The author during intake at a psychiatric facility in his teens. He recovered the photograph years later through a records request.
Photo illustration by Slate. Photos by Getty Images Plus and courtesy author.
FENTANYL KILLS. That’s what the billboard says. That’s all the billboard says—FENTANYL in a cold, light blue, KILLS in stark white against an all-black background. Below is a woman on a gurney, treated with the same dead-blue tones as the script above her. She’s covered to her armpits in a sheet, arms at her sides, awaiting an autopsy. Anyone who has seen a cop drama in the past 30 years knows the image.
When an opioid user overdoses, their lips turn a cold, light blue. That was the color of my lips when I lay slumped in a pile outside the automatic doors of an emergency room. Jenny, the girl I had absconded from rehab with just days before, shouted for help, and once she saw the staff stir to action, jumped back in the car. Gustavo, who Jenny had guilted into driving, stepped on the gas, bald tires searching for traction before squealing to life, catapulting them into a night drowning in coastal fog. I imagined the diffuse light from cherry-red plastic growing faint, the EMERGENCY dissolving in their rearview. I’m sure it was traumatic for them. I’m sure they went back to our wretched motel room and immediately got high to blunt the terror. That’s what I would have done.
Splashed across the bottom right-hand corner of the billboard are the insignia of several city agencies proudly supporting its message. What is noticeably absent is any reference to a single resource—not a website, not a phone number, not a mention of how someone might stop using fentanyl and thus avoid their impending death. The billboard looms large over a dirt lot dotted with tarps and tents and other telltale signs of DIY shelters in a southwest Fresno neighborhood where residents already know that fentanyl kills. They’ve lost all manner of kin. In addition to the billboard there are several video spots that run on local television and YouTube: a daughter dies on the floor of her parents’ bathroom; a father sobs over the loss of his precious teenage son, collapsing into the arms of his wife and remaining children.
Donnie, a friend of mine, died in a sober living house he once helped manage. I hadn’t seen him in more than a year, but he was there for me when I was newly sober. He invited me to a gathering of young, sober men where they discussed the novel challenges facing them in the foreign land of abstinence. It turned out the group wasn’t for me—I didn’t feel at home discussing MMA and motorcycles—but I appreciated the gesture. Donnie and I remained friends, chatting frequently outside of meetings about skateboarding and getting locked up and being alive after almost being dead. A year later, when I learned he had overdosed, it stung in a way I wasn’t prepared for. Donnie and I were very different, and we were the same. The thought that he wouldn’t get another chance, not one more day, was devastating.
The billboard ad campaign is one of many tied to California’s $1 billion spending spree that is in part aimed at raising “fentanyl awareness.” In a local news interview, the Fresno superintendent of schools, who was charged with research and development for the project, seemed very pleased with himself. He wore the self-satisfied expression of a do-gooder doing good. He was proud of the message, touting his decision to ask local high schoolers for input, claiming that they had provided valuable information to help them target at-risk youth. In my experience, any teenager willing to work on an anti-drug campaign likely has no idea what at-risk teens need. Those at risk are not staying after school to brainstorm about what version of “Just Say No” is most potent; they’re off getting high somewhere.
Many studies have been conducted on the effectiveness of fear-based abstinence programming, like DARE. The results are in: Fear does not reduce risky behavior in young people. Whether it’s drinking, puffing, fucking, snorting, or shooting, those most likely to engage in this kind of behavior are generally not moved by the spooky presentations given by the people who preach abstinence. And yet here are these billboards, millions and millions of dollars’ worth of them, sprouting up to the satisfaction of the well-meaners and the grim recognition of people who have, at some point or another, looked likely to become one of their cautionary tales. They are grand totems of denial to what might really stop these losses. No one is ready for that.
Photo illustration by Slate. Photos by County of Fresno and Getty Images Plus.
Every Friday at 10 a.m., my sixth-grade class gathered in the cafeteria. The officer’s uniform was tan and gold and blue, with crisp creases. He gave us all workbooks and lots of free swag—pencils, bumper stickers, keychains. He taught us the deleterious effects of drug use, how one sip, puff, or sniff would ruin our lives forever. This all checked out, given the speeches I was getting at home.
