We don’t have Gatorade, but I brought you some juice.” The Neighborcare Health staffer sets a paper cup down on the table, but the man sprawled in the waiting room chair, eyes shut, head tilted back against the wall, doesn’t move. She keeps talking anyway, her voice soft and gentle. Walk-in appointments don’t start for another two hours, she continues, but he can rest here and no one will bother him. The man slowly nods, the effort etched on his face.
On the quiet north end of Post Alley, past the metal bistro tables of the Perennial Tea Room and the racks of onesies outside the children’s boutique, Neighborcare’s Pike Place Market clinic occupies a red-brick building. A nondescript sign dangling from a metal pole is the only external clue. People from all walks of life come here. A bearded man in denim overalls who injured his hand working on his truck. Others for routine checkups or to pick up birth control.
But two afternoons a week, the clinic becomes a place for those who are used to being swept aside: the unhoused, the illicit drug users, the people living in Seattle’s periphery. These days, with the astronomic rise of fentanyl use in King County, those two and a half hours each Monday and Thursday hardly feel like enough.
A couple blocks away from the Pike Place clinic one late Thursday morning, Dr. Richard Waters perches on a concrete retaining wall in Victor Steinbrueck Park. His close-cropped hair and technical pants give him a boyish bent. Behind him, someone unfurls a sleeping bag on the lawn, fiddles with a scrap of foil, and begins to smoke. Waters appears unperturbed—he’s familiar with drug use. He’s the doctor that man in the Neighborcare waiting room is there to see. As an addiction medicine physician, a big part of what he works on with patients is how to reduce or stop their fentanyl or other substance use. It’s also about building trust, learning about their lives, just caring about them. “I think for those of us who do this work,” he says, glancing at Steinbrueck’s park benches filled with many experiencing homelessness, “it’s very easy to see the very human person behind the struggles.”
The struggles he’s talking about, though, have been around long before fentanyl.
For as long as there have been humans, there has been trauma. And as long as there has been trauma, there have been humans who seek ways to cope, from the opium dens that proliferated in the nineteenth century to the post-Vietnam heroin epidemic among U.S. veterans. But the type of opioid use that commandeers clickbait headlines and salacious news segments today only began a few decades ago, and fentanyl, even later.
In 1996, the Washington State Medical Quality Assurance Commission, now called the Washington Medical Commission, released new guidelines for the management of pain, specifically citing opioids for under-treated conditions. Over the next decade, opioid prescriptions increased by 500 percent. It wasn’t by chance. Pharma had been pushing that message for a few years, says Dr. Caleb Banta-Green, acting professor at the University of Washington School of Medicine’s Addictions, Drug, and Alcohol Institute. He points out, unprompted, that he’s never accepted a penny from pharmaceutical companies.
OxyContin rained down, and by 2006, Washington was in the top third of states for unintentional drug overdoses. Shortly after, stricter regulations hit: opioid users who could formerly pick up their pills from the pharmacy had to turn somewhere else. “What it did is create a vacuum,” explains Brad Finegood, strategic advisor at Public Health—Seattle and King County. Community members already heavily addicted to prescription opioids had to seek an alternative. Black tar heroin worked for some, but the stuff is sticky and smelly. It requires needles.
Then two decades after the prescription opioid floodgates opened, fentanyl infiltrated the local market in earnest. In 2016, King County had 23 overdose deaths involving fentanyl. In 2021, that number ballooned more than 16-fold to 385. This year, the county surpassed that record-breaking stat in September, with Seattle’s Black and Native communities disproportionately impacted.
Most fentanyl in King County looks like legitimate prescription meds, made to mimic the oxycodone Percocet. Many who died from an overdose in the early days of the fentanyl wave—notably, a straight-A Ballard High School student and two Sammamish teens in 2019—probably didn’t even know those blue M30 pills were manufactured by a drug cartel. These pills feel safer and are cheaper and easier to use. You can buy them on Snapchat. King County opioid overdose deaths, which formerly skewed in the 40 and older age group, now trend into 40 and younger territory. By messed-up design, fentanyl has all-ages appeal. Even longtime heroin users converted. “Everybody switched to the blue pills, these blue fentanyl pills,” says Waters, the Neighborcare physician.
That shift is most jarring looking at a scatterplot of overdose deaths. “There’s a lot of people who die of drug overdoses with methamphetamine and heroin in the downtown urban core,” Finegood says. “Fentanyl was everywhere, like it was killing people everywhere.”
In January 2017, two years before those teenagers died and raised the red flag for the public at large, UW Medicine researcher Banta-Green helped catalyze a response to the opioid problem inside a nondescript building on Fourth and Blanchard. At the county-run Downtown Public Health Center, the city’s most vulnerable can access the health care they need and, often, can’t get elsewhere, like cancer screenings, vaccines, dental work—and clean syringes. For Banta-Green, it was the perfect combination that happened to deploy as fentanyl use ticked upward. “I’m putting all my eggs in one basket.”
