By Andrew Engelson

Tricia Howe, who directs an outreach program for drug users at REACH, Evergreen Treatment Services’ homeless outreach program, had firsthand experience of King County’s overdose crisis earlier this summer. In a matter of weeks, there were two overdoses outside REACH’s Belltown office.

“One of our case managers came into my office and said, “I think there’s somebody outside who doesn’t look like they’re breathing,” Howe said. “I grabbed a whole bunch of Narcan out of my drawer and ran outside.”

The man’s lips were blue, Howe said, and he wasn’t breathing, though he did have a pulse. She gave him a standard dose of naloxone nasal spray (Narcan), which can reverse the effect of opioids and restore a person’s breathing, but he failed to revive. So Howe gave him a second dose. “He took one deep breath, but was still not responsive,” she said. As Howe was preparing to administer a third dose, first responders arrived, put the man on oxygen, and he finally started breathing.

Based on the man’s response, fentanyl was almost certainly involved. The drug, which is up to 50 times more potent than heroin, can cause overdoses even among frequent opioid users. According to Howe, because fentanyl is cheaper to manufacture, it is quickly replacing heroin and oxycontin as the primary drug available to people who use opioids.

Data from the Washington State Patrol shows that the share of fentanyl in King County drug seizures has climbed dramatically, from around 10 instances in 2018 to more than 100 in 2021. Howe said that all of the counterfeit oxycodone (OxyContin) pills her staff have recently tested have been positive for fentanyl.

“It’s so available now and people are actually seeking it out at this point, where that was not the case before.” According to Howe, because fentanyl is cheaper to manufacture, it is quickly replacing heroin and oxy, and is making overdoses more common and more difficult to reverse. 

A 2017 study showed that 83 percent of fentanyl overdoses in Massachusetts required a second dose of naloxone. Howe notes that overdoses of heroin or oxy were easier to reverse than fentanyl. “In the past, you could definitely expect the person to wake up and almost walk away,” says Howe.

Seattle and King County are in the midst of a severe overdose death crisis that began to spike during the pandemic and shows no sign of abating. People without shelter are particularly at risk. A ten-year study published in September by the King County Medical Examiner’s Office and Public Health Seattle-King County found that that accidental deaths nearly quadrupled  between 2012 and 2021 among people living unsheltered, and that overdoses now account for 71 percent of such deaths. 

As of last week, according to King County Public Health, there had been at least 710 fatal overdoses in the county this year. Of those, at least 473 involved fentanyl. That number has already eclipsed last year’s 708 overdose deaths, including 385 caused by fentanyl.

“When we first started our heroin and opioid task force in 2015, there were three fentanyl overdose deaths,” said Brad Finegood, a strategic advisor at the public health department. “The numbers have grown exponentially.”

Drug users tried to avoid fentanyl when it first arrived on the West Coast, Finegood said, but that attitude has dramatically shifted, and now people are actively seeking out fentanyl. According to a Pew study published in 2019 on drug use in San Francisco, more than half of opioid drug users now actively seek it, despite the dangers. Complicating matters, fentanyl is either smoked or vaporized and then inhaled, so traditional initiation barriers have fallen away.

“For younger people who are experimenting with drugs,” Finegood said, “that makes it much more feasible because they don’t have to use a needle.” Public Health and REACH have had to counter the misinformed belief that fentanyl is safer because it’s smoked rather than injected.

According to the US Department of Justice, most fentanyl originates in China and is made into pills or powders by cartels based in Mexico. Batches of fentanyl that are poorly blended can result in what Finegood calls the “chocolate chip cookie effect,” in which pockets of higher concentrations cause accidental overdose.

A young man named Ian who was living in an encampment near the Home Depot in the Bitter Lake neighborhood said in August that he had no choice but to start using fentanyl. Originally from Wasilla, Alaska, Ian said he first became addicted to opioids while taking Oxycontin for pain. “Then oxy disappeared,” he said. In 2016, the CDC advised doctors to lower prescription levels of oxycodone and this, combined with the Drug Enforcement Agency’s recent crackdown on illegal and fraudulent prescriptions, has made medical-grade pills rare.

Ian said that in the absence of oxy, he did heroin for a while. “Then that disappeared. Now it’s all fetty.”

Half a dozen people at the encampment told me they use fentanyl and know many others who do. Nearly everyone had witnessed overdoses and several said they knew people who’d died.

“Everyone’s doing fetty,” said Jessie, who’s 26 and has been using drugs, including meth, since she was 11 years old. She didn’t live in the Bitter Lake camp, but was helping a friend pack up their belongings before the city came to sweep the site. “I’ve been sober, but it didn’t last,” she said. When asked if she’d seen friends overdose, Jessie said, “Yeah, of course.”