My much older brother had started the emancipation process at 14, and subsequently went off to sip and snort and puff and play music and make art. Our mother cried about it openly and frequently, making me promise—which I did, earnestly—never to engage in that kind of behavior. As such, I felt right at home in the DARE program, my hand constantly and confidently rocketing into the air with the answers to everything. My vehement support of abstinence earned me a gold medal made of bronzed metal. At 12, I was the absolute best at not doing drugs. By 14, if I was handed a pill and told it would make me feel good—or even just a little better—I swallowed it.
By 14, if I was handed a pill and told it would make me feel good—or even just a little better—I swallowed it.
I also smoked a lot of weed. I found it helped soothe many of the symptoms associated with the myriad mental health diagnoses I had received. But for my mother and the psychiatrists, the idea that I would “self-medicate” was intolerable. They didn’t want me to self-medicate; they wanted me to follow the medication regimen they’d prescribed. In no way am I knocking psychiatry—psychiatric medication has been profoundly life-altering for me—but I had to find that out for myself, years later. At 15, when I was handed all those diagnoses and the prescriptions that came with them, I felt powerless, forced to take what I perceived to be too many pills: Paxil and Seroquel and Zyprexa and Klonopin and Restoril, and on and on and on.
In America, there are two broad categories that drugs fall under: sanctioned and unsanctioned. Those who use the sanctioned drugs exactly the way they are told to are “taking care of themselves.” Those who use the unsanctioned drugs, or use sanctioned drugs in an unsanctioned fashion, are “weak” and “sick” and “need help.” In the United States, current drug policy is meant to stop unsanctioned drugs from entering the country, punish those who sell them, and force unsanctioned drug users to quit, often steering them toward the sanctioned drugs instead. Because the supply of unsanctioned drugs is wholly unregulated, they often wind up doing much more damage than drugs made in laboratories with government oversight. And sanctioned drugs are simply far more expensive to procure and keep supplied. Many people who turn to fully unsanctioned drugs are trying to get relief for a whole lot cheaper than they can otherwise.
Both sanctioned and unsanctioned drugs can and do ruin lives and lead to death. (An obligatory rant about alcohol would typically come here, because it is a sanctioned drug—as it should be—but it is also among the leading causes of preventable death in the United States.) Yet it’s unsanctioned drugs that usually capture the darker imagination of the public. Modern drug use epidemics that have real consequences for real people become entertainment, rife with sensationalized headlines that miss or misrepresent major aspects of what’s happening, pretending to care about users while instead using their suffering to sell ads and supplement content for 24-hour news cycles. Current anti-drug legislation does something similar, with prosecutors across the nation dusting off laws created during the hysteria that accompanied the crack epidemic and retooling them for the current one. Teenagers with no intention of hurting anyone are being charged with murder for providing pills to their classmates. That’s not justice for the victim—that’s a head on a pike, a warning to people who sell unsanctioned drugs.
In truth, these overdose deaths are accidents that predominantly occur due to one key factor: the unregulated drug supply. Around the turn of the century, as prescription opioids began flooding American streets, overdoses did certainly rise; however, they did so at a much slower and steadier rate because the drugs were pharmaceutical grade and held to stringent FDA testing standards. When people bought an 80-milligram Oxycontin, they knew exactly what they were getting and in what quantity. It wasn’t until that supply suddenly dried up that overdose deaths exploded. This is no surprise, given that the regulated, safer supply was replaced with an unregulated, unsafe supply of stronger drugs manufactured under dubious “lab” conditions.
Fentanyl itself isn’t poison—it is a legitimate medication used in a wide variety of medical procedures every day. Anyone who has been put under for surgery has probably been on the stuff. But here’s the thing about fentanyl: It is a fully synthetic opioid, meaning it can be produced in a lab with only chemicals, no finicky poppy crops needed. It is also quite a bit more potent than its cousins heroin, morphine, oxycodone, et al. This makes it easier to ship and distribute because every dose is of lower volume. Less is more. Around 2016, as doctors pulled back on prescribing opioids, labs in China began making fentanyl to fill the gap in supply. It was so cheap and so potent that cartels and street dealers started making counterfeit pills, buying presses so their product would look just like the prescription opioids their customers were familiar with. When a person is expecting a certain substance in a quantity they’re used to, but instead receives something much more potent, problems arise. Deaths occur. And right now, there is a whole lot of death.
