How does San Francisco's overdose crisis compare to the rest of the U.S.?
The rate at which people are dying of accidental drug overdose in San Francisco has soared in recent years. That increase is largely due to the rise of fentanyl, a synthetic opioid that is exponentially more powerful  and lethal  than heroin. Recently released data show that overdose deaths in San Francisco have now surpassed the rates of many East Coast and Midwest communities that encountered the deadly fentanyl epidemic years before it came to San Francisco. Accidental drug overdose deaths tend to be higher in places where fentanyl is more widespread in the community, said Dr. Phillip Coffin, director of substance abuse research for the San Francisco Department of Public Health. We know solidly from data that fentanyl poses a several-fold higher risk of overdose and that in the event of overdose, its more likely to result in death compared to heroin. The intake of just 2 milligrams of fentanyl can be lethal. A Chronicle analysis of mortality data from the U.S. Centers for Disease Control Prevention and reports from state and local health departments shows that as fentanyls influence grew in San Francisco, especially in the late 2010s, overdose death rates rose above places like Philadelphia, which has been battling the same epidemic, but for longer. Philadelphia, which is both a city and a county, was the place with over 500,000 people with the highest overdose rate in 2019. San Francisco surpassed it in 2020. Fentanyls role in driving the skyrocketing overdose death rates is evident in the numbers: In 2020, San Francisco medical examiners office data shows 516 out of 712 total overdose deaths, or 72%, involved fentanyl  in many cases, in combination with several other drugs. Between January and May of this year, preliminary data showed the percentage was at about 73%. This is up from just 16% of overdose deaths in 2017. In Philadelphia, 81% of overdoses involved fentanyl, according to its public health department. Just 34% of overdose deaths in 2020 were related to fentanyl in King County, where Seattle is located, according to the countys overdose deaths dashboard. But Fentanys prevalence in the community appears to be rising. More than half of the 284 confirmed overdose deaths have been attributed to fentanyl-related causes. Assuming fentanyl comes to dominate, [Seattle is] going to see the kind of scary increase that we saw as well, Coffin said. The deadly synthetic opioid used to be a mostly East Coast issue, Coffin and other experts said. A 2018 study in the Drug and Alcohol Dependence Journal found that the 28 states east of the Mississippi River accounted for 88% of synthetic opioid overdose deaths.  In 2019, the most recent year for which comparable data for multiple cities and counties were available, San Francisco stood out as the lone Western community represented in the top 10 with the highest accidental overdose death rates. This data includes major cities and counties in large central metro areas as defined by the CDC and may exclude some smaller areas, such as Baltimore, with higher death rates. However, data show fentanyl is increasingly becoming a problem in the West, and not just in San Francisco. Overdose deaths due to fentanyl are also rapidly increasing in Arizona, Los Angeles, Seattle and Houston, the Drug and Alcohol Dependence study said. Still, San Francisco has the highest overdose death rate of all major California counties, and experts say, a higher concentration of fentanyl out in the community. San Francisco is kind of the bellwether of the West in terms of the introduction of fentanyl, Coffin said. Researchers, and public health and law enforcement officials are still trying to understand why San Francisco became the epicenter of the West Coasts fentanyl epidemic. What they do know is that in most places across the country, fentanyls rise is the result of it being pushed by suppliers, not demanded by users. Suppliers prefer it because of its cheap costs, and use it to boost the potency of other drugs or make counterfeit opioid pills. But San Francisco is one of the places where there is a specific demand for fentanyl, according to researchers at the University of California-San Francisco. We know that in San Francisco, fentanyl is being sold both in counterfeit opioid pills and as fentanyl, under its own name, which is different from much of the East Coast and Midwest, where it is often sold as heroin, said Dr. Sarah Mars, associate professional researcher in the Department of Family and Community Medicine. Mars added that the combination of fentanyl with stimulants, especially methamphetamine, has been a key contributor to San Franciscos recent rise in overdose deaths. To address San Franciscos opioid crisis, Mars believes the city needs to do more than just look at the drugs that are fueling it. San Franciscos extreme inequalities, worsened by the housing crisis and the pandemic, create toxic conditions that may be fueling the citys fentanyl overdose epidemic. she said. We need to address the conditions that underlie the seemingly endless increase in this countrys overdose deaths if we are to save lives.  Yoohyun Jung is a San Francisco Chronicle staff writer. Email: yoohyun.jung@sfchronicle.com Twitter: @yoohyun_jung