SAN FRANCISCO — In early 2019, Tom Wolf posted a thank-you on Twitter to the cop who had arrested him the previous spring, when he was homeless and strung out in a doorway with 103 tiny bindles of heroin and cocaine in a plastic baggie at his feet.
“You saved my life,” wrote Wolf, who had finally gotten clean after that bust and 90 days in jail, ending six months of sleeping on scraps of cardboard on the sidewalk.
Today, he joins a growing chorus of people, including the mayor, calling for the city to crack down on an increasingly deadly drug trade. But there is little agreement on how that should be done. Those who demand more arrests and stiffer penalties for dealers face powerful opposition in a city with little appetite for locking people up for drugs, especially as the Black Lives Matter and Defund the Police movements push to drastically limit the power of law enforcement to deal with social problems.
Drug overdoses killed 621 people in the first 11 months of 2020, up from 441 in all of 2019 and 259 in 2018. San Francisco is on track to lose an average of nearly two people a day to drugs in 2020, compared with the 178 who had died by Dec. 20 of the coronavirus.
As in other parts of the country, most of the overdoses have been linked to fentanyl, the powerful synthetic opioid that laid waste to the eastern United States starting in 2013 but didn’t arrive in the Bay Area until about five years later. Just as the city’s drug scene was awash with the lethal new product — which is 50 times stronger than heroin and sells on the street for around $20 for a baggie weighing less than half a gram — the coronavirus pandemic hit, absorbing the attention and resources of health officials and isolating drug users, making them more likely to overdose.
The pandemic is contributing to rising overdose deaths nationwide, according to the Centers for Disease Control and Prevention, which reported last month that a record 81,000 Americans died of an overdose in the 12 months ending in May.
“This is moving very quickly in a horrific direction, and the solutions aren’t matching it,” said Supervisor Matt Haney, who represents the Tenderloin and South of Market neighborhoods, where nearly 40% of the deaths have occurred. Haney, who has hammered City Hall for what he sees as its indifference to a life-or-death crisis, is calling for a more coordinated response.
“It should be a harm reduction response, it should be a treatment response — and yes, there needs to be a law enforcement aspect of it too,” he said.
Tensions within the city’s leadership came to a head in September, when Mayor London Breed supported an effort by City Attorney Dennis Herrera to clean up the Tenderloin by legally blocking 28 known drug dealers from entering the neighborhood.
But District Attorney Chesa Boudin, a progressive elected in 2019 on a platform of police accountability and racial justice, sided with activists opposing the move. He called it a “recycled, punishment-focused” approach that would accomplish nothing.
People have died on the Tenderloin’s needle-strewn sidewalks and alone in hotel rooms where they were housed by the city to protect them from covid-19. Older Black men living alone in residential hotels are dying at particularly high rates; Blacks make up around 5% of the city’s population but account for a quarter of the 2020 overdoses. Last February, a man was found hunched over, ice-cold, in the front pew at St. Boniface Roman Catholic Church.
The only reason drug deaths aren’t in the thousands, say health officials, is the outreach that has become the mainstay of the city’s drug policy. From January to October, 2,975 deaths were prevented by naloxone, an overdose reversal drug that’s usually sprayed up the nose, according to the DOPE Project, a city-funded program that trains outreach workers, drug users, the users’ family members and others.
“If we didn’t have Narcan,” said program manager Kristen Marshall, referring to the common naloxone brand name, “there would be no room at our morgue.”
The city is also hoping that this year state lawmakers will approve safe consumption sites, where people can do drugs in a supervised setting. Other initiatives, like a 24-hour meth sobering center and an overhaul of the city’s behavioral health system, have been put on hold because of pandemic-strained resources.
Efforts like the DOPE Project, the country’s largest distributor of naloxone, reflect a seismic shift over the past few years in the way cities confront drug abuse. As more people have come to see addiction as a disease rather than a crime, there is little appetite for locking up low-level dealers, let alone drug users — policies left over from the “war on drugs” that began in 1971 under President Richard Nixon and disproportionately punished Black Americans.
