The overdose crisis has finally reached California, following a relative delay in the arrival of fentanyl there which I described for Filter in 2018. Meanwhile, in the State Senate, legislators have an opportunity to deploy an effective response.
There were an estimated 6,518 drug-overdose deaths across California last year, according to preliminary data released by the Centers for Disease Control and Prevention on July 15. That’s up from 5,626 in 2018—an increase of 15.9 percent.
The picture that emerges is one where California, until now largely spared from the tragedy of the opioid-involved overdose crisis, is beginning to catch up to so much of the rest of the United States. “We’re a little bit behind everybody else, but we’re still following the same timeline,” Michael Marquesen of the Los Angeles Community Health Project warned in 2018. “I’m sure it’s going to show up everywhere.”
California is one of the last areas of the country where “black tar” heroin remains available. The viscous consistency that characterizes black tar means it is difficult for suppliers to mix in fentanyl, the synthetic opioid responsible for the so-called “third wave” of the overdose crisis. Most of the country’s “China white” heroin—of varying consistency but always sold as a powder—was easily adulterated with fentanyl. But California’s black tar provided a modicum of relative predictability (if not security). At least until 2019, when it appears that began to change.
A February 2019 report by Insight Crime confirmed that Mexican cartels were steadily replacing heroin with fentanyl. And among states that saw significant increases in overdose deaths through 2019, California ranks among the top.
By 2019, California could have had safe consumption sites operating in several key cities.
Did it have to?
By 2019, California could have had safe consumption sites (SCS) operating in several key cities where large drug-using populations reside.
For years, Susan Eggman, assemblywoman for California’s 13th Assembly District, has patiently and repeatedly moved bills through the state legislature that would allow for the establishment of SCS—healthcare facilities where people can bring drugs to inject with clean equipment and under the caring eye of nurses.
Eggman came closest in 2018. By that September, Bill 186 was approved by both the state’s Assembly and Senate. Local agencies like the San Francisco Department of Public Health were ready to go with plans to open facilities with buy-in from local communities and without further delay. But just before Governor Jerry Brown left office, he vetoed the bill.
Today, legislators have State Assembly Bill 362 under their consideration. Eggman’s third attempt, it would allow for a six-year supervised-injection pilot program in San Francisco. The bill cleared the Assembly in May 2019 and last month received a second reading in the Senate.
The scientific literature in support of SCS is voluminous and widely available online. It says that they reduce the spread of infectious diseases like HIV and hepatitis C, and prevent overdose deaths. When deployed with complementary services, they also reduce crime in a neighborhood, move people into supportive housing, and connect users with mental-health services and other healthcare programs, including long-term treatment.
Most of the data on SCS pertaining to North America come from Insite, a Vancouver, Canada facility founded in 2003 and the only sanctioned site on the continent until 2016.
According to Insite’s operator, PHS Community Services Society, from March 2004 to December 2019, facility staff responded to 7,884 drug overdoses. Their success rate was 100 percent. Documents obtained under freedom-of-information legislation confirm that Insite has never seen one death.
A more recent and more relevant case study comes from Vancouver’s province of British Columbia. The region was the first in Canada where fentanyl sent overdose deaths soaring. In response, the provincial government declared a state of emergency and allowed for the establishment of a new class of SCS. Called overdose-prevention sites (OPS), these stripped-down injection facilities were deployed in affected communities quickly and effectively. Within a year, overdose deaths began to decline.
Through the winter of 2016, deaths across BC averaged 144 per month, according to the province’s coroners service. By the same period the following year, that number had declined to 115. And then in the same three-month period in 2018, average monthly deaths dropped to 100.
BC’s response to fentanyl was harm reduction. Although implementation could have been wider, it was beginning to work.
By that time, there were more than a dozen injection facilities operating in BC. The province’s response to fentanyl was harm reduction. And although implementation could have been wider still, it was beginning to work.
And then the COVID-19 pandemic swept into Vancouver, disrupting services and causing the adulteration of illicit drug supplies, and overdose deaths soared. According to the BC Coroners Service, there were 113 deaths across the province in March, 118 in April, 170 in May, and then a new record 175 in June.
All of this demonstrates that SCS are not the only solution to the overdose crisis, nor adequate in themselves. If people cannot access them, or do not wish to, their scope is clearly limited. Yet their pre-pandemic impact in BC illustrates what an important part of the solution SCS can be. Meanwhile, California, which, like all of the United States still doesn’t have SCS, just recorded, pre-pandemic, its worst year for overdoses. There are widespread expectations that national and state figures for 2020 will be worse still.
In response to North America’s overdose crisis, there’s one message that health authorities have pushed harder than any other: Do not use alone. Over and over again, officials have warned, if you use drugs, use them in the company of a friend. Should someone overdose, there is safety in numbers.
In response to the COVID-19 pandemic, authorities are instructing people to do the exact opposite. “Social distancing” and “self-isolation” are the precautions they are asking people to take today.
Authorities could soften the blow by finally allowing, with appropriate wraparound services and safeguards, the safe consumption sites that in 2018 both the state’s Assembly and Senate voted to support. A 2019 federal court ruling in Philadelphia that SCS would not violate federal law removed one potential barrier.
The first time I spoke with Eggman about her harm reduction efforts, back in 2017, she explained it like this: “Having a drug addiction should not be a death sentence.”
Photograph of Insite in Vancouver by Travis Lupick