, and a single dose of the nasal spray was once enough to re-start breathing. But because fentanyl is sometimes secretly laced into less-potent drugs, first responders are now needing two, three, four or even five rounds to bring somebody back — and that can come on top of naloxone that patients already received from friends.
“We’re losing the battle right now,” said Daryl Davies, a professor of clinical pharmacy at the University of Southern California. “Fentanyl is getting spiked into everything.”
Second, drugs like xylazine, a sedative used by veterinarians, can be further mixed in, making pills impervious to naloxone. Personally testing a substance is sometimes the only way to know what you have.
On that Eighth Street sidewalk, the group broke off a tiny piece of their pill. Somebody filled a plastic lid with water. Newhart, the substance abuse counselor, pulled out two test strips and stirred in the pill fragment. After a few moments, a line appeared on a strip.
“It’s animal tranquilizer in your dope,” said Newhart.
A young woman stared at the lid.
“Oh s—-.”
***
Walking through encampments with certain groups of outreach workers invites a near constant refrain.
“Narcan?”
“You have Narcan?”
Heads poke from tents. Hands reach for boxes. The spray disappears into hoodies.
Last year, officials handed out more than 84,800 doses to 100-plus providers, including at least 7,650 containers made available, for free, in vending machines countywide.
First responders can burn through the spray so fast they don’t have to worry about expiration dates. “I always know where my gun is, I always know my Narcan is in my left cargo pocket,” said La Mesa police Officer Danny Sandlin.
The prevalence of Narcan, from the company Emergent BioSolutions, has been criticized by those who think the region’s too reliant on one brand. That chorus includes Jerome Adams, a former U.S. Surgeon General who now spends part of his time promoting Opvee, a different nasal spray designed to be more effective against synthetic opioids.
“As the enemy has changed form,” Adams said, “we need our response to change form.”
The effort is partially a response to Gov. Gavin Newsom’s veto last year of a bill that would have made available for mass distribution any “opioid antagonist” approved by federal regulators. The governor argued that some Narcan competitors have “dosage strengths which may not be suited for the general public.”
As it stands, Narcan is often handed out on the street by harm reduction teams. The goal is to distribute as much as possible, but there’s always a chance outreach workers might encounter somebody who needs reviving.
This requires a special kind of vigilance, particularly in encampments. Tents can serve, however imperfectly, as homes, and jabbing one, even to check on those inside, is a faux pas. Unzipping an entrance without permission can be taken as an invasion.
One afternoon at the start of the year, two people from Father Joe’s Villages and a third from Neighborhood Healthcare El Cajon pulled a cart filled with Narcan through downtown. A number of people stopped the group to ask how the spray worked.
“I used to be there, you know — you want to get high, you want to get high,” Michelle Lefever, an outreach worker, told one couple in a pickup. “But we gotta save ourselves.”
Further down the street, Lefever stopped by one orange and gray tent near C Street. “Hey guys, Father Joe’s,” she called out. No answer.
The tent stood at an odd angle, its fabric pulled taut. Something inside was pressed against a corner.
“Water,” Lefever asked. “Snacks?”
The bulge looked about the size of a human head. She poked the fabric. “I just want to make sure you’re OK.”
Still no response. Two colleagues moved closer in. Lefever finally grabbed the front of the tent and yanked back the flap.
She exhaled. The bulge had been caused by a piece of wood. The tent was empty.
***
The number of fatal overdoses countywide from drugs or alcohol more than doubled from 2019 to 2022. A staggering 1,203 people were lost last year.
Most of those deaths were at least partially due to fentanyl, which has been unknowingly added to so many other drugs that some surviving family members have traded the word “overdose” for “poisoning” on the grounds that their loved ones weren’t trying to get high. One mother said her daughter likely thought she was taking Adderall.
A strong batch can sweep through a neighborhood like a pandemic. Paramedics with East County’s Heartland Fire and Rescue once encountered three men splayed out in front of a house party and had to rush an oxygen mask from person to person until more gear arrived.
Naloxone isn’t always enough. Thirty-eight people in the city of San Diego died last year despite getting Narcan, either because they’d been gone too long or something besides opioids had stopped their breathing, according to data from the San Diego Fire and Rescue Department.
Lawmakers are coming at the problem from multiple directions. In the state Legislature, there have been a number of proposals intended to quickly save lives, including bills to boost awareness of detox drugs and require naloxone in the workplace, both of which the governor signed into law. San Diego County is further preparing to implement Senate Bill 43, which makes it easier for police to detain residents incapacitated by substance abuse.
There’s also a broader effort to rethink some criminal justice reforms.
Voters will decide in November whether to change key parts of Proposition 47, a decade-old law that reduced punishments for many nonviolent crimes. Proposition 36 would instead create a three-strikes system: Anyone found carrying contraband, like fentanyl, who already had two drug convictions could be charged with a new type of felony, and failing to complete a treatment program would potentially lead to years behind bars.
Yet even when someone agrees to get help, there’s not always a place to go. As of this summer there were fewer than 100 detox beds countywide that accepted Medi-Cal, the state health insurance for low-income residents, and officials recently flagged about 100 people being treated for substance abuse disorders by day who were still homeless at night.
As a result, the Board of Supervisors has invested in a new treatment facility in National City, Father Joe’s continues to convert its Paul Mirabile Center downtown into a detox space and UC San Diego Health, a recipient of settlement money from a nationwide lawsuit targeting opioid makers, is creating teams to follow up with patients who ended up in the ER because of overdoses.
And all the while, opioids exert their near gravitational pull.
Several months ago, an older man sat cross-legged on a downtown corner. His right hand held a white pill. It was unclear if he knew exactly what it contained.
His fingers were long and flat and they struggled for a moment to break off a piece. He eventually slid a shard into a clear tube and placed the pipe in his mouth. A lighter flicked on and flames turned the pill into smoke. There were three wonderful things about this world, he said: God’s grace, sex and this.
The man inhaled, breathed out his nose and pumped a fist in the air.
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