Postcard from San Francisco: A controversial war on fentanyl

The synthetic opioid is killing dozens monthly, but authorities and health campaigners can’t agree how to stem the deadly epidemic, writes Mallory Moench.

The World Today Updated 4 July 2024 Published 28 July 2023 3 minute READ

Mallory Moench

Reporter, San Francisco Chronicle

Kenneth Ray Russworm says he regrets ever taking fentanyl. The San Francisco native tried the synthetic opioid that is up to 50 times stronger than heroin while living in a homeless shelter after his mother died last year and hasn’t been able to stop using it since.

‘I ain’t never had a type of drug that had such a hold on me,’ Russworm, 43, a father of seven, said, crouching beside tents that serve as homes. In his hand he holds the tinfoil he uses to smoke the drug that has taken over his life.

Fentanyl struck the East Coast of the United States first, driving up the number of drug-related deaths and hitting San Francisco in full force at the start of the Covid pandemic. Last year, the city had the second highest overdose rate among US cities, after Philadelphia. In the first half of the year in San Francisco, 406 people died of accidental overdoses and more than three out of four deaths involved fentanyl.

The crisis cuts across class, race and geography, in a wealthy, largely quiet city. But nearly one in five deaths this year occurred in the Tenderloin, a low-income community near City Hall. This is where the problems are most visible, with some pavements clogged with people selling drugs or in fentanyl-induced stupors.

A tougher stance

Addressing the health crisis is a priority for London Breed, the mayor, and other city leaders as the political stakes are high with world leaders due to descend on San Francisco in November for the Asia-Pacific Economic Cooperation conference.

Breed has pushed for a tougher stance on drug activity in response to concerns from residents and business owners. She has urged police to arrest drug dealers and recently directed officers to detain people who are high in public and offer them treatment in jail.

Critics accuse officials of recreating the War on Drugs that failed to eliminate crime or addiction in America. San Francisco public health department’s recent overdose prevention plan highlighted studies that show imprisoning drug offenders increases the risk of overdose deaths. An official said the department has been working to save lives by providing treatment to thousands of people and handing out overdose-reversing medication.

Medical experts have urged the city to create supervised drug using sites where staff can reverse overdoses

Medical experts have urged the city to create supervised drug-using sites where staff can reverse overdoses. Such sites, more common in Europe, are illegal under US law, but a non-profit organization openly runs two in New York City.

Breed has poured money into healthcare services, but also pushed for more policing. In December 2021, she declared a three-month emergency in the Tenderloin and a crackdown on open-air drug markets after families asked for help. She opened a drop-in centre that linked people to services and let visitors use drugs.

Some 333 overdoses were reversed by staff in the 11 months before Breed closed the centre, saying it didn’t fulfil its purpose of connecting people to long-term help. After it closed, overdose deaths rose. Breed has promised to open smaller, similar centres.

In June 2022, voters recalled Chesa Boudin, the city’s progressive top prosecutor, whom critics accused of being too lax on crime. Breed appointed Brooke Jenkins as a replacement who won the recall election after pledging to hold fentanyl dealers accountable. Drug arrests and prosecutions have since increased. From January to June this year, police took 60kg of fentanyl off the streets – 160 per cent more than in the first half of 2022.

‘The most lenient city in the world’

The city has asked for outside help, leading to Gavin Newsom, California’s Governor, deploying state police to the Tenderloin and Congresswoman Nancy Pelosi announcing an Operation Overdrive designation for San Francisco which should unlock federal money to fight the fentanyl epidemic.

Despite these efforts, Russworm called San Francisco the ‘most lenient city in the world’. Azalina Eusope, who runs a Malaysian restaurant in the Tenderloin, said ‘We’re not seeing the results.’ Dealers and tents remain on the pavement where children walk to an after-school programme.

Eusope wants customers to see the positive side of this historic, close-knit neighbourhood. She is part of a coalition of business owners who asked Breed for more policing against open-air drug markets. ‘I want these users to get help because it’s very important. We can’t let them suffer like this,’ she said. ‘You’ve got to hold people accountable. Otherwise, nothing is going to change.’

I don’t have to agree with what I see on the streets, but I don’t need people to die

Fenalie Castro, a case manager with social justice orgnanization the Glide Foundation

But Felanie Castro, a case manager with Glide, an organization fighting for social justice, who spends her days giving out health supplies and helping clients access social services, is against criminalizing drug users, arguing that enforcement only drives people with addiction into the shadows.  ‘I don’t have to agree with what I see on the streets, but I don’t need people to die,’ she said.

She has lost friends to overdoses and reversed at least 50 herself, once bringing back a young woman whose lips had turned blue and who apologized when she woke up. ‘That broke my heart,’ Castro said. ‘It’s really tough in San Francisco, but I’m going to keep doing this.’

Russworm, who has a job picking up litter, moved into a flat outside the Tenderloin to help him get off fentanyl. ‘I’ve got everything I need to quit, but I can’t stop it,’ he said. 

The geopolitics of fentanyl

Fentanyl has become another sticking point in relations between the United States and China. It belongs to a class of powerful synthetic opioids which are the biggest killer of Americans aged between 18 and 49, responsible for two-thirds of the 110,000 Americans who died of a drug overdose in 2022.

China banned all types of fentanyl at the behest of the US in 2019

Antony Blinken, the US Secretary of State, raised the issue of fentanyl with Chinese President Xi Jinping, during his visit to Beijing in June. The Asian powerhouse is the source of most of the ‘precursor’ chemicals used in fentanyl’s illicit manufacture, but it has refused to join a US-led international initiative to counter the threat of dangerous synthetic drugs. While Blinken pointed the finger at ‘transnational criminal enterprises’, Chinese state media instead blamed American users themselves for the fentanyl crisis.

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China banned all types of fentanyl at the behest of the US in 2019. But as relations worsened on issues of trade, human rights, Taiwan and Russia, it is believed that Chinese authorities relaxed enforcement, greatly increasing the export of fentanyl’s precursor chemicals, including to the Mexican drug cartels. Notably, Mexico has joined the initiative launched by Blinken.

By contrast, China described as illegal the charges brought in June by US authorities against several Chinese companies. They are accused of trafficking chemicals used in fentanyl production to Mexican drug cartels. 

Mike Higgins