ICU workers see California’s fentanyl crisis up close

SAN DIEGO — As Fentanyl Awareness Day arrived last week, the public got a fresh look at the extremes — lives lost to overdoses and lives saved by the wonder drug naloxone.

But those who work in hospital intensive care units know that this picture is incomplete. They live in the fentanyl fight’s middle ground, seeing an endless cycle of patients arriving, often unconscious, many waking forever changed.

This scourge that killed more than 800 people across San Diego County in 2021, and by all accounts has not let up in 2022 or 2023, has changed the fundamental reality for those who work in the medical intensive care unit at UC San Diego Medical Center in Hillcrest.

Since 2021, the university health care system reported 100 to 120 fentanyl-related hospitalizations per month at its two main facilities in Hillcrest and La Jolla. In March and April, that number exceeded 200.

There are days, said Dr. Jess Mandel, chief of pulmonology, critical care and sleep medicine, when nearly half of the Hillcrest unit’s 13 beds are simultaneously occupied by patients suffering from fentanyl overdose.

“Before fentanyl, I’d say normal was zero to one overdose patients at a time,” Mandel said. “I’ve been a doctor for 32 years, and we’ve always had narcotic overdoses, but fentanyl, I’d say, hit an inflection point about five years ago and has just kept getting worse.”

Critical care specialists have had front-row seats to this particular tragedy.

They receive those who end up in a sort of medical purgatory, surviving an initial attack, generally with the help of naloxone, a drug capable of counteracting the powerful opioid’s deadly effects, but often having gone long enough without breathing that brain damage is a common occurrence.

ICU charge nurse Beth Espinoza says that fentanyl’s ability to put its users in hospital beds has been enough to change her unit’s fundamental patient demographics.

“I’ve been doing this for over 30 years and prior, our average patient age in the ICU was in the 70s or 80s; now, it’s 20s, 30s, 40s,” she said. “They’re not doing fentanyl; they’re doing meth, they’re doing heroin, and everything is laced with fentanyl.”

One case, though it occurred before the COVID-19 pandemic, has stuck with her.

A young couple visiting San Diego ended up in the hospital after taking fentanyl-laced Molly, otherwise known as ecstasy or MDMA, a common party drug. The woman, she said, recovered only to find that her companion was brain dead.

“The guilt she had, she will never ever get over, never,” Espinoza said. “Just watching her say goodbye, it just tore us all apart.”

True victories, she noted, are hard to come by when fentanyl is involved. And impacts do not fall only on the person who overdosed, but on their family, their friends and the people who try to return them to some semblance of normalcy.

Advanced medical care, though, can only do so much. Ten to 15% never wake up. Those who do are not assured a full recovery.

“It’s horrible because you’re seeing these families go through so much,” Espinoza said. “There are just so many of them that end up with lifelong changes that just affects their ability to function independently.

“They’re not able to hold jobs, even if they do survive.”

And some who survive, especially those already living in the margins of society, end up returning in short order.

Mandel said that this relentless churn is difficult to witness.

“I think the hardest thing for some of the health care workers is to see people who Herculean efforts have gone into making better, but then they wave off interventions that might help them chronically,” Mendel said. “We think, ‘That’s a person we’re gonna see again, in a week, a month or six months,’ and it kind of imparts a certain futility to the short-term victory that we had.”

The general public, adds Dr. Daniel Sweeney, a UCSD critical care specialist, often does everything it can to look away from people who are suffering from addiction. Given how addictive opioids are, it’s a mistake, he said, to think that many who return again and again are going to be able to escape the cycle on their own.

“I come back to individualized care,” Sweeney said. “It really depends on that social network, to what their home situation is, to whether they have mental illness or not.”

“And to their friends situation,” Mandel adds. “If every friend they have is also doing this, it’s very, very hard to be part of that network and not go back to using.”

In the end, Sweeney said, it is not likely that fentanyl will be conquered unless there is more embrace of those who are struggling to make progress on their own. There is still far too much social sigma, he said, around treatment options such as methadone and a new drug with similar effects called buprenorphine which, while technically opioids themselves, have been shown effective in medical research to help people return to living productive lives.

“If you asked me what I would want the public to do differently, it is to stop thinking of them as modern-day lepers and to sort of remove some of the judgment associated with this condition,” he said.