In this file photo, Roger Boyd, 35, holds a piece of foil containing fentanyl while spending time on McAllister Street in the Tenderloin district of San Francisco on June 21, 2019.

San Francisco is in the grips of an unprecedented drug epidemic as fentanyl floods the street-drug marketplace, intensifying the peril of addiction and leading to a staggering number of overdose deaths. 

While other drugs such as cocaine, heroin and especially methamphetamine are part of the city's recreational drug supply, the number of accidental overdose deaths tied to the astonishingly cheap, potent and addictive synthetic opioid went up 483% from 2018 to 2020. Fentanyl was detected in the blood of 89 of the 260 total people who died from overdoses in San Francisco in 2018, while it was present in 519 of the 712 people who overdosed in 2020, data shared by the city with SFGATE showed. 

Illicit fentanyl, which can be 50 times more powerful than heroin, emerged in San Francisco only a few years ago. As recently as 2015, the U.S. Drug Enforcement Administration said it didn't seize any fentanyl in its Northern California region. The agency confiscated 15 kilograms in 2016 and numbers rose in following years. In 2020, the division seized 29 kilograms of fentanyl, and this year so far 74 kilograms have been confiscated — an amount that could kill up to 37 million people when you consider 2 milligrams is a lethal dose. 

"That’s double what we seized last year and we’re not even done with the year," said Wade Shannon, special agent in charge of the U.S. Drug Enforcement Agency's San Francisco field division with a region stretching from the California-Oregon border to Bakersfield. "We are drowning in fentanyl."

The San Francisco Police Department seized more than 30 pounds of drugs in Oakland on June 3. 

As with all illegal drugs, fentanyl flows into the United States through a complex underworld spread across the globe, passing through many different hands, its value increasing with each step.

China is the main source of ingredients used to make fentanyl and it also produces the drug in a completed form, usually powder. The Chinese government has recently cracked down on the drug, and India has emerged as a new player, the DEA said in a 2020 report. From China and India, the ingredients and powder are sent on container ships to Mexico. Much smaller amounts are sold over the dark web and sent through the mail, sometimes directly into the hands of people who intend to use the drug in the U.S.

Transnational criminal groups, also known as cartels, are the next step in the supply chain, and they're synthesizing the drug, producing mainly powder, packaging it to be sold in the U.S. in pure form and also lacing other drugs such as cocaine and heroin with it, the DEA said. Fentanyl is an inexpensive and easy way to pump up the potency of other drugs.

Cartels are also stamping fentanyl into pills made to look like legitimate prescription pills such as OxyContin, Adderall and Xanax.

The DEA launched a nationwide campaign this week to increase awareness about the increasing prevalence of criminal drug networks mass-producing fake pills, with the number of DEA-seized counterfeit pills containing fentanyl jumping nearly 430% since 2019. 

Shannon said 2 milligrams of fentanyl is considered a potentially lethal dose and recent DEA lab testing revealed that two out of every five pills with fentanyl contained a deadly amount. 

"The quality of these pills … it’s an inexact science," said Shannon. "The cartel who are stamping these pills don’t have quality control. You can get what we call hot batches."

Unlike heroin, cocaine or marijuana, fentanyl doesn't require farmland, sunshine, rain or field hands. The highly potent and addictive drug is easily synthesized with few ingredients in a lab, making it a drug trafficker's dream.  

Shannon said a cartel can purchase a kilogram of fentanyl powder for $3,000 to to $5,000 and that can make a half-million pills.

"This leads to a $1.5 million return on that investment," Shannon said. "That’s a huge benefit for the transnational criminal organizations."

The cartels are working with local distribution networks, street gangs or smaller entities in the U.S. to sell the drug on the streets and also through social media.

"For San Francisco, it’s usually coming through the Central Valley and working its way north into San Francisco," Shannon said.

Pills are sold on the streets of San Francisco for $4 to $10 each, Shannon said. People are also buying the drug in powder form, sometimes smoking it. Often they're getting the drug unknowingly when they purchase pills and other drugs. 

How much of the use is intentional versus accidental? "The simple answer is that we don’t know," Dr. Sarah Mars, a UCSF associate researcher studying fentanyl use with USCF professor Dr. Daniel Ciccarone, wrote in an email. "When people are able to buy fentanyl as ‘fentanyl,’ use is clearly intentional but when drugs are mixed together, it is difficult to tell. Much of the data we have is obtained post mortem after overdoses and we do not know whether the person who took the drugs planned to mix them with fentanyl or not."

Up to 100 times more powerful than morphine, fentanyl, like all opiates, is a respiratory depressant and can impact a person's ability to breathe. In an overdose situation, a person's breathing can entirely stop with little or no oxygen reaching the brain and this can lead to a coma, irreversible brain damage and death.

Research shows that the potency of fentanyl is more likely to trigger an overdose than other opioids. One reason the risk for overdose is so high with fentanyl is it acts almost immediately. While a heroin overdose can take 20 to 30 minutes to progress to cardiac arrest, with fentanyl it can happen in minutes. 

Fentanyl was initially created in the 1960s to manage pain after surgery, and its clinical use expanded in the 1990s with the introduction of the extended release patch for chronic pain, typically advanced cancer pain. 

Illicit fentanyl first emerged on the East Coast in about 2014, mainly found as an adulterant in powdered heroin. 

"They called it a poisoning epidemic because it was being called heroin but it had this 40 times more potent product in it and it was poisoning people," said Ciccarone, who specializes in addiction medicine and has followed the westward expansion of fentanyl. "After 2018 it started coming into the West."

Through their research at UCSF, Ciccarone and Mars have found evidence that people who use opioids on the East Coast may tend to actively avoid fentanyl, as test strips that alert consumers to its presence in their drugs have become more common.

Ciccarone said there's some evidence some people in San Francisco are seeking out and choosing to take fentanyl, but there's still a lot more research to be done. A 2021 quantitative and qualitative study on fentanyl use in the Bay Area found some people who use drugs were switching from injecting tar heroin to smoking fentanyl, citing benefits such as lower cost and less social stigma by reducing visible "track marks" from injections.

Researchers such as Ciccarone and Mars are launching studies to better understand how fentanyl is being used on the streets, while the DEA, in conjunction with the San Francisco Police Department, tries to get the drug off the streets. Meanwhile, city agencies are working hard to reduce drug use and prevent overdose deaths, helping get users into recovery and administering Naloxone, an overdose-reversing medication. Across the city, Naloxone is on hand everywhere from public libraries to bars. With fentanyl at the center of this effort, none of it is easy. 

"It’s like nothing I’ve ever experienced in my career," Shannon said. "There have been drug overdoses ever since there have been drugs, but the data and deaths we’re seeing with fentanyl, it’s uncharted territory."

Amy Graff is the news editor for SFGATE. She was born and raised in the Bay Area and got her start in news at the Daily Californian newspaper at UC Berkeley where she majored in English literature. She has been with SFGATE for more than 10 years. You can email her at agraff@sfgate.com.