Statistics alone don’t paint the full picture. When I read articles chock-full of stats, I stop seeing people. I see numbers. I’m a person who does better with visuals. For instance, how wide, how deep, would a grave need to be to accommodate the nearly 300,000 overdose victims from the past few years? I conjure images from pandemics and wars—dead upon dead upon dead. Where did they OD? At home? In a car? A bathroom? The airport? Work? Donnie was on his bunk bed. Wherever it happened, they were individual people, each one a life. Fresno County decided they’d amalgamate them into one likeness, approximate them on a billboard to remind those who don’t need the reminder: FENTANYL KILLS.
When I regained consciousness after my overdose, I was confused and pissed off. I had no idea where I was or why an intubation tube was being yanked from my throat. I started clawing at the mess of smaller tubes snaking from my veins. Nurses tried to hold me to the bed and talked sweetly to me. Their tone shifted when I asked the doctor if I was required by law to stay in the hospital. He cautioned me, strongly, against leaving, but also said he couldn’t keep me there. In my small town, the police often showed up in ERs to question—and sometimes arrest—overdose victims. As I put on my pants, soaking wet from an ice bath at the motel (Jenny and Gustavo’s first attempt to reverse my overdose), and one remaining shoe, the nurses were angry. “Ungrateful little shit,” one of them muttered, side-eyeing me.
She was right. I was ungrateful. I didn’t care about my life or all they had done to save it. I was a little resentful that they had bothered. When I asked where my missing clothes were, a nurse said they’d cut my shirt off with scissors before defibrillating. As for the shoe, she shrugged and told me I’d arrived that way. I walked for the exit in my cold, damp pants, wearing one shoe and no shirt.
I tried to return “home,” which was upstairs at a Salvation Army, sleeping on the top bunk in a small room with 15 other guys. It was much better than where I had been sleeping: at the Rescue Mission, or under the freeway, or in a hole I dug next to the hull of a rentable catamaran pulled high onto dry sand. I felt safest by the catamaran, although sleeping on the beach in the middle of January was less than ideal, wet dew soaking through my hood, pulled and tied tight, a sopping mummy in a shallow grave. When the staff found out about the OD—tipped off when the hospital was calling around trying to find someone to claim me—they put me back out on the street for violating the rules. For using drugs. Back to that shallow grave.
I didn’t want to die. I simply wasn’t ready to stop blotting out memories I spent nearly all my time trying to outmaneuver.
Within a few days, I was getting high again. I was, though, a tad more careful in the dose department, given my near-death experience. Deep down, I didn’t want to die. I simply wasn’t ready to stop blotting out those memories I spent nearly all my time trying to outmaneuver. I wasn’t ready to face my trauma or what I had done to others in the subsequent years—I just wanted a break. For many years, getting that break was priority No. 1. I couldn’t yet imagine another way.
While California recently allocated part of their $1 billion fentanyl bill to future fear campaigns like the one in Fresno, Congress is seeking to continue funding something called the SUPPORT Act, which set up a $20 billion fund to help state and local governments access money to treat those in their communities with opioid use disorder. This is a good thing. Offering treatment is most certainly better than trying to scare people straight. It isn’t, however, working. Since they passed the act in 2019, overdose deaths have continued to soar. Meanwhile, America continues to invest resources that dwarf that total in the war on drugs, which just about everyone agrees has been an abject failure of almost unfathomable scope and consequences.
To the north, there is another view. Vancouver’s Downtown Eastside neighborhood, like the rest of North America, has an overdose problem. The scene there can be pretty grim—throngs of people sleeping on sidewalks, or shuffling around, dead on their feet, so to speak. There is no denying that a lifetime of drug use can, indeed, be pretty grim. Even if a person doesn’t die from overdose, veins collapse, abscesses emerge, bloodborne pathogens proliferate, and a lack of proper hygiene or nutrition leads to rashes, infections, tooth decay, and emaciation. It has also led, in many cases, to abject poverty, hopelessness, and despair. It’s worth acknowledging that this is the far end on a spectrum, and that there are plenty of dependent users living what most consider a “normal” life, camouflaged among all the other “normal” lives. Still, this neighborhood in Vancouver isn’t hiding the potential consequences of drug dependence.