In practice, San Francisco police don’t arrest people for taking drugs, certainly not in the Tenderloin. On a sunny afternoon in early December, a red-haired young woman in a beret crouched on a Hyde Street sidewalk with her eyes closed, clutching a piece of foil and a straw. A few blocks away, a man sat on the curb injecting a needle into a thigh covered with scabs and scars, while two uniformed police officers sat in a squad car across the street.
Last spring, after the pandemic prompted a citywide shutdown, police stopped arresting dealers to avoid contacts that might spread the coronavirus. Within weeks, the sidewalks of the Tenderloin were lined with transients in tents. The streets became such a narcotics free-for-all that many of the working-class and immigrant families living there felt afraid to leave their homes, according to a federal lawsuit filed by business owners and residents. It accuses City Hall of treating less wealthy ZIP codes as “containment zones” for the city’s ills.
The suit was settled a few weeks later after officials moved most of the tents to designated “safe sleeping sites.” But for many, the deterioration of the Tenderloin, juxtaposed with the gleaming headquarters of companies like Twitter and Uber just blocks away, symbolizes San Francisco’s starkest contradictions.
The Federal Initiative for the Tenderloin was one such effort, announced in 2019. It aims to “reclaim a neighborhood that is being smothered by lawlessness,” U.S. Attorney David Anderson said at a recent virtual news conference held to announce a major operation in which the feds arrested seven people and seized 10 pounds of fentanyl.
Law enforcement agencies have blamed the continued availability of cheap, potent drugs on lax prosecutions. Boudin, however, said his office files charges in 80% of felony drug cases, but most involve low-level dealers whom cartels can easily replace in a matter of hours.
He pointed to a 2019 federal sting that culminated in the arrest of 32 dealers — mostly Hondurans who were later deported — after a two-year undercover operation involving 15 agencies.
“You go walk through the Tenderloin today and tell me if it made a difference,” said Boudin.
His position reflects a growing “progressive prosecutor” movement that questions whether decades-old policies that focus on putting people behind bars are effective or just. In May, the killing of George Floyd by the Minneapolis police energized a nationwide police reform campaign. Cities around the country, including San Francisco, have promised to redirect millions of dollars from law enforcement to social programs.
“If our city leadership says in one breath that they want to defund the police and are for racial and economic justice and in the next talk about arresting drug dealers, they’re hypocrites and they’re wrong,” said Marshall, the leader of the DOPE Project.
But Wolf, 50, believes a concerted crackdown on dealers would send a message to the drug networks that San Francisco is no longer an open-air illegal drug market.
Like hundreds of thousands of other Americans who’ve succumbed to opiate misuse, he began with a prescription for the painkiller oxycodone, in his case following foot surgery in 2015. When the pills ran out, he made his way from his tidy home in Daly City, just south of San Francisco, to the Tenderloin, where dealers in hoodies and backpacks loiter three or four deep on some blocks.
When he could no longer afford pills, Wolf switched to heroin, which he learned how to inject on YouTube. He soon lost his job as a caseworker for the city and his wife threw him out, so he became homeless, holding large quantities of drugs for Central American dealers, who sometimes showed him photos of the lavish houses they were having built for their families back home.
Looking back, he wishes it hadn’t taken six arrests and three months behind bars before someone finally pushed him toward treatment.
“In San Francisco, it seems like we’ve moved away from trying to urge people into treatment and instead are just trying to keep people alive,” he said. “And that’s not really working out that great.”
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Purdue Pharma pleaded guilty to criminal charges over the handling of its addictive prescription painkiller OxyContin, capping a deal with federal prosecutors to resolve an investigation into the drugmaker’s role in the US opioid crisis.
During a court hearing conducted remotely on Tuesday before US district judge Madeline Cox Arleo in New Jersey, Purdue pleaded guilty to three felonies covering widespread misconduct.
But in January, Angevine’s pharmacy on Long Island ran out of oxymorphone and he couldn’t find it at other drugstores. He fell into withdrawal and had to be hospitalized.
“You just keep thinking: Am I going to get sick? Am I going to get sick?” Angevine said in a phone interview. “Am I going to be able to live off the pills I have? Am I going to be able to get them on time?”
His pharmacy did not tell him the reason for the shortage. But Angevine isn’t the only pain patient in New York to lose access to vital medicine since July 2019, when the state implemented an excise tax on many opioids.
