Local designer Luis Romero, second from right, started making shirts “four or five years ago when three of my friends died, all within a month of each other.”

“Fuck Fentanyl” — a slogan you may have seen on a T-shirt or hoodie around San Diego of late. Or perhaps you’ve spotted it on social media: local designer Luis Romero posts shots of his work adorning a broad range of bodies on Instagram (@fuckfentanylsandiego) and elsewhere. Most of the shots are of individuals modeling the merch, but some are of groups, all sporting the slogan, standing in solidarity. This isn’t the lone bleat of “Speed Kills” that got sprayed onto walls back in the ‘60s. This is an in-your-face, communal, street-level response to an escalating epidemic.

Romero started making the shirts “four or five years ago when three of my friends died, all within a month of each other.” And of course, Romero is not alone — especially here in San Diego. According to a United States Department of Justice report dated August 12, 2022, Fentanyl seizures in San Diego land ports and cities accounted for approximately 5000 pounds of the drug between October 2021 and June 2022 — over half of the national total in the same time period. The frequency and quantity of these apprehensions prompted the Department of Justice to identify America’s Finest City as a “trafficking epicenter.”

Illustration by Audrey Isaacson

Keeping two and a half tons of fentanyl from reaching the streets is an accomplishment, but it isn’t even close to a solution. “We’re having record numbers of seizures, but we have more coming in,” says Dr. Roneet Lev, who works in the emergency room at Scripps Hospital, and is also the former Chief Medical Officer of the White House Office of National Drug Control Policy and former chair of the San Diego Prescription Drug Abuse Medical Task Force. She tells me that the medical examiner reports an average of 2.5 deaths per day in San Diego from fentanyl overdoses.

Fentanyl is not a new drug; the opioid, up to 100 times more powerful than morphine, was created in 1959 for use in surgical procedures. The abuse of fentanyl is also not new; there is historically a high rate of occurrence among those who have easy access to it: people in the medical profession. Peter Tharp is an RN who used the liquid form of fentanyl until NCIS investigated him and he got clean. He tells me, “Dilaudid was kind of the sweet spot. And when I couldn’t get my hands on the Dilaudid, I needed to stay well, so I got the fentanyl. Injectable was pretty much the only type I could steal. A patch is harder to steal, because if I pull it out of the machine, I’ve got to give it to the patient. You can’t cut the patch in half and take half the patch. Whereas with the [liquid] fentanyl, very rarely is the patient going to necessitate that whole vial. The rest is supposed to be documented and wasted. I got wasted instead.”

Courtney Roebuck, a Substance Use Disorder Counselor at Action East, is a former opiate/opioid user who was active in her addiction when the heroin supply started being spiked with fentanyl. “I remember calling someone and saying, ‘This seems a little light.’” Here, she’s referring to the color; heroin is typically brown. “I’d call someone, and they would tell me just do way less than what I was doing, and I would and I never felt it was enough.” It’s even been linked to overdoses before: in the DOJ report that named San Diego an epicenter, U.S. Attorney Randy Grossman stated, “A decade ago, we didn’t even know about fentanyl, and now it’s a national crisis.”

But that isn’t quite true: the fentanyl analog alpha-methylfentanyl — known as China White — started killing heroin users in the late ’70s. Eventually, enough analogs were being produced that the government implemented the Federal Analog Act in an effort to control them all together instead of going after each one individually. The difference now is in who’s dying, and how many. (During the interviews that informed this article, I heard several variations of, “We’ve been dying for fucking years, and now you give a shit because it affects the ‘good’ people?”)

Courtney Roebuck, a Substance Use Disorder Counselor at Action East, is a former opiate/opioid user who was active in her addiction when the heroin supply started being spiked with fentanyl.

How did we get here? Sadly enough, it may have started with good intentions. As Dr. Reuben Farris, president of the Scripps Physicians’ Group, explains, “Twenty-five years ago there, was this big move in medicine to be sensitive to pain. ‘Pain is the fifth vital sign.’ ‘You need to be more in tune with people’s pain.’ ‘Don’t be afraid to treat them with pain medicines.’ In California, we had to get 25 hours of continuing education in recognizing and treating pain. Then the OxyContin people marketed to us and fed us this whole lot of research that was not accurate about short-acting and long-acting, all on the coattails of ‘You gotta treat pain.’”

But then people started dying from opioid overdoses. It wasn’t like heroin in the 19th century, which was considered a wonder drug until doctors started noticing its negative effects on their patients and stopped prescribing it. Now, you had the drugmakers assuring the Food and Drug Administration that their product was safe, and the FDA absolutely fumbling the regulatory ball, until the problem became too big to ignore. At that point, according to Dr. Farris, “We swung from ‘You’re asshole doctors because you’re not treating pain’ to ‘You’re heartless doctors who are killing people.’”

