D-Nice’s hands are shaking, so I take the matchbook and light the barbecue for him. The coals catch and he quickly hoists a metal, pizza-sized plate of mashed, second-hand enchiladas atop the flame. He empties a jar of Lay’s French onion dip onto the now-sizzling mound of food, and scoops up the resultant concoction with slices of wheat bread. 

It’s 2 p.m. on a Wednesday and we’re huddled between a parked car on Capp Street and a tarp draped over a pair of squat, wheeled carts stacked with D-Nice’s worldly possessions — clothes, food, electronics, a framed map of the world. In this compact space there’s just enough room for the grill and a beach chair. D-Nice eats his lunch, but he doesn’t enjoy it: His last encounter with the San Francisco Police Department, he says, resulted in a bag being carted off, and his diabetes medication was in there. “And now,” he says, “everything tastes like salt.” 

And, with the grill lit and food served, we can talk about fentanyl. Or, as a pair of other homeless people on Capp referred to it, “that drug that’s stronger than heroin” — 50 to 100 times stronger, in fact — and “that new drug that’ll kill ya.” 

In fact, per data released by the Department of Public Health last week, 89 San Franciscans died of fentanyl overdoses in 2018 — a 300-percent jump since just 2016 and more than any other opioid. Per the medical examiner, 39 people overdosed on fentanyl in just the first quarter of 2019 alone. That number will, all but certainly, rise with further analysis. When extrapolated, it’s not unreasonable to anticipate that hundreds of San Franciscans will die from fentanyl use this year. 

And D-Nice would know. 

“Fentanyl knocked me on my back for nine hours,” he said. “I just sniffed a tiny piece — dust! It wasn’t shit! And it knocked me on my back. I woke up hella turnt and it was like that for three fucking days. And that is an experience I don’t want to experience again.” 

D-Nice says he’s personally revived four people who overdosed on fentanyl using the Narcan kits widely disseminated throughout the city. But he couldn’t be there for Melanie. 

“I had a girlfriend. She shoulda been on the cover of a magazine, she was so fine,” he says. “She usually did heroin but she switched to fentanyl. She got off the streets, she got inside. And she overdosed in the fucking bathroom.” 

He sighs. “That fucked me up. That really fucked me up. That girl loved me to death.” He glances around at the bubbling plate of meat and sauce, the tarps, his scattered ephemera on the dirty pavement. “And I woulda had a place to stay.”  

Kristen Marshall, who heads up the DOPE project, says that policies that push homeless and vulnerable people into solitary and/or secretive drug-use have been disastrous.

Coverage of the growing fentanyl epidemic often mirrors the stories, decades ago, about killer bees closing in on California: An unstoppable, deadly force that has wrought havoc elsewhere is coming! Be afraid! Be very afraid! 

Fear is not unwarranted. San Francisco’s numbers, as grim as they are, are still dwarfed by those from the East Coast and Midwest. And yet, to put things in a local context, Fentanyl killed nearly four times as many San Franciscans in 2018 as automobile-on-pedestrian collisions. 

These numbers pain Kristen Marshall because, to her, they’re not numbers. They’re people. They’re her community. Marshall runs the city-funded Drug Overdose Prevention & Education (DOPE) Project. She’s the woman overseeing the dissemination of those Narcan kits like the ones D-Nice used to likely save the lives of four people. In this city, she says with experience, when someone shouts “I need Narcan!” people come running. And when there’s no Narcan? “Those motherfuckers get real quiet and everyone else scatters,” says D-Nice. 

The natural reaction to stories about growing numbers of fentanyl deaths is a primal scream of WE NEED TO DO SOMETHING! Marshall would like you to know: WE ARE.

The city disseminated some 30,000 doses of Narcan (naloxone) last year, in intravenous form like this vial or in nasal spray bottles. Some 1,658 opioid overdoses were reversed.

Her $258,000-a-year outfit, funded and working closely with the Department of Public Health, last year distributed nearly 30,000 Narcan doses in this city. By a highly conservative count, 1,658 overdoses were reversed. Through April of this year, at least 735 overdoses were reversed. But we do more. 

The city already provides drug-users with test strips that indicate whether fentanyl is within other drugs — and, because fentanyl is so powerful, even a little bit in, say, meth or heroin can be lethal. But fentanyl has gone from being the MSG of drugs, tossed into other materials, to being a substance people seek out on its own. 