Canadian law, while certainly not perfect, does allow for a measure of compassion that the United States decidedly does not. Vancouver, along with some other cities in Canada, has institutionally staffed safe injection sites and needle exchange programs, not to mention universal coverage for medical and mental health care, including treatment for substance use disorder. And on the revolutionary fringe of Canadian law is a precarious operation run by compassionate medical professionals, a pilot program that actually prescribes diacetylmorphine—more commonly known as heroin—to patients who are chronically dependent. Most of these folks have been using for 20 years or more, but now, they travel down to the clinic four times a day to get their fix. (Eligibility requirements vary, but typically only people who are diagnosed with treatment-resistant substance use disorder and are actively using illegal street drugs qualify.) According to a doctor who once ran the program and was interviewed for the documentary Opioid Tragedy, chronic users who participate in the program are no longer required to spend all their time and money procuring drugs by any means necessary. So instead, they do things like “reunite with family, get jobs, go back to school, attain housing.” One patient, a man who has robbed 60 banks and spent decades in prison, was also interviewed. “I’m grateful to say that I’m now a retired bank robber,” he said. He is not alone: other reporting bears out how the program has transformed lives in Canada.
This may seem hard to fathom. Giving people these drugs? There are certainly critics: Some suggest the safe-supply drugs could end up resold on the streets, while others believe administering them violates a doctor’s oath to do no harm. (Those same doctors often push people toward “opioid substitution therapy,” which is the practice of prescribing opioids to treat use disorders—in other words, safely supplying opioids.) And the idea remains a third rail in America, where New York City only recently opened the nation’s first safe-use clinic—in which drug users are supervised, but bring their own drugs—and the Biden administration is still in the early stages of quietly studying the efficacy of such sites. While policymakers in the United States tinker with the bare minimum, the Vancouver programs are actually addressing the dangers inherent to an unsanctioned drug supply that contains unknowable amounts of fentanyl and its analogs. It has been running for about a decade, during which it has provided a stable of research on the matter. “The public health response to a poisoning epidemic must be to provide a safer alternative,” as one researcher put it. “Unless there is a radical change in our approach to the epidemic, overdose deaths will continue unabated.” The results are promising, particularly in avoiding preventable death, and researchers are steadily conducting studies that are providing much-needed insight into what has been, historically, an elusive population.
These developments make me both hopeful and a little weary. Academics do studies; substance use specialists tout treatments. I’m not an expert, but I reckon the reason our federal government can spend a collective $60 billion a year on prevention and treatment and still see an astronomical increase in deaths is simple: The prescribed method doesn’t work. There are lots of nuanced elements at play here, but at the center is something fairly straightforward: the collective “we”—meaning the majority of American citizens and nearly all policymakers—cannot stomach the idea that we would let people get high on unsanctioned drugs. That concept is beyond what’s tolerable. We feel we must save people from themselves.
What I want to know is: Why doesn’t anyone ask us?
When I saw that dead body on the billboard, casting a long, dark shadow over a suffering community that didn’t need its message, a deep sadness washed through me, followed by an all-too-familiar sense of resignation. It’s a common scenario: The government folds to pressure, knowing it must do something about a problem, but is more interested in optics than meaningful intervention. I was staring at a billboard that offered a generic message above a terrifying image, with all those official logos poised as endorsements along its bottom border. Advertisements. Like they were supporting something noble. But being noble is not what they’re interested in. Not really. They just know they need to do something. The billboard is, I suppose, a thing. And that’s all it is.