The tax was touted as a way to punish major drugmakers for their role in the opioid epidemic and generate funding for treatment programs. But to avoid paying, scores of manufacturers and wholesalers stopped selling opioids in New York. Instead of the anticipated $100 million, the tax brought in less than $30 million in revenue, two lawmakers said in interviews. None of it was earmarked for substance abuse programs, they said.
The state’s Department of Health, which has twice this year delayed an expected report on the impact of the tax, did not respond to questions for this story.
The tax follows strong efforts by federal and New York officials to tamp down the use of prescription opioids, which had already cut back some supply. Now, with some medications scarce or no longer available, pain patients have been left reeling. And the law appears to have missed its target: Instead of taking a toll on manufacturers, the greater burden appears to have fallen on pharmacies that can no longer afford or access the painkillers.
Among them is Epic Pharma. Independent Pharmacy Cooperative, a wholesaler, confirmed it no longer sells medications subject to the tax, but still sells those that are exempt, which are treatments for opioid addiction methadone and buprenorphine and also morphine. AvKARE and Lupin Pharmaceuticals said they do not ship opioids to New York anymore. Amneal Pharmaceuticals, which manufactures Angevine’s oxymorphone, declined to comment, as did Mallinckrodt.
Since the tax went into effect, Cardinal Health, which provides health services and products, published an extensive 10-page list of opioids it does not expect to carry. Cardinal Health declined to comment.
The New York tax is slowly gaining attention in other states. Delaware passed a similar tax last year. Minnesota is assessing a special licensing fee between $55,000 and $250,000 on opioid manufacturers. New Jersey Gov. Phil Murphy proposed such a tax this year but was turned down by the legislature.
The company that makes the first point of sale within New York pays the tax. That isn’t always the drugmaker. It can mean wholesalers selling to pharmacies here are assessed, explained Steve Moore, president of the Pharmacists Society of the State of New York.
Independent Pharmacy Cooperative said about half its revenue from opioid sales in New York would have gone to taxes.
Mark Kinney, the company’s senior vice president of government relations, said the law is putting companies in a very difficult position.
When wholesalers like IPC left the opioid market, competitive prices went with them.
Without these smaller wholesalers, it’s hard for pharmacies to go back to other wholesalers “and say, ‘Hey, your prices aren’t in line with the rest of the market,’” Moore said.
Indeed, nine independent pharmacies told KHN that when they can get opioids they are more expensive now. They have little choice but to eat the cost, drop certain prescriptions or pass the expense along.
“We can trickle that cost down to the patient,” said a pharmacist at New London Pharmacy in Manhattan, “but from a moral and ethics point of view, as a health care provider, it just doesn’t seem right to do that. It’s not the right thing to ask your patient to pay more.”
In addition, Medicare drug plans and Medicaid often limit reimbursements, meaning pharmacies can’t charge them more than the programs allow.
Stone’s Pharmacy in Lake Luzerne was losing money “hand over fist,” owner Leigh McConchie said. His distributor was adding the tax directly to his pharmacy’s cost for the drugs. That helped drive down his profit margins from opioid sales between 60% and 70%. Stone’s stopped carrying drugs like fentanyl patches and oxycodone, and though that distributor now pays the tax itself, the pharmacy is still feeling the effects.
“When you lose their fentanyl, you generally lose all their other prescriptions,” he said, noting that few customers go to multiple pharmacies when they can get everything at one.
If pharmacies have few opioid customers, those price hikes have less impact on their business. But being able to manage the costs is not the only problem, explained Zarina Jalal, a manager at Lincoln Pharmacy in Albany. Jalal can no longer get generic oxycodone from her supplier Kinray, though she can still access brand-name OxyContin. New York’s Medicaid Mandatory Generic Drug Program requires insurers to provide advance authorization for the use of brand-name prescriptions, delaying the approval process. Sometimes patients wait several days to get their prescription, Jalal explained.
“When I see them suffer, it hurts more than it hurts my wallet,” she said.
One of Jalal’s customers, Janis Murphy, needs oxycodone to walk without pain. Now she is forced to buy a brand-name drug and pays up to three times what she did for generic oxycodone before the tax went into effect. She said her bill since the start of this year for oxycodone alone is $850. Lincoln Pharmacy works with Murphy on a payment plan, without which she would not be able to afford the medication at all. But the bill keeps growing.