He found himself in a difficult position. “At this point in my life, I’m doing primary care medicine and dealing with a lot of chronic pain patients. And a lot of the primary care physicians are kind of hung out in no-man’s-land…There are pain management doctors, but most of those are guys that do injections and procedures for controlling pain, which are very lucrative, and they want to do things that they don’t have to spend a lot of time and energy on, and go to the high income procedures. In my case, I see patients that have been on this stable dose of hydrocodone for 15 years, and at the same time, I feel the government looking over my shoulder and saying, ‘You’re prescribing narcotics to these people? You’re a bad doctor.’ Give me an alternative! Give them an alternative!”

As the crisis entered the public consciousness, painkiller prescriptions became harder to come by, and drug dealers exploited the situation by making heroin — a once-taboo drug — both easier to get and, eventually, cheaper. Cheaper because it started getting stretched with fentanyl. Opiates such as morphine and heroin are derived from the natural source of certain poppy plants. Opioids, on the other hand, are made in a laboratory. The profit margin is huge: as of 2017, fentanyl could be created for two-thirds of the price for manufacturing the same amount of heroin, and sold for twice as much in its pure form. (The profit rises even further when a tiny quantity of it is made into pill form and sold on the black market, or put in other drugs to stretch the supply.) And the systematic addition of fentanyl has led us to the present day, in which heroin is scarce and opioid addicts are knowingly using straight fentanyl.

Klea Melville of community advocacy group Doll Face Club has used profits from her clothing line and fundraisers to finance a documentary on fentanyl titled Nobody Plans On Dying which she hopes to get into schools.

It may seem strange that anyone would want to deal in such a deadly product, one that can prove lethal on its first use, and in minute quantities. Why kill your customers? But paradoxically, when it comes to opioids, overdoses are the ultimate advertisement. They indicate a potent batch — “the good shit.” The increase in sales that comes from the bump in reputation more than replaces the non-returning customers. Fentanyl helps even when it’s not an advertised ingredient. Pandemic lockdowns fed the demand for drugs, especially among high school students who wanted to experiment. And many of them wound up purchasing counterfeit prescription painkillers from social media contacts, counterfeit painkillers that contained fentanyl. Further, fent-laced meth goes further and is more addictive than the straight stuff, turning good meth customers into great ones. Until they die, anyway.

I have been clean for 36 years; when I was using, my drug of choice was methamphetamine. At first, the thought of fent-laced meth, downer mixed with upper, seemed almost offensive: during my using days, selling me meth that made me fall asleep would have resulted in an ass beating when I woke up. But it was explained to me by other former users that the initial physiological response to the combination was a typical amphetamine high, followed by a “nodding out” as the fentanyl took over. Some users found that they enjoyed the combination — it was akin to the effect of the cocaine-and-morphine speedballs that killed comedian Chris Farley, among others. And some users, unaware there was fentanyl present, simply felt an unexplainable craving to repeat the drug use. They became physically addicted.

A word about addiction: I identify as an addict because of my modality of recovery. Even after decades without drugs, I still see my obsessions latch onto things that can be damaging, damaging because they throw me out of balance. Some people say my condition is genetic, that I have a predisposition, and my alcoholic father and my mother who died from cirrhosis because of pills probably lend credence to that claim. All I know is that when I think a cold beer looks good on a hot day, I play the tape through and realize that I will eventually need meth to keep drinking longer, and acid for day four of being up because the hallucinations have already started, and it will enhance the trip.

My detox from methamphetamine was unpleasant, and was characterized by never feeling rested enough, a massive appetite that resulted in vomiting and diarrhea, plus paranoia and depression. But as horrible as it was, my hair never hurt, and my muscles didn’t contract me into a fetal position — common symptoms for opiate/opioid users when they don’t get their fix. I didn’t get sick from not having meth, because I wasn’t physically addicted. Opiates and opioids cause a dependence, an addiction in the medical sense, such that even people with no predispositions to substance abuse find themselves in serious physical need.

And people respond to serious physical need. Counselor Roebuck wonders how she is supposed to help her clients when she has lost family members who proved beyond her reach. Dr. Lev relates a story about a man who overdosed nine times. Committed, she stayed late and pulled some strings to get the patient into treatment. He left anyway.

Suppliers respond to need as well. Marc Stevenson, a social worker and therapist, has worked in social services for over 20 years. For the last 17, he has been focused on San Diego’s homeless population at Father Joe’s Village. He’s been in recovery for three decades. “I feel like where they’re at, they are definitely a target,” he told me. “They have general relief money, they have social security money, disability, that type of thing. You can believe that market is getting tapped into. The goal of working with the homeless, of course, is to get them into permanent housing. But permanent housing has become an awesome way for drug dealers to know exactly where everybody is. They’re wiggling their way in, giving somebody some drugs so that they let them into their apartment, so they have a base station. Sometimes they’ll take over the apartment, maybe to the point of threatening them if they try to do anything about it. They’re in these buildings now, and able to sell when people get their checks.”