The first day I drove by it, I began researching its origins right when I got home. What I found first were several news stories lauding the effort. What struck me most was the disconnect. No one seemed to know anything meaningful about the problem—not the newscasters, not the City Council officials, not the teens who helped develop the message—aside from the fact that “fentanyl causes death.” I also found the campaign was not a one-off: Another had been developed by a local woman who lost her son to an overdose. It was crafted using the same kind of frightening imagery—the Grim Reaper, skull and crossbones, etc.—only the slogan was ONE PILL CAN KILL. I have no doubt this mother was grieving the loss of her son and wanted nothing more than to save another parent from her pain. I know that at least some of these people have the best intentions. Unfortunately, there exists a cavernous gap, a fundamental chasm, with fear-based and ultimately meaningless signals on one side, and the complicated nature of saving lives in an often maligned and misunderstood community of chronic users on the other.
It does no good to blame policymakers or journalists or the public for this misunderstanding—it is a narrative that has been passed down through generations. What I want to know is: Why doesn’t anyone ask us? So much time and money and energy are spent trying to prevent people from using drugs, while almost none is spent trying to mitigate the effects of something that is, quite frankly, not preventable. America’s appetite for drugs has a one-way trajectory: up. Part of the solution can be education—real education, based on scientific evidence, centering harm reduction rather than abstinence—but that doesn’t seem to be of much interest. The collective agreement is that if we can scare the kids, they won’t do drugs. With hundreds of thousands of overdoses in recent years, something tells me the kids of my generation weren’t sufficiently scared into abstinence, nor was the generation that has come of age since. The politics of fear has proven quite effective in elections but pretty useless when it comes between a person and their vices.
At the time of my overdose, I was actively driving my life off a cliff. In the years following, I got a steady job, sought therapy, and stopped engaging in much of my former high-risk behavior. I wouldn’t, however, stop using for a number of years. By then, I was leading what many consider a “normal” life. It was still full of dysfunction, but I managed to keep my job, my car, my housing, my marriage, my friends—all the things one points to and says, “Look. Normal!” I was able to stop using thanks in part to medically assisted treatment, and I’m very grateful for that. But that was just one piece. It also took a lot of hard work to become healthy again, and I had many luxuries that many with my disorder aren’t afforded: health care, a supportive network of people, and enough money to get by while I sorted myself out. There are plenty of users who would likely start seeing a profound difference in their lives if they simply stopped having to hustle for dope, if they didn’t have to congregate in the liminal spaces where we herd the dispossessed, and if, instead, they obtained their drug of choice legally, from licensed clinicians who care.
The above idea likely causes many readers to squirm. But if there were a sincere interest in damming the flood of death swallowing up so many lives, it is what we would do. The way things are set up now, a drug user has two choices: get treatment in whatever fashion is mandated or keep using and work their way toward death. Dependent users know a thing or two about the loss of autonomy—they live every day at the behest of their habit. Many would stop if they could. And perhaps, if given the chance to do so in their own time, in their own way, they would eventually stop using. But why must that be a requirement? Why must a user do it the way they’re told, or else risk losing access to services? It’s just another way to dehumanize drug users, assuming they can’t possibly know what’s right for them. While it’s true that many drug users engage in self-destructive behavior, much of that behavior stems from the fact that they’ve been relegated to the edges of society. Shamed into isolation. Exiled.
FENTANYL KILLS. A dead body. Those are the only two things on that billboard. It isn’t a lie—fentanyl is killing a lot of people. The grave is wide, long, and deep, and growing more cavernous every year. But that billboard is not, in any way, helping. It is, in fact, a callous disregard for human life. The billboard towers over a community in desperate need of aid. It represents millions of dollars spent trying to scare people into abstaining from use altogether rather than implementing policy initiatives that might prevent fentanyl overdoses. With all the money currently being hurled at the problem, creating an emergency order that includes a safe supply for dependent users is an actionable solution. Saving lives might not look the way many envision it. And unfortunately, it seems that without that vision, which always seems to include some version of the sparkling redemption narrative, no one is interested.
An actor was paid to play a dead woman for a scare campaign while a now-deceased fentanyl user could have been kept alive for one more day for a lot less money. And maybe, after a string of one-more-days, that user would have decided to try something new. That it was time for redemption. Or maybe redemption has nothing to do with it. Redemption is just another day alive.
Addiction
Congress
Drugs
Mental Health
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