It’s been almost a year since ANTIGRAVITY published “The Story of the Winter 2016 Overdose Crisis: A Case For A Regulated Drug Market” (April 2015, #141), which detailed a surge in fatal overdoses across New Orleans, and outlined steps that users and harm reduction groups were taking to address and alleviate the harm caused by unintended overdoses. Over the past year, Louisiana drug users have continued to adapt and respond to a changing heroin supply while navigating practical concerns, legal frameworks, and shifting risks in the era of “the new dope.”
THE NEW DOPE
It’s mid-morning on a sunny November day in San Diego, and I’m choking back tears in an anemically-lit conference room. Sitting around me are hundreds of harm reduction practitioners, drug users, and public health professionals. I’m not the only one crying. In the front of the room, six people are describing their experiences as syringe exchange operators and researchers navigating through unprecedented changes in the U.S. drug supply. “Illicitly Manufactured Fentanyl in the United States” is one of the first panels in a weekend-long conference that would be dominated by discussions of adulterants, supply chains, and overdoses. What I had initially expected to be a relatively dry panel on drug sources turned out to be a raw and illuminating look into a wave of changes being felt at every level of heroin use and harm reduction across the nation.
Illicitly produced fentanyl, according to researchers such as Dr. Dan Ciccarone of UCSF and harm reduction coordinators like Eliza Wheeler from the DOPE Project, has been appearing in every major heroin market in the country. Adulterants, like the powerful synthetic opiate fentanyl, are usually non-heroin substances that are added into mixtures of the drug to alter its effects or increase profits. What began as the suspicion of a strong adulterant in isolated regions became the reality of a potentially epochal change in the makeup of street heroin across the United States. Many now suspect a cartel-level shift from an Afghan and Colombian supply to fentanyl-laced powder heroin products, believed to be originating from production in Mexico and China.
As illicit manufacturing of these adulterants becomes cheaper and more widespread, the constitution of street heroin may become a heroin-fentanyl mixture: the new dope. Even markets classically dominated by sticky “black tar” heroin have seen a rise in fentanyl, sold as “China White” or “Mexican White” powder. Fentanyl has also been found pressed into counterfeit pills and branded as Xanax or Vicodin. Users have been reporting higher potency, increased longevity, changes in consistency and color, and unfortunately, a significant rise in overdoses.
Siblings Mary and Eliza Wheeler, both sitting on the panel, described their experiences coordinating harm reduction and overdose prevention services in Lynn, Massachusetts and the San Francisco Bay Area. “We are on track to have 2,000 fatal overdoses in 2016 in Massachusetts alone,” declared Eliza. In 2015, the CDC estimated that there were 28,000 fatal opiate overdoses nationwide. Preliminary reports suggest that 2016 was likely the most dangerous year in American history for opiate users, a fact partially attributed to the rise in heroin purity and the presence of synthetic opiates such as fentanyl. From January to May of 2016 alone, New Orleans Coroner Jeffrey Rouse counted 63 deaths as opiate overdoses. Nearby, the Jefferson Parish coroner reported over 67 deaths in that area in 2015. Nationwide, significant rises in opiate overdoses linked to fentanyl-related adulterants have been reported in over 20 states, and while government agencies and police departments are slow to locate and test illicit substances, users across the country have reported noticeable shifts in their on-the-ground experiences with heroin and other drugs.
Audience members in attendance at the November conference described seeing a rise in fast-acting overdoses with strange symptomatology in their respective communities. “We are seeing people go into sudden cardiac arrest and die because they no longer have a strong enough pulse to push the Narcan to their brain,” reported one panel member, referring to the overdose reversal drug naloxone. “I had a participant walk up to me and say ‘I’m going to fall out,’” described Mary Wheeler. Within seconds he was unconscious.
There was talk of seeing new overdose symptoms, such as people clawing or banging on their chest during an overdose. “We’ve been calling it rigid chest syndrome,” interjected Dr. Ciccarone, along to nods of recognition from the audience. Others reported “laryngospasms,” or a sudden constriction of the vocal cords, causing people to grab at their face or throat. These new symptoms may represent a neurotoxic effect of the adulterants, or are potentially symptoms of sudden cardiac arrest. Most overdoses present fatal complications due to central nervous system depression, meaning that death comes from lack of oxygen due to decreased breathing or unconsciousness. Cardiac arrest, which is far more dangerous and difficult to reverse, may be the most troubling symptom of these new and powerful fentanyl mixtures.
From across the country, people shared experiences of overdoses that required three to four separate doses of naloxone to reverse. In some cases, groups of fatalities would occur simultaneously where users had shared an unexpectedly potent mixture containing fentanyl. Even non-injection users, such as those who purchase counterfeit pills, have been experiencing surges in fatal overdoses. Voices began to crack on the panel as people described the feeling of never knowing where or when a spike in deaths would occur in their communities. “I’m sorry,” said one panelist “we just lost three of our participants this week. We’re all grieving.”
