“A lotta people switched playing hard ball to playing Russian roulette”: Experiences with rising overdose incidence caused by drug supply changes during the COVID-19 pandemic in the San Diego-Tijuana border metroplex

Highlights

• •In the face of a hemispheric rise in potency and availability of synthetic substances (fentanyl and methamphetamines in the San Diego-Tijuana metroplex) people who use drugs (PWUD) face contradictory health priorities: consuming increasingly unpredictable substances versus avoiding fatal overdose.
• •Participants viewed recent incarceration and combined methamphetamine and fentanyl use as increasing overdose risk.
• •Some participants perceived risks associated with changing from injecting heroin to smoking fentanyl.
• •Participants emphasized the life-saving utility of easily accessible naloxone in the context of rising overdose incidence.

Abstract

Background

People who use drugs (PWUD) in the San Diego, USA and Tijuana, Mexico metroplex face high overdose risk related to historic methamphetamine use and relatively recent fentanyl introduction into local drug supplies. The personal overdose experiences of PWUD in this region are understudied, however, and may have been influenced by the COVID pandemic.

Methods

From September-November 2021, we conducted 28 qualitative interviews among PWUD ≥18 years old sampled from an ongoing cohort study in the San Diego-Tijuana metroplex. Interviews explored overdose experiences and changes in the drug supply. Thematic analysis of coded interview transcripts explored overdose experiences, perspectives on drug supply changes, interactions with harm reduction services, and naloxone access.

Results

Among 28 participants, 13 had experienced an overdose. Participants discussed rising levels of fentanyl in local drug supplies and increasing overdose incidents in their social networks. Participants discussed a general shift from injecting heroin to smoking fentanyl in their networks. Participants’ most common concerns included having consistent access to a safe and potent drug supply and naloxone.

Conclusion

Participants prioritized adapting to drug supply changes and preventing overdose compared to other health concerns, such as HIV and COVID-19. Efforts to address overdose in this region could benefit from drug checking services and expanded, equitable delivery of naloxone.

1. Introduction

Overdose deaths involving fentanyl and methamphetamine have increased dramatically across North America over recent years, yet important geographic differences have emerged (Ciccarone, 2021). In addition to the nationwide expansion of methamphetamine and fentanyl, East Coast and Midwest urban drug markets are experiencing the enhancement of fentanyl with xylazine (an animal tranquilizer) which is also beginning to emerge in West Coast drug supplies (Friedman et al., 2022). While East Coast and Midwest “rustbelt” urban drug markets in the U.S. experienced earlier expansion of fentanyl and more recent increases in methamphetamine use, in the Southern region of the West Coast, drug trafficking across the U.S.-Mexico border has resulted in a dynamic criminalized drug supply characterized by historic methamphetamine production and heroin trafficking and more recent fentanyl introduction into local supplies (Bailey et al., 2022).

These trends have contributed to a heightened overdose risk environment in recent years. For instance, San Diego County, which abuts Tijuana, Mexico experienced a 70% increase in opioid-related deaths between 2019 and 2020 largely attributed to fentanyl (California Department of Public Health, n.d.). As in other areas of the country, in the entire San Diego-Tijuana metroplex, the COVID-19 pandemic disrupted access to health and harm reduction services for people who use drugs (Friedman et al., 2022), where supplies of naloxone were already suboptimal (Stowe et al., 2020), while fentanyl contamination of local drug supplies likely increased (Aponte-Melendez et al., 2021; Bolinski et al., 2022; Gleason et al., 2022; Williams et al., 2022). Despite growing research on drug-related overdose nationwide during the COVID-19 pandemic period, however, much less is known about the experiences and perspectives of PWUD in the San Diego-Tijuana metroplex. We thus conducted a targeted qualitative analysis to explore their experiences with overdose, local drug supplies, and use of overdose reversal medication (i.e., naloxone).

2. Methods

2.1. Study design & sample

From September-November 2021, we conducted qualitative interviews with participants of an ongoing cohort study examining cross-border drug use, overdose, and infectious disease risk among people who use drugs (PWUD) in the San Diego-Tijuana metroplex (Strathdee et al., 2021). For this qualitative substudy, we used purposive sampling to recruit cohort participants who were ≥18 years old, reported past-month injection drug use, and spoke English or Spanish (Valasek et al. 2022). We obtained verbal informed consent and provided $20 monetary compensation for qualitative interviews. The Human Research Protection Program of the University of California San Diego approved all study protocols.

2.2. Data collection

Trained interviewers conducted qualitative interviews, lasting 45 min on average, in person (in outdoor public spaces near where PWUD live and spend time) or via secure video conferencing (Valasek et al. 2022). Interviews were audio-recorded using a handheld recorder, professionally transcribed, and translated from Spanish to English as necessary by a bilingual, bicultural study team member. Interview topics included participants’ experiences with the drug supply, overdose, and overdose prevention, and access to healthcare and HIV prevention services generally and during the COVID-19 pandemic (see Supplemental File). Examples of interview questions included, “Can you tell me about the drug scene around here?;” “What do you do to help prevent overdose?;” and “How do you usually get syringes?” Immediately after interviews, interviewers wrote detailed notes to record their observations on key topics and potential emergent themes.

