Fatal overdoses have more than doubled in the San Antonio area. Driving the surge is fentanyl, a synthetic opioid 50 times more powerful than heroin.
She walked out of a rundown apartment and approached a nondescript gray minivan stopped in the street on San Antonio's near West Side . Her name was Stephanie , and she was wearing a gray T-shirt, rolled-up blue jeans and no shoes.
In her hands was a metal cash box stuffed with used hypodermic needles. She grabbed two fistfuls of needles, used to shoot up heroin and fentanyl, and dumped them into a bright red biohazard container brought by the people in the Ford minivan, outreach workers from Corazón Ministries. In all, she turned in 80 used needles. She got 90 clean ones in return, plus a pack of Narcan, a medication to reverse opioid overdoses. Depending on your perspective, the exchange was a small victory in the fight against IV-related diseases — or it was a grim illustration of the surge of addiction that has swept South Texas, accompanied by a drastic increase in overdose deaths, many caused by fentanyl, a synthetic opioid 50 times more powerful than heroin. Fatal overdoses across San Antonio and the rest of Bexar County have gone through the roof, an analysis of state health department data shows. In 2013, there were 197. Last year, there were 501, a 154% increase. In 2023, the county's rate of overdose deaths was 24 per 100,000 people — double the rate of just five years earlier. The San Antonio Fire Department responded to 4,276 overdoses in 2023, both fatal and non-fatal. That’s 12 calls a day on average, from every part of the city. “Overdoses are happening at a much higher rate because of the introduction of fentanyl,” said Andrea Guerrero-Guajarado, who oversees Bexar County’s response to addiction as director of the department of preventative health and environmental services. “There’s a crisis.” The wave of addiction has created a new normal, especially in downtown San Antonio, a center for the homeless population, many of whom deal with addiction. 'Under the influence' Trish DeBerry, president and CEO of Centro San Antonio, a nonprofit that cleans streets and sidewalks, assists tourists and aims to revitalize downtown, has noticed the change. Walking along Houston Street in the heart of the tourist district three to four times a day, she regularly encounters 'folks that are under the influence.' Some are passed out on benches. Others have sores on their face, an indicator of meth use. “Certainly, we have seen a rise in the use of synthetic drugs,” said DeBerry, a former Bexar County commissioner, political consultant and public relations executive. “It makes folks more aggressive. Meth is a big problem. There’s also opioid use. Then there’s hallucinogens. You see people walking the streets talking to themselves, yelling at people, which makes folks very uncomfortable.” Outreach workers at Christian Assistance Ministry's downtown campus, five blocks from the Alamo, deal with the same problems daily. The nonprofit provides clothes, access to showers and up to 300 sack lunches a day for homeless individuals. Most have severe mental health and substance abuse issues. On a recent Monday morning, a line snaked around the ministry's parking lot as clients trickled into the gated courtyard for lunch. Many were visibly stoned. Some were on edge, ready to fight. Others dozed in the grass or on the cement, apparently sleeping off highs. One man was kicked off the campus after he began arguing with staff members and other clients. A month and a half earlier, paramedics gave him Narcan after he overdosed nearby. Heather Clemmons, the ministry's homeless services coordinator, walked up to another addict with mental health problems. 'As soon as I have a bed, I'll come find you,' she said. He grew agitated, cursing as she walked away. The nonprofit recently hired extra security to deal with increased fighting and substance abuse on its property. Clemmons motioned to one of the guards. 'Hey, Mark, I think someone is smoking meth in the restrooms,' she said as a sweet, burning odor wafted from a portable toilet. 