For harm reduction groups based on a participant-centered model, this is devastating. Participants are our friends, co-organizers, partners, community, and closest allies. They are the people who keep us safe, the people who we try to keep safe. To lose even one friend is an incurable wound and inexcusable injustice. To lose three community members in one week is an unbearable loss.
WE’VE ALWAYS BEEN TAKING CARE, THEY’VE ALWAYS BEEN TAKING AIM
But is the “new dope” a bad thing? Not exactly. As many participants at the 2016 National Harm Reduction conference pointed out, changes in supply, potency, and drug consistency are nothing new. Drug using communities have been self-educating, self-testing, and self-selecting drug variants since time immemorial, looking out for newer or better highs, learning how to avoid dangerous variants, and tracking local availability of different mixtures. The presence of a powerful adulterant is not always a cause for crisis. The rise in heroin purity and power is, according to most heroin users, not in itself a bad thing. Drugs change. Drug users change with them.
As always, the true national discourse is happening in the bar, at the show, in the backseat, outside the bail review hearing, and on the corner.
The problem is that these efforts at self-care, self-correction, and self-awareness are complicated by structural processes that explicitly sever communication between drug users while criminalizing education and reducing access to life-saving overdose prevention tools. A harm-enhancing model of drug prohibition—in which the negative consequences of drug use are amplified by the threat of imprisonment, loss of housing, social stigma, and physical vulnerability—is what forces users away from safer use habits and towards the dangerous and deadly patterns we are seeing across the nation.
“YOU SAID TO CALL…
…if we see a rise in overdoses. Well, we’re seeing it.”
It’s late November, and an emergency medical provider in New Orleans tells me they have seen multiple fatal overdoses that week. They have successfully reversed a number of others. I call up a friend at a local hospital who tells me, “I was actually just about to get in touch, you getting this as well?” A few weeks have passed since the conference, and my anxieties about new and powerful adulterants arriving in New Orleans have stayed with me. One speaker had put it directly: “Don’t wait til it gets to you, start preparing now.”
We have been: harm reduction providers have been stocking up on naloxone, connecting participants to safer use supplies, and keeping an ear to the ground for any rumblings of increased overdoses. Throughout the following weeks, users across the city confirm that they are seeing a rise in overdoses connected to dark brown or blackish powder heroin. The blackish heroin, some report, is due to the possible presence of a research chemical of unknown origin. Others report overdoses and increased side effects from a lighter brown drug with noticeable chunks. People put the word out: Don’t use alone, take a tester shot of your heroin to make sure you are aware of its potency, learn to recognize the signs of an overdose, and always keep Narcan on hand.
We aren’t exactly sure what is causing this December 2016 rise in overdoses, but we have seen spikes before. In 2013, multiple participants reported a strong cut, rumored to be fentanyl, causing a rise in overdoses. In June 2015 a strain of heroin laced with strychnine claimed several lives. A batch of “Mexican White” fentanyl arrived on the scene during the holiday season of 2015, resulting in 12 EMS calls for overdoses on Christmas Eve alone. Fentanyl-related deaths saw a dramatic rise in 2016 as well, with the Orleans Parish coroner reporting in March that 72% of that year’s fatal overdoses involved fentanyl. In July 2016 the coroner held a press conference to announce that fatal opiate overdoses had begun to far outpace murders in the city.
The struggle to provide overdose prevention in the wake of changing heroin supplies is taking a toll across the country as well as in New Orleans. As I am writing this article, I receive a text from a harm reduction coordinator in Philadelphia:
“we lost over 70 people in the last 2 wks. 3 new stamps that are mostly fentanyl and killing everyone. we keep doing prevention/reversal trainings but literally don’t have access to enuf narcan for this amount of ODs.”
Our national networks of communication and education help us keep our communities safe and aware, but we often struggle with limited supplies and limited support. While the legal environment for harm reduction work remains contested, there have been major strides in the past year. Most notably, the government announced in January that it would end its ban on federal funding of needle exchange programs. A 2014 Good Samaritan Law also protects those who call 911, including the caller and the victim of overdose, from criminal charges, excluding possession with intent to distribute. Ultimately though, the majority of harm reduction progress still relies on street-level support, enhancing access to safer use practices and supplies, reducing stigma in our communities, and ensuring the availability of naloxone.
While safe, effective, and easy-to-use, naloxone is still not available to the public in every state and there are many barriers to widespread access. Fortunately, some of these barriers are being dismantled. Act 370 of the 2016 Louisiana Legislature increases access to naloxone by allowing medical professionals to issue a “standing order” for the drug. This pre-written medication order authorizes pharmacies to sell naloxone to the public without a prescription and allows community groups to distribute it free-of-charge. This law also states naloxone is legal for anyone to have on hand.
Any Louisiana pharmacy that receives a standing order can sell naloxone. Big name pharmacies like CVS and Walgreens were issued company-wide standing orders; most store at least one kit on-site. If they do not store naloxone on-site, they can order it by request. Prices range from $5 with most Medicaid plans to $30 without insurance. In New Orleans, the following pharmacies stock naloxone:
2000 Canal St.
Marine Building (3308 Tulane Ave.)