2.3. Data analysis

We developed a preliminary codebook through an iterative, consensus-based process involving five rounds of codebook testing and revision by the lead interviewer (CV) and three investigators (AB, HP, and SA Streuli). We first drafted general deductive codes including “Drug Supply” and “Overdose.” Draft codes were then refined through an inductive and iterative process involving close reading of interview transcripts, independent code testing, and comparisons of coding and discussion of discrepancies between coders to refine codes and improve coding consistency. The lead interviewer (CV) then applied finalized codes to transcripts using Nvivo (v12). Through a close reading of data coded for “Drug Supply,” “Overdose,” and “Drug Use,” we identified key themes including (1) drug supply as a top health priority, (2) changing drug supply, (3) behavioral changes and personal overdose experiences, and (4) community experiences of fatal overdose and prevention. We then selected representative quotes related to each theme and created pseudonyms to maintain anonymity.

3. Results

3.1. Sample characteristics

Among 28 participants, median age was 40 years (interquartile range: 32–53), and most identified as Hispanic/Latino (64%) and male (64%; Table 1). Fentanyl was the most consumed drug (n = 17) followed by methamphetamine (n = 15); most participants discussed using multiple substances and lacking stable housing. In qualitative interviews, 13 described experiencing an overdose and the following key topics.

Table 1.

Socio-demographic characteristics: people who inject drugs in the San Diego-Tijuana metroplex (n = 28).

Age in years: median (interquartile range; IQR)	40 (32–53)
Hispanic or Latino	18 (64%)
Racial identity:
White	9 (32%)
Black or African American	1 (4%)
Mixed	8 (29%)
Other	10 (36%)
Gender identity:
Male	18 (64%)
Female	10 (36%)
Educational attainment
Less than high school	2 (7%)
Some high school	6 (21%)
Completed high school or GED	8 (29%)
Completed trade school	3 (11%)
Some college	4 (14%)
Completed college	5 (18%)

3.2. Qualitative findings

3.2.1. Drug supply as a top health priority

While many participants wanted more access to various healthcare services, including COVID-19 vaccines and pre-exposure prophylaxis (PrEP), most agreed that their biggest health concern involved the safety of the local drug supply. Participants talked about their personal priorities of health concerns, as well as the general health concerns in their larger communities of unhoused PWUD. For instance, Jorge said “…most people out here are not worried about COVID and HIV…they're more worried about getting their next fix; that's priority over everything.”

3.2.2. Changing drug supply

Participants were aware of increasing rates of fatal overdose in their communities and perceived growing risks, personally, from using drugs from an unregulated supply, particularly during the COVID-19 pandemic. As Steven said, “They're [PWUD] dropping like flies [around here].” Most participants believed that fentanyl was causing the rise in overdose, as they observed fentanyl overtaking heroin consumption as well as fentanyl contaminating supplies of other drugs including methamphetamine. Angel described this shift as occurring gradually over September 2020-September 2021 with fentanyl becoming more accessible than heroin in his community. During this shift, Angel initially told others to avoid fentanyl (“Don't you see how many people are dying, like how much worse it is? Like, stay on heroin.”) but eventually started using fentanyl himself, seeking a “better high.”

Manuel described his shift to using fentanyl simply because it had recently supplanted other opioids: “Less heroin, [the market is] flooded with fentanyl.” Some expressed concerns about the danger caused by fentanyl taking over local drug supplies, as Manuel continued, “[Fentanyl] is the main drug: a lotta people switched from heroin [to] fentanyl, basically switched [from] playing hard ball to playing Russian roulette.” This shift was most apparent to those recently released from incarceration, as Victor explained, “I did about 12 years straight. And [fentanyl] came out. So when I came out [of prison], I got back into looking for heroin, and I was wondering what would top the crystal [methamphetamine], and lo-and-behold, there came the fentanyl.”

Changes to the drug supply during the COVID-19 pandemic prompted some U.S. residents to cross the border into Tijuana searching for uncontaminated heroin and cheaper drugs. At least one participant stopped using drugs and others altered their purchasing strategies. Luis, a Tijuana resident, talked about how the rise of fentanyl and other suspected contaminants in the stimulant drug supply caused him, and likely others, to try to cease using psychoactive drugs altogether: “In my opinion, the drugs are not good. They're mixing them with fentanyl. They're cutting them with the one known as ‘crocodile’ [and] people are getting sores and their skin is falling off. It's not good anymore; many of us are trying to get off drugs for that reason.” Roberto in San Diego shared a similar concern, stating, “If it's got fentanyl in it, I just don't buy it.”

