Inside Mothership’s darkened, otherworldly bar, some life-saving tools can be found just behind the LED-lit counter.
If you ask, there’s Narcan, generically known as naloxone, which reverses a fentanyl overdose. And there are also fentanyl test strips, which detect the dangerous synthetic opiate in party drugs like cocaine, pills, meth or MDMA (molly or ecstasy).
Sean Mabry, co-owner of the Mission Street bar, knows all too well how a person could unwittingly take a drug that’s laced with fentanyl, leading to a potentially fatal overdose.
“I’ve personally lost friends,” he confirmed.
That made the decision to stock test strips and naloxone at Mothership a no-brainer when the bar opened in 2021.
“I’d just rather mitigate the cause, than hope to treat the result,” Mabry said.
Like the “fish bowls” of condoms that began appearing atop bar counters during the AIDS crisis, Narcan and strips are touted as a newer public-health strategy to combat the country’s fatal overdose crisis. And, just like those condoms, not all bars have immediately embraced Narcan and the strips.
Out of 75 bars Mission Local contacted*, almost half carry Narcan behind the bar, and 20 of those also carried strips. Public health officials say they should.
“You cannot trust any pill you buy on the street these days,” said Dr. Daniel Ciccarone, a professor of addiction medicine at the University of California, San Francisco. In the bag of public health crisis tools, “the fentanyl test strip is the latest and greatest,” he added.
Eileen Loughran, the Department of Public Health’s Harm Reduction Program Manager, agreed. “Unfortunately, addiction and overdose is impacting so many of us,” Loughran said. “More people are wanting to empower themselves to be able to save a life.”
Some bar owners Mission Local interviewed are staunchly against providing strips or Narcan, arguing they are confident their customers don’t use drugs. Others cited fear of liability if a person uses illegal substances in the bar, and some said stocking resources would exacerbate overdoses by encouraging risky, life-threatening behavior. Some were interested, but simply confused as to how to get a steady supply of strips.
The stigma argument is a familiar one. Gay men were told to stop having sex during the HIV/AIDS crisis, and abstinence is still touted in sex education classes as the sole way to prevent unplanned pregnancies or sexually transmitted diseases.
“The opposite argument is to say ‘no’ to people, to restrict things,” Ciccarone said. “No to spontaneous sex, no to gay sex. But in the public health world, we know that people make all sorts of choices. We provide the tool … whether it be a condom, a needle, or a test strip.”
Stocking the Mission is a good place to start; it’s one of the top four San Francisco neighborhoods where accidental overdoses occur, behind the Tenderloin, SoMa and Russian Hill. Between 2020 to 2022, almost 100 Mission residents died from accidental overdoses, and at least seven have died so far this year.
Josh Yule, a graphic designer and local music programmer who runs Savoir Faire Booking, began creating harm-reduction boxes filled with strips and Narcan in late 2022 following the deadly overdose of a close family member. Like many of those who overdose, it was not someone who fits a “stereotype” of a drug user. The family member worked as a nurse and had chronic pain, and Yule never suspected their drug use.
So, Yule wants to see harm-reduction boxes installed and fully accessible at Mission bars like Mothership. Mabry signed up for one, noting that they can “de-stigmatize testing for drugs,” he said.
“I think there is almost a secrecy and shame that comes with obviously using illegal substances that might make people less inclined to ask [a bartender for one] … even though it can possibly save their life,” Mabry said.
Overdose deaths affect young and old
In San Francisco, fentanyl was behind some 70 percent of the city’s 647 accidental overdose deaths in 2022. Yet many of the city’s deaths also involved other drugs, including methamphetamines and cocaine, often considered party drugs.
Last year, 40 percent of people who fatally overdosed tested positive for cocaine, and more than half for meth, according to an Office of the Chief Medical Examiner report. Meanwhile, thousands of overdoses were reversed, thanks to Narcan.
Ciccarone said that, in his research, there is bi-modal curve in age-affected overdose deaths. That “means there’s two humps on the age graph. So we see overdoses happening a lot among people who are older — over 50 or 55. And then, the 20-somethings.”
In San Francisco, more than 40 percent of accidental overdoses in 2022 affected those 55 and older, and 17 percent affected those aged 15 to 34.
“If you are between 15 and 30, you one hundred percent know someone who does drugs,” Ciccarone said.
What some view as fun can accidentally turn fatal. Last year, nine Los Angeles Unified School District teens overdosed, one from a version of Percocet that may have contained fentanyl; one girl died in a school bathroom. Last year, a 16-year-old in San Francisco was found on the streets who had died of a mix of drugs, including alcohol, fentanyl, heroin and cocaine.
