Months into his fentanyl use, Gabriel watched someone die in front of him for the first time, he said.
He tried chest compressions and CPR before he fled.
It’s a typical thing, he said, among fentanyl users he knew.
“It’s like a death culture,” said Gabriel, who requested that only his first name be used for fear of losing future employment.
Fentanyl-related fatal overdoses continue to devastate King County’s homeless population. In 2023, it was the No. 1 cause of reported deaths — 67% — leading to a staggering new record of people who died on the street, in shelters or without permanent housing. Methamphetamine is often involved as well.
The drug leads a rise in deaths overall, with at least 421 people experiencing homelessness dead in 2023, according to the King County Medical Examiner’s Office. That’s a 36% increase from 2022, which recorded 309 deaths. And a 115% increase from 2018.
“It’s staggering on every front,” said Dr. Caleb Banta-Green, research professor at the University of Washington’s School of Medicine and director of the university’s Center for Community-Engaged Drug Education, Epidemiology and Research.
But despite these unprecedented numbers, researchers like Banta-Green are saying there’s reason to have hope that things will slowly improve.
From the federal government down to street-level clinics, officials are trying to eliminate barriers to medication for opioid-use disorder, no matter a person’s circumstances.
It’s a dramatic change from winter 2023 when local officials had almost no programs prepared to stem the growing crisis on the streets and decades-old federal laws limited what doctors could do.
Now, Public Health – Seattle & King County has a 24/7 hotline to start medication with only a phone call. The city of Seattle launched a pilot program to start someone on treatment immediately after overdose. King County is working to open a treatment center for people with mental health and substance use disorders by this fall.
While most of these interventions aren’t solely targeted at homeless people, and many are months to years away, some expect a payoff in the long-term.
But many people experiencing homelessness aren’t feeling these impacts yet.
As of April 15, at least 79 people died from an overdose this year.
A path to treatment
Gabriel had detoxed in jail before. The fear of going through that again — the nausea, vomiting, headaches and worse — kept him high.
But now he is on buprenorphine. He’s been in recovery for more than a year.
Medication for opioid-use disorder is the “best tool we have by far to dig our way out of this,” said Banta-Green, one of the region’s leading experts on opioid-use disorder.
And that’s not because it helps people to enter recovery — though that’s an added benefit.
It’s because large population studies completed in the U.S. and U.K. have shown that treatment medications, methadone and buprenorphine, prevent death by about 50%, according to Banta-Green.
“We have to save people’s lives,” Banta-Green said.
Public Health – Seattle & King County officials agree.
They used one of several key changes in federal law, spurred by the current fentanyl epidemic, to launch the county’s 24/7 buprenorphine hotline at the beginning of this year.
In the first two months, more than 70 prescriptions have been written, according to Brad Finegood, who leads the opioid and overdose response for Public Health – Seattle & King County, which he’s taking as a sign of success.
“That just tells me that people want access, (and) whatever the barrier they experienced otherwise, they haven’t been able to get access,” Finegood said.
Anyone can call the hotline, but it can particularly help people who don’t have a car or bus fare or face physical difficulties getting to a brick and mortar clinic. And prescriptions are free.
Additionally, Washington state recently removed a barrier to help medical providers obtain Brixadi, a new long-acting buprenorphine injectable that doesn’t require refrigeration, so it’s easier to bring to people living outside.
“Which gives us some hope,” Finegood said.
Gabriel said his doctor recently switched him from an oral medication to an injectable that lasts for one month.
“It’s definitely a win for sure,” he said.
Currently, people taking oral buprenorphine have to remember to take the daily medication. Methadone requires a person find a way to get to a methadone clinic regularly, but work is currently underway to reduce a person’s clinic visits.
The daily, constant challenges of surviving outside or in shelter make staying consistent difficult, leaving people more susceptible to overdose if they decide to use.
The opposite of isolation
A dearth of affordable housing remains the driving force behind people becoming homeless, not drug use, according to research by University of Washington professor Gregg Colburn and Clayton Aldern.
But sometimes people who are struggling with an untreated physical and mental health issues do turn to drugs to cope with the brutality of surviving on the street. Or people lose housing in the midst of addiction.
Tony Cappa, 31, lost his apartment in the fall of last year. He’d been homeless before, so he told his mom not to worry. “It’s not going to be like this forever,” his mom Patricia Wyllys said he told her.
Tony was sleeping outside a bar in Lower Queen Anne. He was friendly with the people who worked there and cleaned up his bedding every morning, Wyllys said.
But Tony didn’t pick up his bedding one November morning.
Tony died from an acute combination of fentanyl and methamphetamine, according to the King County Medical Examiner’s report.
He was alone. Using alone is one of the biggest concerns public health experts have about homeless people using fentanyl.
“It is very isolating because of how people look down on homeless people,” Wyllys said. “Everybody out there is somebody’s baby.”
To try to foster more connections, Recovery Cafe is partnering with a mobile clinic to offer treatment services, primarily methadone, from the parking lot of its Sodo location five days a week, in addition to offering a free indoor health center.
They want to create “a mini hub of support,” said David Coffey, executive director of Recovery Cafe.
“It moves at the speed of trust,” Coffey said.
But he’s hopeful that providing critical services to help people begin opioid treatment can allow them to slowly build connections with social service providers and learn more about the recovery support and resources the Cafe provides.
On a sunny March day, there was a steady stream of people coming to the parking lot. Some pull up on bikes, get out of the back seats of cars or walk up on foot.
This is the third mobile clinic operated by Auburn-based treatment center We Care Daily Clinics. The model has been such a success, said mobile clinics manager Brooke Gower, they’re currently working to add a fourth.
So far, they’re helping about 30 people daily start or continue opioid-assisted treatment. Gower estimates that at least half of their patients are currently homeless.
Evergreen Treatment Services has offered mobile methadone treatment for over two decades, but last year it launched a new mobile clinic that provides wraparound services and allows people to walk-up and start treatment immediately. It’s currently serving about 120 people and plans to open a second site that will be served by the same mobile clinic in Pioneer Square later this month.
Researcher Banta-Green said that these new interventions, especially providing a wide array of medication access points and increasing the supply of the overdose reversal drug naloxone, are having an impact, even if it’s not obvious to the average person.
“This curve will bend down. It will,” Banta-Green said. “It will probably be within five years, I pray.”
Finding a way out
In the past six months, there’s been a slight decline in overdose deaths in King County, but Public Health spokesperson Sharon Bogan said it’s too early to say if these trends will continue or what’s behind them.
Banta-Green said King County is doing the right things in addressing this crisis, “but the scale has to be so much larger.”
And at the same time, these interventions designed to address our fentanyl epidemic don’t cure a person’s homelessness or solve the region’s broader affordable housing crisis, Banta-Green said.
The U.S. reported the highest number of homelessness in its history last year with more than 653,000 Americans experiencing homelessness. King County and Seattle’s homeless population has increased by 33% since the crisis was declared an emergency in 2015.
But we do know there is chance of survival.
These days, when Gabriel takes the bus downtown and sees people outside using on the street or slumped over in a doorway, he remembers the feeling of being trapped.
“Those people are in a living hell that they don’t know how to get out of,” he said.
He lives in sober housing provided by Weld Seattle, a nonprofit helping people in recovery who have been formerly incarcerated and/or homeless. He’s got two jobs now. He works on cars and is the community beautification specialist for Georgetown.
“So, I pick up trash,” he said, smiling.
He’s put on weight. And that’s a good thing.
After decades of drug use, using fentanyl for two years took Gabriel to the darkest place he’d ever been, he said.
But it taught him one important thing, he said.
“It’s that I don’t want to die.”