3.2.3. Drug use behavioral changes and overdose experiences

Several participants attempted to gage the potency of their drugs by using small “testers” before a normal-sized dose. Manuel reported doing this each time he bought drugs: “[I] take a hit just to see how it is. What level it's on; what level I'll be on; you know?” Many other participants shared Manuel's concern and asserted the importance of not using alone to prevent fatal overdose. Several participants specifically highlighted heightened risk of overdose upon release from incarceration, as Jim noted, “People that just got out of jail overdose quite, you know, daily.” Victor described overdosing the very first time he used fentanyl after a long prison sentence. Some people also viewed extended methamphetamine binges (i.e., staying awake for over 24 h) as increasing overdose risk, as Emily noted, “If you've been up for a couple days, those are the people that usually go out [overdose].”

Many participants were shifting from injecting to smoking fentanyl. Angel explained, “A lot of people are very excited and happy to be smoking fentanyl and not using needles anymore.” Manuel appreciated an additional benefit of switching to smoking fentanyl because it reduced his need “to walk around with a pocket full of needles.” While smoking fentanyl was perceived as reducing infectious diseases (e.g., HIV, HCV) and abscesses from injecting, a couple of participants believed that smoking fentanyl could increase overdose risk, possibly by decreasing individuals’ tolerance. For instance, Manuel shared his experiences living under a freeway and observing many overdoses, stating that he noticed “whoever was using a lot with a needle and all that could handle the fentanyl. If you weren't using the needle and you tried fentanyl, that's mostly who the people are overdosing.”

3.2.4. Community experiences of fatal overdose and prevention

Most participants were deeply concerned about the frequency of overdose within their networks. The loss of friends, family, and community members to overdose was highly distressing. As Manuel explained, “I've never seen so many overdoses and deaths. Never had to revive so many people.” Several participants emphasized the importance of naloxone for reversing opioid overdoses, including Manuel, who anthropomorphized naloxone as “a hero to help out overdose[d] people.” Manuel claimed that he had “about 60 people under my belt” who he had revived using naloxone. Several others, such as Melinda, stated that she tries to “pass ‘em [naloxone] out to people” who also live without housing.

In summary, participants understood the growing overdose risks associated with the changing drug supply, as well as the need for naloxone to reduce said risks.

4. Discussion

Through qualitative interviews with people using drugs in the San Diego-Tijuana metroplex, our findings show that PWUD know that the risk of overdose has greatly increased due shifting local drug markets during the COVID-19 pandemic. Due to economic scarcity and limited access to health services during the COVID-19 pandemic (Friedman et al., 2022; Strathdee et al., 2021), PWUD rationally pursued their prioritized health and survival concerns (Motavalli et al., 2021), including the ways that they tried to mitigate harm while simultaneously prioritizing pleasurable but more potentially deadly psychoactive substances (Race, 2017).

Since participants indicated that many PWUD in the area know about the changing drug supply and know that naloxone can reverse overdose due to opioid use, interventions must go beyond education to instead focus on the priorities of PWUD. The top two (competing) priorities in our sample were to “get well” and avoid fatal overdose, suggesting an urgent need for accessible, street-based drug checking services to reduce harms from fentanyl contamination of local drug supplies (Maghsoudi et al., 2022; Wallace et al., 2021). Other harm reduction interventions implemented in other jurisdictions (e.g., Canada), such as “safe supply” initiatives (McNeil et al., 2022) and overdose prevention sites (Wallace et al., 2019) could also be helpful. Increased availability of naloxone for opioid overdose reversal and harm reduction supplies that support smoking rather than injecting (e.g., sterile fentanyl pipes) should also be prioritized. San Diego County initiated a naloxone expansion program in September 2022 through various mobile and fixed sites including vending machines. In addition, while naloxone may soon become available over-the-counter in the United States, research evaluating policy differences that influence naloxone availability across the border will be needed.

In conclusion, PWUD perspectives on the evolving, potent, contaminated drug supplies in the San Diego-Tijuana metroplex during the COVID-19 pandemic highlight the need for dramatically increased access to overdose prevention and harm reduction services, including, naloxone, safe smoking kits, fentanyl test strips, and precise drug-checking technologies (e.g., spectrometer equipment).

Author disclosures

Funding

This work was supported by the San Diego Center for AIDS Research (NIH/National Institute of Allergy and Infectious Diseases grant P30AI036214), the NIH/National Institute on Drug Abuse (grants K01DA043412, R01DA049644-S1, R01DA049644–02S1, DP2DA049295, and T32DA023356).

Role of funding source

The funding sources did not have a role in study design, in the collection, analysis and interpretation of data, or in the decision to submit the paper for publication.

Ethics

Participants provided verbal informed consent for participating in this study; the Human Research Protection Program of the University of California San Diego approved all study protocols.

Contributors

Conceptualization, Methodology, Supervision, Funding Acquisition: ARB, SA Streuli, HAP, SAS; Software, Validation, Data Curation: CJV; Formal Analysis, Writing - Original Draft: CJV, SA Streuli; Investigation: ARB, CJV; Resources, Project Administration: CFV, AHV, SAS; Writing - Review & Editing: CJV, SA Streuli, HAP, SAS, AB, PB, TB, CFV, AHV, ARB. All authors reviewed and approved of the final manuscript.

Declaration of Competing Interest

No conflict declared.