About 11 percent of cocaine Ciccarone tested in an unpublished study had traces of fentanyl, he said.
Test strips in bars
Placing free fentanyl test strips in convenient places people are likely to frequent may reduce those risks. “Test strips are cheap, easy to use and easy to read,” Ciccarone said.
At the Makeout Room, the bar and club on 22nd Street, Paul Costuros said he watched an overdose happen in late 2022. He saw a man fall off the barstool onto the floor, landing unresponsive. As Costuros and others rushed over, the bartender grabbed Narcan and administered a dose up the man’s nose. By the time paramedics arrived, the man was up and talking.
Costuros, who is a bartender at the Knockout, said this is why it’s important to stock resources at bars, where customers may arrive already high on drugs or clandestinely use them in the bathroom to keep the party going.
Last December, two people overdosed at the bar Phone Booth on South Van Ness Avenue, according to an Instagram post. Those overdoses were purportedly reversed with Narcan.
However, similar to other health crises or issues, the resources to save lives carry a stigma. “There’s a sense, for some, that if a bar has Narcan or test strips, it means they’re supporting the use of drugs in their establishment,” Costuros said. “But it really just shows the sense of safety toward their clientele.”
Shotwell’s Bar, at 20th and Shotwell streets, said they know their clientele too well to need Narcan or test strips. In a message, they said they “haven’t had any issues.”
El Trebol, at 22nd and Capp streets, was firmly against carrying harm-reduction supplies. “This is a family bar,” said Alex, the manager. “If I see someone using drugs, I kick them out.”
While stocking Narcan has gained slight popularity over the course of the overdose crisis — Assemblyman Matt Haney just pushed a bill to require it in all bars — fentanyl strips are in the early stages of being widely embraced. That could change.
Yule, who dreamed up the harm reduction boxes equipped with strips and naloxone, remembers the resistance to Narcan in 2017. He was a bartender in the Mission and attended training. Back then, Yule said, “the stigma was insane.”
“I went to a training, and everyone was scared to go; it was weird,” said Yule. “And every time I put Narcan on the shelf, someone would push it behind, or put it in a drawer.”
By distributing his visible, decorative harm-reduction boxes in Mission bars, that stigma may lessen over time. Plus, he adds, “It makes you feel safer that the box is there, and has all the tools to save a life within seconds,” Yule said. Bars must restock supplies on their own.
Supplies of Narcan and fentanyl strips
Other organizations, including the Bay Area-based nonprofit and fentanyl strip supplier FentCheck, helps supply resources and combat stigmas. About 12 San Francisco organizations use FentCheck, including local bars like Mothership, Royal Cuckoo Market, Beauty Bar and the Sycamore.
Some other organizations also partner with FentCheck, but “prefer to remain unlisted,” FentCheck founder Alison Heller wrote in an email. Individuals feel stigma, too.
“Many people feel uncomfortable using their credit card to purchase these online,” Heller said. That’s why the company provides them for free, “typically in restrooms, so that folks have the privacy to take what they need!”
Some studies show fentanyl strips can deliver false positives and, in rare cases — most likely with pills, Ciccarone said — fail to make contact with the part of the drug that is laced. (Heller said FentCheck’s strips produced “no known” false positives for MDMA, cocaine or meth.) Overall, however, doctors and the U.S. Centers for Disease Control and Prevention encourage using them. Federal funding could be used to purchase strips and distribute them on a local level.
In San Francisco, the Department of Public Health offers strips and Narcan free of charge at 1380 Howard St., where Community Behavioral Health Services is. Loughran said the health department and partners distributed 72,000 Narcan kits last year. More than 4,500 test strips have been distributed this year.
That can feed the supply for local bars. Debi Cohn, owner of Asiento, said she has two doses of Narcan behind the bar, some of which she gets from nearby San Francisco General Hospital and the methadone clinic. Like many of the bars we visited, Cohn has no test strips.
“We don’t see much in the way of people doing unknown drugs. We are way off the beaten path, a neighborhood and regulars’ bar,” Cohn explained. She has, however, had friends die in their homes from an overdose.
“One never really knows, so we want to be able to help anyone, whether they are a guest or not,” Cohn said.
Mabry agreed. “You can never be too careful.”
* Some of establishments expressed interest in procuring resources in the future, or have yet to respond. Mission Local will update if necessary.