'Again?' the guard asked. The effects of addiction are less visible but no less deadly in wealthy and middle-class suburbs across the region. Brooke Treanor, 31, who grew up on San Antonio's South Side and lived in Tobin Hill, was described as a free spirit who loved the outdoors and travel. She died in 2021 after taking heroin laced with fentanyl. Kyle Hinkel, 28, of Adkins in eastern Bexar County, was an EMT and self-described animal lover who occasionally used recreational drugs. He died from fentanyl in 2022. Fifteen-year-old Noah Rodriguez of Buda, an athlete and jokester who loved playing with his siblings, overdosed on fentanyl the same year amid a string of such deaths in Hays County. ‘Caught a bit by surprise’ A decade ago, most overdoses in the region were linked to heroin and other opioids. Today, the main culprits are fentanyl, a powerful sedative, and psychostimulants such as methamphetamine. Fentanyl and other synthetic narcotics contributed to 183 deaths in Bexar County last year, compared with 14 in 2019, state health department data show. In 2013, autopsies detected the presence of psychostimulants such as meth in just 18 deaths in the county. In 2023, the number was 295, a 16-fold increase. That year's other fatal overdoses were linked to cocaine, heroin, prescription opioids and other drugs, alone or in combination. Among the dead are hardened addicts, but also teenagers, young people and occasional users who didn’t know they were taking a pill or street drug laced with fentanyl, which is so potent that even a minuscule dose can kill you. In 2023, 271 children and teenagers died from overdoses in Texas, including 18 in Bexar County. The numbers of drug-related deaths cited in this article and shown in charts are from the Texas Department of State Health Services. They cover the period 2013-23 and include overdoses classified as accidental, intentional and undetermined. Deaths are listed by the county in which the person died, even if they lived elsewhere. Data for 2021-23 is “provisional,” or subject to change. That’s because it can take a year or longer for authorities to determine whether a death resulted from an overdose. “I think we were caught a bit by surprise to have fentanyl in our midst now,” said Jennifer Sharpe Potter, vice president for research at UT Health San Antonio, a professor of psychiatry and an expert on opioid addiction and treatment. “For a number of years, we have not had to worry about fentanyl in the drug supply,” said Potter, who is also executive director of Be Well Texas, a statewide addiction treatment program. “Now, we have in Texas a poisoned illicit drug supply.” ‘You don't need sunlight’ Nationwide, fatal drug overdoses began climbing in the 1970s. Last year, the number fell for the first time in five years, from 107,941 in 2022 to 105,007 in 2023, a 3% drop, according to provisional data from the U.S. Centers for Disease Control and Prevention. Texas, however, got no relief. Overdose deaths increased 3% in the state as a whole and 4% in Bexar County, according to the same provisional data. During the first three months of 2024, confirmed overdose deaths in Texas and the nation dropped sharply compared to the same period a year earlier, reflecting wider availability of Narcan, among other factors. But experts say it's too soon to draw conclusions about the magnitude of the decline because of a lag in reporting: It can take months, sometimes more than a year, to determine whether a death was drug-related. For that reason, a year's final tally of fatal overdoses can differ markedly from provisional counts. The addiction crisis was decades in the making. In the late 1990s, doctors began overprescribing opioid painkillers such as OxyContin, leading to broad misuse of prescription pills. In the 2000s, as U.S. officials cracked down on opioids, many Americans who had become addicted switched to heroin, which is much more powerful and deadly. As for fentanyl, it has been around for decades and was used primarily to relieve severe pain from surgical procedures. Over the last decade, Mexican cartels recognized an opportunity: Instead of relying on plant-based drugs such as heroin, cocaine and marijuana, they could switch to synthetic drugs, such as fentanyl and meth, which are easier and cheaper to manufacture and far more profitable. Mexican cartels often put fentanyl in fake pills with the same markings as legitimate prescription drugs. “The people who are producing fentanyl are able to do it much more covertly than those who were growing the plants that heroin was manufactured from,” said Dr. Christopher Healey, medical director of two opioid treatment programs at the Center for Health Care Services, Bexar County’s largest provider of mental health and substance abuse services. “It’s lab-based,” Healey said. “You can do it in a covered building. You don’t need sunlight or a big crop field.” What is more, fentanyl powder is much easier to transport. Its potency means traffickers can smuggle small amounts that are hard for law enforcement to detect. In some cases, drug dealers spike cocaine and methamphetamine with fentanyl. “They add it to other narcotics to cut down the amount that they need to use and get a stronger high,” said an undercover narcotics officer for the San Antonio Police Department, speaking on condition he not be identified. Katharine Neill Harris, a fellow in drug policy at Rice University’s Baker Institute for Public Policy, said that for years, fentanyl-related fatal overdoses in the United States were limited largely to