Marc Stevenson, a social worker and therapist, acknowledges that building a culture that helps people to avoid using and remove suppliers will not be an easy task.

Stevenson acknowledges that building a culture that helps people to avoid using and remove suppliers will not be an easy task. For now, “A lot of these places have the tenants come down and sign guests in and sign them out at night. These are people that have a lease, just like any other human being. A lot of it ends up being put back on the tenants, which is a shame. I don’t have a solution to that.”

What’s to be done? There are tools available to reduce exposure and, such as test strips to detect fentanyl in other drugs. These are accessible through Harm Reduction Coalition On Point (hrcsd.org) and The Safe Point through Family Health Centers of San Diego. But the Center for Disease Control’s instructions — to throw the drugs away if fentanyl is detected — were met with laughter from the over 100 addicts I’ve talked to about them.

Consider: an addict goes through a process to obtain drugs, a process that can include anything from the simple risk of getting arrested to exchanging sex for dope. Then the addict tests their drugs and finds an undisclosed amount of fentanyl. The addict is an addict — quite possibly physically sick from withdrawal, or maddened by the fear of it, and is supposed to toss their drugs in the garbage? The laughter is more understandable now. Besides, in my experience, scare tactics have never worked with either addicts or young people. Addicts know that death and depravity are part of using, and many of us would rather be dead before we get clean, anyway. Young people, meanwhile, have always thought they were invincible, and it is in their job description to be rebellious and say “fuck authority.”

Another tool is Naloxone, sold under the brand name Narcan, which reverses the effect of opioid overdose. Naloxone is considered a form of “harm reduction,” and is available for free at County Public Health sites and through other modes of community distribution. (There has been a movement to install vending machines around the county, but the only one I was able to easily locate was at the Live and Let Live Alano Club, which is now closed due to lack of funding.) I walked into the El Cajon office and walked out in under ten minutes with two doses and instructions, no questions asked. But Nurse Tharp loses his usual laid back and logical demeanor when I ask if “harm reduction” is the right term for the stuff. “What could be more harm reduction than saving someone’s life?” he spits. “If we are going to take that stance, let’s remove all the AEDs” — automatic external defibrillators, used to treat sudden cardiac arrest. “I didn’t tell you to eat that cheeseburger, right?”

Still, I get what they’re getting at with the term. Part of harm reduction involves using in pairs, with one person ready to administer Narcan at signs of overdose. However, addicts that have “been Narcaned” by a friend or using partner often report taking only a brief break (days or hours) before resuming using, instead of following instructions to seek medical attention post-overdose. And while Narcan is without a doubt an indispensable lifesaver, it will not reverse the long-term effects of an overdose, which can include permanent brain damage. Narcan can give a false sense of security — it may take multiple doses to be effective. It’s an is emergency intervention, not long-term harm reduction.

For his part, Stevenson says there needs to be a change in what we mean by the term. “I’m a firm believer that harm reduction is not cleaning a needle,” he explains. “It’s a way you’re with someone, teaching them all the things that are important to us in recovery even while they are still using. It’s got to be a process; it’s got to be a technique, and people have got to be really good at being able to deliver it. It should be a language. We’ve got to have some kind of new way of life, even if they’re still using. Otherwise, it’s just the same thing.”

Historically, addicts seek treatment after “hitting bottom,” the point at which bad things happen more quickly than we can lower our standards to make them acceptable. Interventions by family and professionals can help hasten the move to treatment, or at least give an addict reason to pause in their using. Courts have aided the process by ordering treatment of some sort when drug offenses are filed. But because it can be lethal after just one use, fentanyl doesn’t always allow for a bottom, and addicts who manage to stay alive long enough to want to kick fentanyl are not always offered inpatient detox. Instead, they told me, they are given Suboxone, a drug replacement that eases withdrawal symptoms, and are instructed not to take it for 24-48 hours after their last use. Then they are sent back to wherever they came from — with no support — and become even more vulnerable to the predatory dealers who can offer them relief.

“We’re having record numbers of seizures, but we have more coming in,” says Dr. Roneet Lev, who works in the emergency room at Scripps Hospital.