The transformation of fentanyl from risky outlier to the opioid of choice in King County mirrors national trends. In 2021, fentanyl accounted for the majority of overdose deaths in the U.S, though methamphetamine continues to be a close second, both nationally and locally. 

Although Seattle, King County, and the cities of Renton and Auburn formed an opiate overdose task force in 2015, local leaders have shelved a key recommendation from the task force’s report: establishing two supervised consumption sites in King County. 

Seattle could have been home to the first such sanctioned site in the U.S., following the lead of Vancouver, B.C. and 200 other sites currently operating elsewhere in Canada, Europe and Australia.

Though former mayor Ed Murray expressed early support for what would have been the first such sanctioned site in the US, Jenny Durkan’s administration showed little enthusiasm for supervised consumption. Durkan downgraded the plan in 2019 to a single site in a mobile van, citing concerns about the Trump administration’s legal action against a proposed consumption site in Philadelphia. 

Even as the Biden administration changed course and said it would consider allowing sites, neither Durkan nor Mayor Bruce Harrell followed through on the scaled-back plan. Earlier this year, New York City moved past Seattle and opened two safe consumption sites that have already succeeded in preventing 500 deaths.

Kris Nyrop, who spent two decades working on HIV prevention among drug users in Seattle and helped design Seattle’s Law Enforcement Assisted Diversion (LEAD) program, says the window for action in King County is quickly closing.

“We have two years,” Nyrop said. “Biden is not going to prosecute if Seattle moves forward. So how do we get Mayor Harrell and a majority of the council behind this?”

In fact, Councilmember Lisa Herbold added $1.1 million to the 2021 Human Services Department budget to create safe consumption spaces in existing social services facilities. The city did not move forward on that approach and Harrell’s proposed 2023-2024 budget does not fund it. 

Instead, Mayor Harrell has vowed to crack down on people who sell and use drugs, in a highly publicized effort to target “hot spots” such as the intersection of 12th and Jackson in Little Saigon. Anyone walking through the area today can see that this short-term strategy was ineffective at reducing public drug use and sales in the area.

Howe said that the only effective way to reduce visible drug use on the street isn’t more policing, but sanctioned consumption sites. “It’s a no-brainer. … If you don’t want people to use right in front of you and you don’t want needles all over your parks, then you’ve got to give people a place where they can go.”

In the absence of sanctioned sites, Public Health has been quietly moving forward on other, lower-profile strategies aimed at empowering drug users to consume drugs as safely as possible. 

In addition to social media campaigns to educate young people about the extremely high risks of fentanyl pills (“blues”), Finegood says Public Health is doing more targeted educational outreach to users about safer consumption practices. 

This includes training drug users to recognize the symptoms of overdose, encouraging people not to use alone, and making the overdose reversal medication naloxone widely available. Finegood said Public Health has set up the first mail-order naloxone program in the country, and is working extensively with local pharmacies to offer the drug free, without a doctor’s prescription. “We’ve also set up a couple naloxone and fentanyl tester vending machines,” Finegood said.

Such programs require subsidies from Public Health—especially since the pharma company Pfizer recently hiked the prices of Narcan kits from $2.50 to $75 per dose.

In addition to Public Health’s efforts, the Seattle Public Library reversed a ban on employees administering naloxone late last month. The library will stock one two-dose kit of the medication each of its 26 branches and provide voluntary training to staff who want to learn how to stop an overdose—not a wholesale embrace of overdose reversal, but a start.

Public Health is also significantly increasing distribution of fentanyl test strips. These inexpensive kits allow drug users to dissolve a small portion of a pill or powder in water and detect whether fentanyl is present. Finegood says strips are a “fairly imperfect tool,” because they can’t detect how much fentanyl is present. But they can help users of other drugs such as methamphetamine or cocaine know if their supply is contaminated with fentanyl. 

Finegood notes that connecting with opioid drug users has become increasingly difficult during the shift from heroin to fentanyl. Needle exchanges, run by user-led organizations such as the People’s Harm Reduction Alliance, have for decades provided free, clean syringes to help stop the spread of HIV. These sites in turn also provide critical social services, counseling and help for those ready to seek treatment. Because fentanyl users don’t typically need needles, they’re less likely to be in contact with case managers and volunteers who can assist them.

“We don’t know who a lot of these people are because they’re not touching a lot of our social service network and systems,” said Finegood. “So that means we have to do better.”

Howe said that REACH’s mission is to make exactly that sort of street-based connection between drug users and social workers. Her organization is also having extensive conversations with users to learn what their experience is and identify barriers to seeking medically-assisted treatment (MAT), such as buprenorphine and methadone. 