the East Coast and the Midwest. That’s because white-powdered heroin was prevalent in those regions, and it was easy to mix in fentanyl, a powder with the same color and consistency. In Texas, black-tar and brown-powdered heroin were predominant. Brown heroin is coarser than white heroin, making the presence of fentanyl more obvious to the buyer. Black-tar heroin is a solid substance, difficult to mix with fentanyl. “It didn’t make as much sense to mix in with brown or black tar heroin,” Harris said. “Now, because of the economic benefits of fentanyl over heroin, we’ve seen a very large replacement with the kind of heroin we see here. Now, much more frequently, we’re seeing white powder heroin in Texas.” That white powder is often spiked with fentanyl. ‘To get through the day’ The Corazón Ministries minivan wound through the streets of the near West Side for six hours, trading clean hypodermics for dirty ones, handing out Narcan and trying to coax people into treatment. At the sight of the vehicle, people spilled out of houses and into the street with their used needles. One woman carried them in an old Coke bottle and a dirty Tupperware container. Another had filled a frying pan with them. A young man in a wheelchair was missing a leg, which likely was amputated after becoming infected from IV drug use. One woman had an abscess and a golf ball-sized bump on her arm where an injection site had become infected. Another walked in a bent-over posture, a common side effect of spinal infections stemming from IV drug use. Corazón’s needle exchange program began in January 2022 and is funded by Bexar County. It’s intended to reduce overdoses, prevent the spread of communicable diseases and help coax people into treatment. In 2023, outreach specialists met with 18,814 people and collected nearly 604,000 syringes. They also provided HIV/AIDS and Hepatitis C testing, wound care and connections to detox or treatment programs. Critics say such efforts facilitate drug abuse and put more hypodermics in circulation. Neil Harris, however, said needle exchange programs have been studied extensively and have been found to be effective. “People don't start shooting drugs because you give them a needle,” she said. Stephanie, the woman who approached the Corazón Ministries van carrying a cashbox full of used hypodermics, is frank about her habit. She uses heroin and sometimes fentanyl. But she tries to be smart about it, Stephanie said, declining to give her last name. She invites friends to her apartment at Alazan-Apache Courts, a public housing complex, so they’ll all have a safe place to use. If one of them overdoses, there’ll be someone to help. “I prefer if they’re going to fix, that they fix here. It’s a safe place,” she said, motioning to her apartment. The windows were covered with blankets, and a window AC unit on the second floor looked like it was about to fall to the ground. Stephanie’s friend, Quintin Dotson, also used drugs. A father of six — five sons and a daughter, none of them Stephanie’s — he went by the nickname Q. Just a few days before the Corazón Ministries team visited the neighborhood, he had overdosed, and Stephanie used Narcan to revive him. Raised in San Antonio, Dotson studied auto repair. For a time, he worked alongside his father raising cattle in Burleson County. He had run-ins with the law. He was convicted of burglary once and family violence three times. He talked about getting clean for the sake of his kids. He hoped to regain custody. Stephanie said she, too, was looking for a way out of addiction. She said she didn’t use heroin for the high, like she once did. “You do it to get through the day, to get up and eat,” she said. Stephanie told the Corazón Ministries team she might be open to enrolling in a methadone program. Methadone is a synthetic opioid that doctors prescribe to relieve cravings and ease withdrawal symptoms. In Bexar County, programs pair methadone with counseling, housing assistance and other support. Scott Dion, a harm reduction and peer recovery coach at Corazón, was part of the outreach team that day. He wore a black T-shirt that said, “Never Give Up — Great Things Take Time.' He told Stephanie he would be happy to connect her with a treatment program. He suggested she stop by the nonprofit's downtown office to talk about it. He also had a warning for her and Dotson. A dangerous new compound had entered the drug supply: xylazine, a sedative and muscle relaxant meant for large animals such as horses. In people, it slows breathing and the heart rate and causes large, infected wounds that can lead to amputations. “Do me a favor. Take care of yourself, bro,” Dion told Dotson, pointing to a tattoo near Dotson’s eye. “I don’t want to get one of those teardrops.” 