Photograph by Matthew Suárez

After I got clean in 1986, I helped others do “home detoxes” for opiate addicts; our tools were a couch to sleep on, a bucket to puke and (if necessary) shit in, and a mop to clean up your mess, because personal responsibility starts now. We worked in shifts of at least two, and I am still haunted by the sight of those withdrawals. Fear or lack of money kept people from going to professionals, and even if they did go, those professionals would often just give methadone, extending the addicts’ detox. We were desperate, and we were misinformed: we’d been told that opiate/opioid withdrawals wouldn’t kill you; they’d just make you feel like you were dying. But basic science says that when an emaciated person experiences vomiting and diarrhea — which is a guarantee — potassium and sodium balance can be thrown off, and the chances of a heart attack increase. Professionally supervised detox is vital to the addict’s chances for survival and success. But that takes money, and it’s hard to see where the money will come from. When it comes to fentanyl, it seems that whenever I try to follow the money — whether toward those who push it or those who push back — I find the stench of failure and death.

After over 30 years clean, I still get emotionally affected when someone dies. I will never get used to seeing a selfie taken by someone I know show up a few days later on social media alongside a message that they are dead. I know that if I don’t use, I won’t overdose, so it can be easy to parrot the “Don’t get high, you won’t die” rhetoric. But I remember how fucking hard it was to get that first day clean. To this day, the threat of death doesn’t deter me; it’s the fear of living like I was. The recovery community is a tight knit one; we know each other either by personal interaction or by minimal degrees of separation, and we all have the same basic story. People I love are still using and at risk, and it’s brutal to learn that someone I watched struggle to get clean — then saw build a life and replace a scowl with a smile that only a cell level gratitude can bring — used one last time, and will never have the chance to smile again.

Peter Tharp is an RN who used the liquid form of fentanyl until NCIS investigated him and he got clean.

Photograph by Matthew Suárez

It’s natural to be sad, angry and frustrated. But cynical? Nah, that’s for poseurs who are too lazy to do anything because they have decided nothing changes, anyway. It’s not “hardcore.” It’s cowardice. I remember a nurse who trained me to provide services to people with developmental disabilities, responding to my list of problems and barriers I had encountered. She asked a simple question: “So, do we stop trying?” My answer came out of my mouth with no conscious thought: “Fuck no, we fight.” My answer has remained the same for years.

Narcan signs at East Region Public Health Center on Magnolia in El Cajon.

Photograph by Spike Steffenhagen

I’ll tell you what we don’t need: misinformation and panic. The dangers are real enough; there is no need to exaggerate them. In August of 2021, the San Diego Sheriff’s Department uploaded a video to YouTube showing a trainee supposedly succumbing to fentanyl simply by breathing in proximity to the drug. The video received over 80,000 views and remains up, despite a study by Cambridge University Press which actually placed fentanyl on a subject’s hand in a controlled setting and recorded no reaction and no fentanyl in the subject’s bloodstream. As Savannah O’Neil of the National Harm Reduction Coalition writes: “We have been here before: In the late 1980s, doctors refused to treat HIV patients out of fear of contracting the disease, even once they knew contagion via casual contact was impossible.” The potential ramifications are sobering: imagine a first responder pausing out of fear before treating an overdose victim, with lethal results coming from that delay in treatment. Other rumors abound: fent-laced weed, fentanyl being marketed to children. But drug dealers are businessmen; clean weed is legal, and kids make lousy customers.

More productive responses: Klea Melville of the community advocacy group Doll Face Club has used profits from her clothing line and fundraisers to finance a documentary on fentanyl titled Nobody Plans On Dying which she hopes to get into schools. “We’ve got to reach the kids and let them know that you can be cool and have fun without doing drugs” she says. “I never responded to D.A.R.E. because they were cops, and in my neighborhood, we didn’t talk to cops.” Whether the documentary gets shown in schools or not, on October 11, 2022, the San Diego County Board of Supervisors unanimously mandated fentanyl education and Narcan in schools. And the San Diego Sheriff’s Department followed a recommendation by the Citizen’s Law Enforcement Review Board to make naloxone readily available in jails, following multiple overdoses.

Bre Owens is a case manager who often works with co-occurring disorders.

Romero’s “Fuck Fentanyl” clothing starts conversations and raises awareness. He also uses profits from his promotions as donations to fentanyl awareness causes. Dr. Lev interfaces with agencies such as the DEA and does what she refers to as “mythbusting” by providing accurate information based on evidence. In addition, she wrote a law: SB864, which will require all hospitals in California to require fentanyl testing beginning in January 2023 as a result of studies that began in San Diego. She also hosts a podcast called “High Truths” to disseminate information. Nurse Tharp continues to share his story of chemical abuse with his fellow nurses, urging the component he feels is missing from nursing schools; self-care to decrease the urge to self-medicate due to burnout associated with the job. And then there are the people whose path is being formed as we speak, people like Bre Owens, a case manager who often works with co-occurring disorders. She is looking to do her own work — “trauma coaching outside of this broke ass system.” She also uses social media to spread her message: she has a TikTok channel titled “Spiritually Shitty” that is evolving into a podcast.

So, there is hope. We can fight this battle by communicating honestly and uniting for a common good. And most of all, by following through on the plans we have made to help others before it’s too late.