“I’m almost in tears because I cannot get this bill down,” she said in a phone interview.
Several pharmacists raised concerns that patients who lose access to prescription opioids may turn to street drugs. High prescription prices can drive patients to highly addictive and inexpensive heroin. McConchie of Stone’s Pharmacy said he now dispenses twice as many heroin treatment drugs as he did a year ago. Former opioid customers now come in for prescriptions for substance use disorder.
Trade groups and some physicians and state legislators opposed the tax before it went into effect, voicing concerns about a slew of potential consequences, including supply problems for pharmacists and higher consumer prices.
New London Pharmacy said one of its regular distributors stopped shipping Percocet, a combination of oxycodone and acetaminophen. Instead, the pharmacy orders from a more expensive company. The pharmacist estimated that a bottle of Percocet for which it used to pay $43 now costs up to $92.
“Even if we absorb the tax, we’re not getting a break from reimbursements either,” a pharmacist who spoke on the condition of anonymity explained, adding that insurance reimbursements have not increased in proportion to rising drug costs. “We’re losing.”
Latchmin Raghunauth Mondol, owner of Viva Pharmacy & Wellness in Queens, has also seen that problem. The pharmacy used to be able to purchase 100 15-milligram tablets of oxycodone for $15, but that’s now $70, she said, and the pharmacy is reimbursed only about $21 by insurers.
Other opioids are just not available.
Mondol said she has been unable to obtain certain doses of two of the most commonly prescribed opioids, oxycodone and oxymorphone — the drug Angevine was on.
After Angevine lost access to oxymorphone, his doctor put him on morphine, but it does not give him the same relief. He’s been in so much pain that he stopped going to physical therapy appointments.
“It’s a marathon from hell,” he said.
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Prosecutors believed Purdue was implicated in mail and wire fraud, money laundering, and conspiracy. Yet the firm got a slap on the wrist
The opioid epidemic is not over. Even as Covid-19 rages, opioid-related deaths continue to devastate communities across our states. In New Hampshire, overdose deaths rose in April and May over last year’s levels. In the first four months of 2020, Rhode Island overdose deaths jumped 29% from the same period last year and 38% from the same period in 2018. Opioid addiction remains a persistent, lethal menace.
The justice department could have made a stronger effort to stop a public health crisis in its tracks more than a decade ago. But it didn’t
Maggie Hassan is a US senator for New Hampshire
Sheldon Whitehouse is a US senator for Rhode Island
Detective Ryan Holets, whose personal story includes the adoption of an infant born to a drug-addicted mother, addressed the Republican National Convention on its second night.
He praised President Donald Trump’s efforts in addressing drug and opioid abuse and noted “drug overdose deaths decreased in 2018 for the first time in 30 years.”
The detective has worked for the Albuquerque, New Mexico, police department for nine years and was invited by Trump to the 2018 State of the Union address. The year before, Holets promised an addicted mom that he and his wife would adopt her baby — and they did.
Holets has seen the results of the nation’s drug crisis both professionally and personally. We reached out to the Albuquerque Police Department for the source of Holets’ data, but did not get a response.
The nation’s opioid crisis has been a talking point in Trump’s campaign since 2016 – and his administration has touted efforts it has made to provide money to states for treatment and other programs, so we decided to look into it.
Did the death rate mark the decline in 2018 that Holets noted? Yes, but that’s not the whole story.
First, Some Context
According to the Centers for Disease Control and Prevention, 67,367 people died of a drug overdose in 2018. That number exceeded the tally, based on the most recent data available, for those who died in car wrecks or by firearms.
Two-thirds of those drug overdose deaths involved some type of opioid, including those given by prescription or those purchased illicitly, such as heroin.
The CDC cites a rise in opioid deaths as coming in three “waves.”
The origin of the first wave came after doctors began prescribing more opioids for pain relief in the 1990s, with data showing a rise in deaths emerging around 1999, the CDC said.
Another wave began in 2010, this one was fueled by deaths involving the illegal use of heroin. That was followed quickly by the third wave, starting in 2013, with increases in deaths associated with synthetic opioids, particularly illicitly manufactured fentanyl.