So the DOPE Project also oversees regular testing of the city’s fentanyl supply to gauge just what drug users are putting into their bodies. The purity of the supply can vary greatly from week to week — from, say, 4 percent fentanyl by volume to 34 percent. 

When, as D-Nice noted, even “dust” can incapacitate you for hours or days — or worse — this kind of variability is dangerous. In June, Marshall says, a sudden spike in the concentration of San Francisco’s fentanyl supply led to 10 deaths in one week. These numbers — these people’s deaths — do not register on the annual tallies. Not yet. 

The DOPE project can get the word out about unstable supplies in 24 hours or fewer. It’s not high tech: It’s word-of-mouth, boots-on-the-ground, Baker Street Irregulars-type messaging. 

So, these are the types of things we can do as a city. And, to a large extent, they are working. Yes, more people are dying of fentanyl, but more are being saved. Even by the most conservative estimates, for every person who died of an opioid overdose in 2018 — 177, per the DPH — 10 or more were revived. Fentanyl is not cyanide. San Francisco has proven this. We have also proven that it is both cost-effective and a massive life-saver to distribute Narcan far and wide and make it a ubiquitous part of the city’s drug-using landscape rather than allow drug-users to die on the streets and get emergency responders involved in each and every incident. 

Fentanyl is killing lots of San Franciscans. But, argues Marshall, so are this city’s homeless policies. And she feels like she’s working against both of them. 

A tent encampment on 16th and Shotwell Streets, December 2016. Photo by Brian Rinker.

A bit of mathematical levity: While $258,000, the DOPE Project’s yearly budget, would be a lot of money if, say, presented in a wheelbarrow, it represents the amount the city of San Francisco spends in 11 minutes. It is, roughly, one-fifth what the city spends yearly on toilet paper. Distributing Narcan is, again, a money-saver when compared to the costs of administering emergency treatment to dying drug-users (separate and apart from the issue of saving thousands of lives). 

But it’s not cost-beneficial (or life-saving-beneficial) if people have their Narcan taken from them. Last year, 102 homeless individuals reported that — like D-Nice with his diabetes medication — their Narcan was appropriated by cops or Public Works employees. By May of this year, 86 such reports had already been registered. 

So, that’s a problem. As are homeless policies that, however justifiable for other reasons, push unhoused people out of communities and into solitude. Per a 2003 paper analyzing this city’s heroin deaths, a full 68 percent of overdose victims died alone. 

San Francisco isn’t always the most promethean of cities, but instilling Narcan into the culture over the past 16 years was a good and innovative thing. If you overdose within a group, there’s a better than decent chance someone is going to have a kit, underwent the five minutes of training it takes to use one, and will revive you. 

But if the homeless are being shunted out of communal encampments and know the way to avoid contact with authorities is to stay out of groups; if the lucky recipients of housing are placed into Single-Room Occupancy hotel rooms — and if one’s continued housing is contingent on not getting caught using drugs — people are being placed in situations that all but demand solitary, clandestine drug use. D-Nice’s Melanie purportedly died in the bathroom. “Most people die not outside but in supportive housing,” says Marshall. “Treatment on demand” options in this city, she continues, are highly limited. 

Last week’s federally coordinated drug action in the Tenderloin, in addition to carrying the whiff of an immigration crackdown masquerading as a narcotics raid, left the city’s drug users strung out and even more susceptible to overdosing, Marshall adds.

Speaking of the feds swooping down on San Francisco, if this city were able to legally establish a safe injection center of the sort Mayor London Breed campaigned on, that would be a huge help. “That is an ongoing effort,” says Dr. Phillip Coffin, the Department of Public Health’s director of substance use research. “That would definitely be one of the things we’d like to do to help the situation.” 

But we can’t. Establishing such a center would enable Attorney General Bill Barr to ride into this city on a white steed, Teddy Roosevelt-style, and undertake the GOP base-gratifying move of prosecuting San Franciscans for enabling drug-users to use drugs. 

So, we’ll keep doing what we’re already doing. Both the good and the bad. 

But for this city investing several months’ worth of toilet paper money in Narcan and outreach, San Francisco would be awash with dead fentanyl victims. We’re doing good things, but we could do more if we prioritized this issue. We could do more if the unintended consequences of city homeless policies were frankly addressed. 

We could do more if drug users and homeless people dying was considered a critical issue. 

Until that time, expect the body count to increase. And expect those who deign to pay attention to ask, with increasing urgency, what can be done?