“I see all these surveys of people saying: Yes, I want treatment,” Howe said. “But none of them are accessing treatment. What can we do to fix that?”

Taking MAT to where people are—especially those without housing—is one option REACH is exploring. They’re also moving away from traditional office-based models. “If you have to make an appointment at a specific time, that’s hard for folks who don’t have alarm clocks,” she noted.

Paul Grekin, the medical director of Evergreen Treatment Services, said transportation to treatment sites is a persistent problem in itself. “When we saw this, especially, was early in the pandemic,” he said, “when public transportation was severely curtailed.” To meet the increased need for treatment among the homeless population, Grekin said, REACH is working on a program that sends a case manager and medical provider into RV encampments to get drug users started on a treatment regimen.

Methadone-based treatment, which is subject to federal rules designed for people weaning themselves off less potent opioids, can be a bad fit for fentanyl users. People using fentanyl have a much higher tolerance, Grekin said. “When we start people on methadone, by law we can only start them at 30 milligrams. Traditionally a therapeutic dose [for fentanyl] has been in the range of 80 to 120 milligrams.”

Grekin said it’s quite common for fentanyl drug users to drop out of treatment after the first day. “People come in and get their first 30 milligrams, and they barely feel it,” he said. “It’s not taking care of their problem and its consequences. More so than in the past, people are choosing not to return to treatment because they think the medication is not going to work for them.”

Only a small percentage of Evergreen Treatment’s clients are treated with buprenorphine. Grekin says skepticism about buprenorphine precedes the fentanyl crisis, and likely is the result of people trying it unsupervised and having severe withdrawal symptoms. He also said that in his experience buprenorphine seems to be less effective than methadone at treating fentanyl addiction, especially in the first days of treatment.  

Several people at the Bitter Lake encampment, which was home to about 20 people and was swept the day after I visited, said they wouldn’t accept an offer of shelter from the city because they believed they needed to be sober. “Where are we supposed to go?” a young man named Chase asked. “If we’ve gotta be clean, that’s not going to happen.” In fact, there are a small number of no-barrier housing and shelter options, and most shelters will accept drug users as long as they don’t use on site, but the perception is pervasive. 

Grekin also said that state requirements present barriers to drug treatment. Washington State Department of Health guidelines require people who are entering methadone or buprenorphine treatment to undergo an assessment that can take hours. “For patients who are in distress and who have a lot of immediate, pressing issues, sitting down with somebody to answer an immense number of questions over a 90-to-120 minute period is a really onerous burden,” Grekin said.

A spokesperson for King County Executive Dow Constantine’s office said the executive had no updates on the delayed status of supervised consumption sites. Jamie Housen, a spokesman for Mayor Bruce Harrell’s office, said we should direct our questions to Public Health. 

“The mayor and staff will continue to work and coordinate with Public Health-Seattle and King County, along with our Human Services Department, on future evidence-based initiatives to respond to the opioid epidemic,” Housen said.

The evidence clearly points to consumption sites and harm reduction, rather than increased law enforcement, as the most effective, life-saving response. And some advocates for harm reduction, including drug users themselves, aren’t waiting for government-sanctioned sites, but instead creating safe spaces themselves.

Vancouver’s InSite supervised consumption site began as an underground effort led by drug users, and there are reportedly multiple unsanctioned sites operating in the Seattle area.  

Barrot Lambdin, an affiliate associate professor at the University of Washington’s Department of Global Health, is the co-author of a study published in the New England Journal of Medicine in 2020 that evaluated the impacts of an unsanctioned safe consumption site at an undisclosed US city..

For five years, Lambdin and his colleagues were granted access to an underground overdose prevention site that opened in 2014. More than 10,000 injections occurred at the site. A total of 33 overdoses occurred in that period, and none were fatal.

In addition, reports of crime near the facility—including assault, burglary, theft, and robbery—all declined after it opened, Lambdin said. “We also saw decreases in use of emergency services. People who used the site were less likely to end up in the emergency department and were less likely to be hospitalized.”

People living in the Bitter Lake encampment expressed concern that police would arrive and make arrests if they called 911 because of an overdose. Although the state has had a “good Samaritan” law on the books since 2010, it doesn’t prevent police from making an arrest if someone has an existing warrant. 

Howe says she advises people who use drugs and call 911 not to describe the situation as an overdose. “When you call, just say there’s a person not breathing,” she said.

Jessie, the drug user who was helping a friend pack their things at the Bitter Lake camp, said she was once arrested after calling 911 in order to get help for a friend who’d overdosed on fentanyl. “I mean, yeah—that sucked,” she said. “But I’m glad I saved their life.”