Tulane Tower (2601 Tulane Ave.)
CRESCENT CITY PHARMACY
2240 Simon Bolivar Ave.
Drug users and their communities can also reach out to local harm reduction groups to access naloxone and overdose prevention training:
NO OVERDOSE BATON ROUGE
WHO’S AT THE FUNERAL, WHO’S AT THE FEAST?
In the past year, the declaration of an “opiate crisis” has also enabled the intensification of various harm-enhancing methods of repressing and endangering drug users. A nationwide mandate to cut opiate prescriptions, aimed at reducing the number of new individuals who abuse opiates, has had the unintended effect of forcing opiate-dependent individuals off of a stable, medical-grade supply. 2016 saw the high-profile shutdown of a number of local “pill mills” and the increased scrutiny of doctors who prescribe opiates. Consequently, doctors who should be treating and supporting drug users are wary to prescribe to patients with histories of drug use. Due to limited access to continued care and long waiting lists at substance abuse treatment facilities, many users have been forced to shift from medical-grade opiates to purchasing on the street.
Making matters worse, money earmarked for “addressing the opiate crisis” often ends up in the pockets of local police forces, prisons, and abstinence-based drug treatment methods which show limited effectiveness. There’s ample reason to be skeptical of increased police funding in particular. In early 2016, The Drug Enforcement Agency’s New Orleans Drug Task force was raided by FBI agents, who accused its agents of stealing money and drugs. Multiple officers, including the leader of the Drug Task Force, were arrested on charges ranging from robbery and witness tampering to possession with intent to distribute. In mid-December, FBI agents also raided the Tangipahoa Sheriff’s office and the Hammond police headquarters, searching for information related to officers stealing and then re-selling drugs such as oxycontin and cocaine.
Drug dealers have also fallen under increased scrutiny. In August, The DEA declared heroin and fentanyl combinations to be “the biggest drug threat” facing New Orleans, and have stepped up enforcement and arrests. In early December, eight men in Hollygrove were arrested in connection with fentanyl distribution allegedly linked to two overdose deaths. Two of these men face mandatory life in prison on charges of “distributing drugs resulting in death.” Furthermore, there are increasing calls to create harsher new laws which hold drug dealers responsible for deaths that occur as a result of their product, pushing for murder charges to be leveled against dealers.
Since the beginning of the push to punish and prosecute drug dealers and drug users, commonly referred to as the War on Drugs, heroin has become cheaper, more plentiful, and more pure than ever before.
WAGING WAR ON THE DRUG WAR
Despite rapidly changing drug supplies and increased repression, drug users and their communities can still take steps to reduce harm, promote safer use, and dismantle the stigma around drug use that drives dangerous practices.
Reverse Overdoses: Narcan can be found through local harm reduction groups or purchased over-the-counter in many Louisiana pharmacies. Training yourself and others to recognize and reverse fatal opiate overdoses provides a frontline defense against drug-related deaths. If you work at a bar or a restaurant, organize a staff training. Keep Narcan in your purse, backpack, and in your home.
Support Drug Users: Stigma, isolation, and shame fuel cycles of harmful use. Support drug users and talk openly with friends, co-workers, and family about addressing stigma and supporting each other. Tough love does not work: punitive approaches to reducing drug use are harmful and counterproductive. Make sure everyone you love can live in dignity and safety. Support, care, and validation are the first steps to creating healthy practices of use or abstinence. We are all in this together. You can provide safe spaces to use drugs, you can push for legislation that ends the War on Drugs, and you can protect drug users from harmful policing practices.
Use Safer Practices: If you are a drug user, take straightforward steps to protect you and your friends. Don’t use alone, and stagger your use patterns so that someone remains more sober while others shoot up. Take a “tester” shot of any new bag and make sure that you know its potency and effects. You can always use more, but you cannot use less. Keep Narcan around. Let other drug users know about new products, new packages, and new potencies. Check in on your friends to make sure they are using safer practices as well. Fentanyl, along with other drugs, has been sold in counterfeit pills across the country, so use these practices even when taking pills if you are not sure of their origin.
HARM: REDUCE, RESIST, REMEMBER
Ultimately, it falls on drug users, our communities, and our allies to navigate through changes and challenges like these. Governments, police forces, and even some public health and non-profit groups have consistently shown that they do not have our best interests at heart. We need to have control of our future. Drug users should be coordinating care, support, and growth in our communities. Whether it’s the violence of the drug cartels or the violence of the state, we have learned how to resist, how to grow, and how to remember who we have lost along the way. We have learned a refusal to die, a refusal to be pushed into the forgotten corners and onto the garbage heaps of history. If we have survived this far, we are much stronger than they thought.
This year will not be the last challenging year for drug users, and this current spike in overdoses will not be the last time users will have to weather danger or loss in order to survive and grow. What matters is whether we can make it through difficult times with stronger community, more accessible resources, better education, and the willingness to defend ourselves against systems that would rather see us die alone in the dark than live together in dignity and safety.