Why California Has Largely Been Spared Fentanyl Deaths—So Far

October 2, 2018

America’s crisis of drug-overdose deaths has largely spared California. At 11.2 deaths per 100,000 people in 2016, California’s rate of fatal overdoses is among the lowest in the nation. But there are signs that is changing.

The epidemic is now largely driven by fentanyl, a synthetic opioid significantly more dangerous than heroin. According to the California department of public health, fentanyl was associated with 81 deaths across the state in 2013, then 135 in 2015, and then 373 in 2017. Though on the rise, that’s still very few compared to other regions.

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 said recently. “I’m sure it’s going to show up everywhere.”

While states like Ohio and Pennsylvania buckle under fatal overdose rates as high as 39.1 and 37.9, respectively, California still has time to get ahead of the crisis. Harm reduction programs should be expanded now in order to prevent the sort of public-health catastrophes that have occurred in eastern states.

“I don’t believe that enabling illegal drug use in government-sponsored injection centers … will reduce drug addiction,” Gov. Brown said.

I’ve spent the last five years reporting on fentanyl in Vancouver, Canada, where in 2018 the rate of fatal overdoses stands at 57.8 per 100,000 people—as high as that of the worst-affected cities in America. In my book, Fighting for Space: How a Group of Drug Users Transformed One City’s Struggle with Addiction, I recount Vancouver’s history with harm reduction and the establishment of North America’s first legal supervised-injection facility, Insite. Without harm reduction, British Columbia would not have seen the 1,450 overdose deaths that it did in 2017, BC’s chief coroner said recently. It would have suffered triple that number.

Many US jurisdictions have delayed conversations about harm reduction until debates were forced on them by skyrocketing numbers of drug-overdose deaths. California should break from this pattern. There is no need to wait for so many to die before deploying health services that are proven to work.

On September 30, a bill that would have allowed supervised consumption sites in California was vetoed by Governor Jerry Brown. Bill 186 was approved by both the state’s assembly and senate, and had the support of local authorities such as the San Francisco Department of Public Health. Nevertheless, the governor refused to give the bill his final approval. “I don’t believe that enabling illegal drug use in government-sponsored injection centerswith no corresponding requirement that the user undergo treatmentwill reduce drug addiction,” Brown said in a statement.

His veto will likely prove a significant and lengthy setback for harm reduction advocates in California. Meanwhile, the threat of America’s opioid crisis grows. On October 1, San Francisco Mayor London Breed signalled that the city still wants to see a supervised consumption facility open there. But nowhere is it more important for California to expand harm reduction programs than in the state’s largest city: Los Angeles.

Los Angeles, however, appears reluctant even to begin the public discussions that such a controversial program requires.

Meanwhile, Los Angeles hosts the largest unsheltered-homeless population in America. It’s estimated that 44,000 of the city’s 55,000 homeless residents are unsheltered, with higher barriers to social services. (For comparison, New York City’s homeless numbered 76,000 in 2017, but the vast majority are sheltered.) In addition, LA has long served as a primary hub for the transportation of heroin from Mexico to much of the western half of the country, according to the US Department of Justice.

Deaths attributed to fentanyl remain low in California compared to most other states. Why?

Fentanyl could have arrived in California before it did other regions of America, and burned through Los Angeles’ vulnerable homeless population. But it didn’t. According to the National Drug Early Warning System, in 2016, fentanyl and its analogues accounted for just 0.2 percent of Los Angeles County drug seizures reported by police. There were 373 deaths attributed to fentanyl in California in 2017; meanwhile, states with much smaller populations, such as Ohio and Pennsylvania, saw 3,446 and 3,656 fentanyl deaths, respectively. Deaths attributed to fentanyl remain low in California compared to most other states. Why?

California’s demand for illicit opioids is largely met by the Sinaloa cartel And, for now, the type of opioid that the cartel has chosen to export to California is black tar heroin.

People who use heroin tell me it is difficult to mix fentanyl into black tar heroin. Fentanyl is commonly a powder and black tar heroin is, as its name suggests, usually sticky to touch. It’s hard to sneak a powder into a substance that’s viscous. In contrast, China white heroin, which predominates in other parts of the country, is a powder, and therefore easily adulterated with fentanyl without giving consumers a clue. In most areas where fentanyl has come to account for a majority of drug-overdose deaths, it has infiltrated supply via markets for China white heroin.

California’s success in avoiding the worst consequences of America’s opioid epidemic is therefore not the result of any government action or less drug use. Instead, Californians largely owe thanks to West Coast drug dealers’ traditional preference for black tar heroin over China white.

But that preference is very likely shifting.

It simply makes no sense for a criminal organization to continue producing and distributing heroin when fentanyl is increasingly available. Heroin requires the cultivation and maintenance of a poppy field, then the transportation of relatively bulky cargo across highly secure borders. Fentanyl can be cooked in a basement laboratory and sent through the US postal system. This reflects analyses showing that drug prohibition tends to incentivize shifts toward the sale of more concentrated forms of drugs.

California still has time to avert a public-health emergency.

Fentanyl will only continue to account for a growing portion of America’s supply of illicit opioids. California will not be spared.

In recent months, organizations like LA Community Health Project  have launched new harm reduction initiatives in response to the arrival of fentanyl, including cheap and simple tests for the drug. It’s especially encouraging that such programs have the support of the California Department of Public Health. But if Vancouver’s experience is any indication, significantly greater efforts are required.

In Vancouver, the region’s health authority made naloxone—the so-called overdose antidote which reverses opioids’ effects—available without a prescription and free of charge. And in addition to Insite, it established a half-dozen new overdose-prevention sites (bare-bones supervised consumption sites). Vancouver’s epidemic of drug overdose deaths still continues, but at a pace the city’s health officials maintain is lower than if Vancouver had not committed to such programs.

California still has time to avert the public-health emergency that has already raged through most of the rest of the country. Efforts should focus on harm reduction, and Los Angeles is a key battleground.


Travis Lupick

Travis is a journalist based in Vancouver and the author of "Fighting for Space: How a Group of Drug Users Transformed One City's Struggle with Addiction" (Arsenal Pulp Press, June 2018).

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