Fentanyl is being mixed with other drugs to increase potency, making them more deadly.

No one knows where exactly the overdose is on South Kukui Street in Chinatown.

The call said it was in a parking garage, but there are two on this back street.

A bystander leads the Honolulu EMS team to a locked stairwell, then bangs on the steel door — the ambulance is here. The door bursts open and a man rushes out.

“Is he the patient?” asks Jim Ireland, director of Honolulu Emergency Services Department.

The bystander doesn’t think so. The man he left was unconscious and partially undressed.

narcan drug overdose od parking garage stairwell
A patient overdosed in a stairwell within this parking garage on South Kukui Street in Chinatown, but the EMS team couldn’t find the man when they got inside. (Kevin Fujii/Civil Beat/2023)

But there is nobody at the bottom of the stairs. All that remains are two Narcan nozzles — a brand of the fast-acting medication naloxone that can reverse an opioid overdose — on the concrete floor.

The medical team returns to the street and searches for the patient, but no one recalls what he looks like since he ran away so quickly.

But it is apparent that a man sweating profusely — now sitting against the wall of Longs Drugs with several homeless people — is suffering rapid withdrawal symptoms from being revived.

As the team rushes over to assist, a pair of friends observe from across the street.

They said that when he overdosed someone alerted them. One man administered CPR and the other searched for Narcan in the local homeless community. Luckily someone had it on hand.

A used Narcan nozzle abandoned inside a parking garage on South Kukui Street in Chinatown. (Allan Kew/Civil Beat/2023).

“As soon as I got a pulse I hit him with it,” said the man who gave CPR. “With fentanyl, it takes a little while compared to heroin. It took about two minutes and then it sat him straight up. Like a bad nightmare.”

Ireland asks how many times he has administered Narcan to someone: “More than five, more than 10?”

The friend doesn’t know but says it’s getting close to every day.

Ireland doesn’t doubt it because “he’s got first-responder-kind-of technical knowledge from doing it so much.”

The conversation happened quickly and the men walked away without giving their names. But Ireland says the use of fentanyl is so widespread that users increasingly have to administer the naloxone themselves.

Chinatown is one district where the Hawaii Health and Harm Reduction Center provides the homeless community with resources and training to reverse an overdose like this.

People then share the medication and training through word-of-mouth.

“Our homeless group really forms their own kind of ohana,” said Christina Wang, a doctor with HHHRC. “We find that a lot of our folks kind of congregate and make their own little family centers. They’re not alone, and they are using with others and they have a community.”

In effect that community protects itself, but more overdoses also go unreported.

Datasets intended to track fentanyl cannot capture the drug’s actual presence in Hawaii because local, state, and federal agencies use different metrics.

Drug-related deaths in Hawaii from 2016 to 2022. Multiple drugs are often found in overdose cases. (Provided: Hawaii HIDTA)

What’s certain is five years ago fentanyl caused only nine deaths in Hawaii. In 2022 that rose to 79. And currently three out of every 10 overdose calls to EMS involve fentanyl, according to Ireland.

“It doesn’t spare any part of the island,” he said, and many survivors didn’t know the drugs they used contained fentanyl.

Since October 2022, the harm reduction center has equipped the public and emergency agencies with 14,963 Narcan kits containing two 4-milligram nasal sprays — essentially 29,926 naloxone doses.

It is unclear yet if the wider distribution has curbed local fatalities.

More Intense, More Addictive

The Centers for Disease Control and Prevention refers to fentanyl as the opioid epidemic’s third wave, following hundreds of thousands of deaths caused by prescription opioid and heroin abuse from the 1990s to the 2020s.

The use of fentanyl likely surged as an indirect result of the federal government’s crackdown on prescription opioid abuse, according to the Congressional Budget Office. Consequently, the generation forged in the prescription opioid crisis transitioned to using synthetic opioids.

“With OxyContin, at least that was from a real pharmacy, and you knew the dose you were getting,” says Ireland. “Now they’re taking the fake OxyContin because that’s all they can get hold of, and it’s cheap because it’s fentanyl, and they’re dying.”

narcan drug overdose od parking garage
Chinatown has become a hotspot for drug use and overdoses, leading the Hawaii Health and Harm Reduction Center to dedicate more resources to the district. (Kevin Fujii/Civil Beat/2023)

The synthetic drug is mixed with stimulants and masked as counterfeit opioids because it’s a cheap additive that produces a more intense and addictive product.

“We’re seeing a lot of the drugs aren’t clean anymore,” said Wang. “They’re just mixed with a bunch of crap in there. So it’s very difficult for our patients to know what they’re using.”

Wang recounted an older man who overdosed after snorting cocaine — unaware it was laced with fentanyl — and needed three doses of Narcan to be revived.

Ireland has heard of patients requiring up to six doses. Regardless, naloxone wears off and people can overdose again because they have so much fentanyl still in their system.

Gary Yabuta, executive director for Hawaii’s High Intensity Drug Trafficking Area office, said while the amount of fentanyl seized yearly fluctuates, the drug’s high potency means it can be spread thinner than other additives. Now, no one is sure if street drugs are being mixed with more fentanyl or if people who use are consuming more drugs that contain fentanyl.

“If the mode is transforming from pills to less discrete or encapsulated forms, that might lead to greater consumption,” said Dan Galanis, an epidemiologist with the state Department of Health.

Fentanyl was highlighted in June after it was discovered at a mass overdose at a Waikiki hotel where two people died and three were hospitalized. Honolulu Mayor Rick Blangiardi signed a local ordinance that requires establishments selling alcohol to carry at least two doses of naloxone and to train managers to administer the medication.

Ireland believes people generally stereotype overdose victims, but the Waikiki incident was a wake-up call. “In the bathroom, at a park known for homeless, guy who’s living rough. That’s some of them — but that’s clearly not all of them.”

narcan drug overdose od parking garage stairwell
A locked steel door provided privacy for the patient to use drugs in a stairwell but also prevented the EMS team from reaching him. (Kevin Fujii/Civil Beat/2023)

In Chinatown, the South Kukui Street patient is desperate to be left alone as the EMS team tries to give him medical aid. He’s legally entitled to deny any treatment since he’s alert and knows he overdosed.

Ireland points out that while he appears distressed, the naloxone has suddenly cleared his body of all opioid narcotics.

“So the Narcan took away the fentanyl that was killing him — but it also took away the fentanyl that was getting him high,” he said. “The good news for him is his friends are watching.”

But there’s nothing more EMS can do except pack up and leave for the next call.

The patient becomes an overdose statistic in EMS data and the street tagged as an area with high drug usage where more resources like test strips and Naloxone are needed.

The tracking of fentanyl overdoses may soon change after Hawaii receives its share of opioid settlement payouts, Ireland said. His department plans to buy fentanyl-detection equipment and hire staff to monitor what drugs are causing overdoses. He also wants to buy more Narcan for EMS to use and distribute.

Meanwhile, the homeless community will have to largely fend for itself.

“They’re surviving by grouping together,” says Yabuta. “That increases their survival rate because they can lean on each other.”

Correction: Jim Ireland is the director of the Honolulu Emergency Services Department, not the Honolulu Department of Emergency Medical Services.

Civil Beat’s community health coverage is supported by the Atherton Family Foundation, Swayne Family Fund of Hawaii Community Foundation, the Cooke Foundation and Papa Ola Lokahi.

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