'Don't stop now' The Corazón team headed toward their next stop: a home about a mile away off Guadalupe Street. They were looking for Angel. Dion knocked on the door. “Hey, it’s your favorite white boy,” he yelled. Dion spent 20 years in the throes of meth and heroin addiction. By his count, he went to county jail 18 times and prison four times. In prison, he joined the Aryan Brotherhood of Texas. He has the tattoos to prove it. During his last stint behind bars, he made a promise never to use again. Once released, he slipped up a couple times. But eventually, he entered a detox program. He got a job with Corazón Ministries and cut ties with the Brotherhood. It’s wrenching work. When he visits a client, he doesn’t know if they’ll be alive the next time he goes to see them. After he announced his arrival outside Angel’s apartment, a couple seconds passed before Angel emerged. He was wearing a white undershirt, jean shorts and black Nike sandals, with a white bandage wrapped around his ankle. His dog, dressed in a pink T-shirt, followed him. Three months earlier, Angel was shot in the leg while walking past a McDonald’s nearby. The Corazón team was helping with his follow-up care. Imran Khan, then an EMT-certified biochemistry major at Trinity University — and Dion’s volunteer assistant for the day — asked Angel if he needed help changing his bandage. Angel said he did. He sat down on the steps in front of his house and stretched out his leg. Khan took out a red medical bag, put on some black gloves and knelt next to Angel. Slowly, he unwrapped the white bandage and cleaned the wound, rubbing it with alcohol and a sponge. While Khan worked, Dion talked to Angel about treatment. He told him they’d be back in a week to check on him. “We don’t give up, right?” Dion told Angel. “You’ve come a long way. Don’t stop now.” One more stop That morning, Dion and Khan had loaded the Corazón minivan with roughly 2,500 syringes and 75 packs of Narcan, along with dozens of first aid, safe injection and safe sex kits. By 2 p.m., they had distributed much of it. They packed up and headed back to the office. On the way, a man on the street flagged them down. He told them a young man, around 18, was living in his car outside his grandmother’s home a block or two away. He’s addicted to heroin, the man said. Perhaps the Corazón team could help. Dion thanked the man and hopped back into the van. They had one more stop to make. ‘A beautiful tree’ Two and a half months later, a woman called 911 to report that Quintin Dotson was overdosing in an abandoned apartment a block from Stephanie’s home. When paramedics and police arrived, he was unresponsive. They found syringes near his body. A police report says first responders attempted 'life saving measures,' and someone — it's unclear who — twice tried to administer Narcan. It was no use. The cause of death: an accidental methamphetamine and fentanyl overdose. Dotson was 40. His family said in an obituary that he 'accepted Christ at an early age” and “learned the principles of God’s Word” at Sunday school at True Holiness Pentecostal Church of Jesus Christ on San Antonio's East Side. They invited Dotson’s friends to “plant a beautiful tree” to keep his memory alive. This article is based on interviews, an analysis of government overdose data and a review of police reports, autopsies and investigative files on selected fentanyl- and meth-related deaths. The San Antonio Express-News spoke to public health experts, law enforcement officials, people struggling with addiction and family members of overdose victims. Photojournalist Jessica Phelps and reporter Emilie Eaton also observed the effects of addiction on the streets, in the company of outreach workers and independently, beginning in early 2023 and continuing until September of this year.
Centro San Antonio San Antonio Fire Department Center For Health Care Services Ford Christian Assistance Ministry The Corazón Ministries Be Well Texas Alamo U.S. Centers For Disease Control And Prevention San Antonio Police Department Rice University Baker Institute For Public Policy Aryan Brotherhood Nike Trinity University Sunday School True Holiness Pentecostal Church Of Jesus Christ AC Scott Dion Stephanie Heather Clemmons Quintin Dotson Jennifer Sharpe Potter Noah Rodriguez Brooke Treanor Andrea Guerrero-Guajarado Trish Deberry Kyle Hinkel Christopher Healey Quinton Dotson Americans Angel Katharine Neill Harris Mark Imran Kahn Q. Brown Adkins Neil Harris Christ Hidden Killers: Inside San Antonio Bexar County Texas South Texas West Side Houston Street Hays County UT Health San Antonio South Side Mexican Guadalupe Street U.S. Tobin Hill Midwest East Coast Coke East Side Mcdonald's Burleson County Alazan-Apache Courts Fentanyl The Corazón Corazón Never Give Up -- Great Things Take Time Tupperware God's Word Hepatitis C Narcan Methadone Oxycontin
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