Despite the rising number of deaths, opioid prescribing continued to rise, fueled in part by marketing campaigns aimed at physicians by drug manufacturers. The total number of prescriptions peaked in 2012 at more than 81 prescriptions per 100 people in the U.S., according to CDC data.
To combat that, a growing number of prescribing recommendations have been issued by physician and hospital groups, aimed at reducing the number of pills per prescription and the total number of prescriptions.
The overall prescribing rate fell to 51 prescriptions per 100 people by 2018, according to the CDC.
Still, Americans are more likely to fill a prescription painkiller than patients in other countries and the rate of opioid prescriptions in the U.S. remains among the highest in the world.
Deaths associated with all types of opioid use — from prescriptions to street use — are a lagging indicator of the number of people dependent or addicted to the drugs, said experts. Death rates can be affected by improved access to treatments to help people quit, as well as increased use of overdose reversal treatments, such as naloxone.
The Trump administration has continued and expanded funding efforts, some of which began under President Barack Obama, to help provide treatment, research and other services.
Yet the administration is also actively seeking to end the Affordable Care Act, which includes a provision requiring insurers to offer substance abuse treatment and has expanded access to treatment through Medicaid in the majority of states that fully implemented the law.
So What Happened With Drug Overdose Deaths?
Drug overdose deaths did decrease from 2017 to 2018, dropping by about 4.1%, according to the CDC. Still, the agency notes that the crisis is far from over, as the number of overdose deaths was four times higher in 2018 than in 1999.
Parsing those numbers further, the decrease in deaths in 2018 came in three categories, with prescription-involved opioid deaths falling the most at a 13.5% decrease, followed by heroin deaths, down 4%.
Conversely, deaths associated with the use of synthetic man-made opioids, such as fentanyl, rose by 10%.
So Holets was correct to say drug overdose deaths fell in 2018.
But that statistic doesn’t put the issue in perspective.
“It did decrease slightly, meaning it went from 134 deaths a day to 130 deaths a day,” noted Chad Brummett, a director of the Michigan Opioid Prescribing Engagement Network, a collaboration of physicians that makes recommendations on prescribing.
“It’s disingenuous to pretend that was a huge win,” said Amy Bohnert, associate professor at the University of Michigan. “As someone who does research on this, I would be reluctant to consider a change of that scale to be clearly a sign of a real change as opposed to random error.”
Brandeis University professor Andrew Kolodny said it was the first overall downtick in drug overdoses in 30 years, but he would parse it a bit for opioids, saying it was the first decline in 25 years.
However, a bigger issue for Kolodny is that the speaker failed to mention that drug overdose numbers went up again last year.
“It is misleading to point to a slight reduction in 2018, when deaths went up again in 2019 and we remain at record high levels of opioid deaths,” said Kolodny, medical director for the Opioid Research Collaborative at the Heller School for Social Policy and Management.
The CDC says preliminary data shows reported overdose deaths went up 6% in the 12 months ending in January 2020.
Holets is correct in saying that overall drug overdose deaths ticked down in 2018, although a small category of deaths — those related to fentanyl — actually rose. And it’s pretty close to 30 years since there was a decline.
Still, Holets failed to mention that drug overdose deaths went up again last year, according to preliminary data from the CDC. Also left unsaid were all the factors that may be going into the rising or falling drug death rates — and what that may say about the underlying level of dependence or addiction.
We rate his statement Mostly True.
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RAND has an interesting report titled “The Future of Fentanyl and Other Synthetic Opioids.” What is truly startling is the rise in deaths due to synthetic opioids like fentanyl in the last 5 years: from 3,000 in 2013 to approximately 30,000 in 2018. In fact, synthetic opioids are now involved in twice as many deaths as heroin.
Further, synthetic opioid-related overdoses often occur when individuals use fentanyl along with other illegal substances.
Fentanyl truly has become a top public health priority.
- Former pharmaceutical executive died of cancer on 30 June
- Sackler was named as defendant in key opioid lawsuits
Jonathan Sackler, one of the owners of Purdue Pharma, the maker of the controversial opioid prescription painkiller OxyContin has died, the company confirmed on Monday.
Sackler died on 30 June, according to a court filing. He was 65 and the cause of death was cancer.