His basket is the low-barrier buprenorphine program, Bupe Pathways. Buprenorphine is an oral and injectable medication. It addresses the brain-altering nature of opioids that makes kicking an addiction cold turkey wildly difficult and potentially life-threatening. Instead of the rapid highs and even quicker plummets one might get on a drug like fentanyl, buprenorphine keeps users at an even, steady keel. They can’t get high on it, and they can’t overdose on it. Eventually, cravings for the illicit drug cease all together.
It’s not perfect by any means. Buprenorphine, commonly known by its brand name Suboxone, can be notoriously difficult on the uptake, especially with fentanyl users, who may plunge into precipitated withdrawal. To some, it feels like they’re dying. But in the medical community, bupe and another medication called methadone are considered the gold standard for treating opioid use disorder. Methadone, however, has its drawbacks. “Methadone is a really great medication that is also a little bit easier to start your induction on as a treatment option compared to buprenorphine,” explains Hannah Carmichael, a nurse consultant for the Overdose Data to Action program at Washington’s Department of Health, “but methadone is extremely hard to access.” In some cases, especially on the eastern side of the state, patients have to drive an hour each way to receive their daily dose.
That’s the beauty of Bupe Pathways, Banta-Green says. It’s designed to make a highly effective treatment as easy as possible to access, with few restrictions or conditions, hence the first partnership at the needle exchange site. But one of the problems with fentanyl’s rapid rise and evolution is that most people aren’t injecting—they’re smoking it, which means they no longer need the syringe services that connect them with Bupe Pathways and other amenities. Bupe can be prescribed in some standard primary care settings and also at community health orgs, but their hours are often limited. Sometimes the providers, if they’re not specialists, don’t even want to see those patients.
“We just need to make whatever medication people want available to them in whatever ways possible,” Public Health’s Finegood says, “and there’s just a number of hurdles to that.” A lack of substantial, cohesive funding for these programs means, right now, that all-in bupe basket of Banta-Green’s is only available in a handful of locations. Stigma within the medical community keeps fentanyl users from seeking care in the first place. Outright vehemence from the public at large blocks more progressive options like safe consumption sites or medication alternatives from even entering the conversation. Politicians who prefer to grandstand make public declarations about the crisis while dawdling to vote on proposed harm reduction and treatment strategies.
Activist Malika Lamont is blunt as to the reasons why: “Fentanyl has been visibly affecting white people, and there has been a response that has been targeted to them. It has not been targeted to the other groups of people that are disproportionately impacted.”
Wearing a black T-shirt with the words “Upset Colonialism” emblazoned across the front, Malika Lamont speaks with fire and precision. She has to project both in order to undo centuries of systemic racism and oppression. Growing up, her family was affected by the war on drugs and mass incarceration. As program director for the grassroots policy-change organization Voices of Community Activists and Leaders, she wants to reverse that tide for the next generation.
To Lamont, the hurdles to an effective solution for fentanyl and illicit drug use in King County—and, frankly, the country—begin and end with stigma. Disdain for the homeless population, the Black and brown and Indigenous populations, leads to law enforcement–driven responses, like criminalization, instead of compassionate care. “People say, ‘Bring the hammer down on people.’ What are hammers good for? They’re good for nails, not people.”
Tim Candela, drug user health adviser at Washington State Department of Health, agrees, citing “a whole host” of evidence that shows criminalization of drug use leads to increased overdose rates and unevenly punishes those who “are already shouldering the burden of multiple other forms of systemic racism and systemic oppression.” And even as fentanyl in King County devastates Black and Native communities, their treatment options and harm reduction resources are notably sparser when compared to whiter, wealthier areas of the region.
Take Narcan distribution. If buprenorphine is the gold standard for fentanyl treatment, the overdose-reversing medication Narcan is one of the most touted approaches for harm reduction—strategies to help people use safely and prevent them from dying if they do. North King County has more than a dozen Narcan distribution sites through the Department of Health’s naloxone distribution program. In south King County, with greater ratios of Black residents and traditionally lower incomes, there are just four.
Public Health and local advocates are trying their best to fill in the gaps, meeting with those entrenched in the most affected communities, but NIMBYism and cries of enablement come into play no matter the geography. In more well-to-do parts of town, homeowners protest drug treatment agencies and shelters on their blocks or clutch their pearls at the very idea of safe consumption sites. It attracts drug users and the unhoused—it’s dangerous, they say. What they don’t get, says Public Health’s Finegood, is that these people already exist in the community. And “they do much better when they’re treated versus untreated, healthy versus unhealthy, housed versus unhoused, and we just need to be able to help them.”
Even if, for now, that help starts as a cup of juice and a quiet place to rest.