PROVINCETOWN — Gwen Kavlouskas-Noyes, who owns Big Daddy’s Burritos in Provincetown, says that though she has long been aware of the problem of opioids, they always felt distant from her life. But when a representative of the AIDS Support Group of Cape Cod came to her business promoting training for Narcan, the life-saving opioid overdose reversal drug, she realized something had changed.
There was reason to worry because fentanyl, the potent synthetic opioid, is being found more often in non-opioid recreational drugs. “It scared the crap out of me,” said Kavlouskas-Noyes, who lives with her husband in North Truro. She asked ASGCC to conduct a training session for businesses in the Aquarium Mall, where her restaurant is located.
Over the past several weeks, ASGCC has been sounding the alarm in Provincetown about what it says is fentanyl being found more often in drugs such as cocaine, Adderall, and Percocet. Staff have been conducting Narcan training at bars and businesses and held a first community forum on fentanyl at their new drop-in center at 311 Commercial St. on June 27. A second forum will take place at 4 p.m. on Thursday, July 13.
Fentanyl, about 50 times more potent than heroin, first came on the scene in the late 2010s, when it began showing up in heroin and counterfeit opioid pills.
Because just milligrams can be fatal, fentanyl’s growing prevalence has coincided with a steep increase in opioid-related overdose deaths. In 2012, there were 733 such deaths in Massachusetts; in 2022, according to data released last month by the Mass. Dept. of Public Health, there were an estimated 2,357. In that year, 93 percent of opioid-related overdose deaths where a toxicology report was available showed evidence of fentanyl.
Fentanyl’s presence has “increased significantly,” said Matt Davis, the regional vice president of Acadia Healthcare, which operates a mobile methadone clinic in Wellfleet and conducts drug testing. And not just in heroin but also in cocaine and other types of injectable drugs, he said.
On the Outer Cape, fentanyl has become essentially ubiquitous in opioids. According to Kim Powers, a former ASGCC staff member who now leads her own harm reduction services under the nonprofit Access HOPE, fentanyl in opioids is so common that testing for it simply won’t make a difference.
Eliza Morrison, ASGCC’s assistant director of harm reduction services, sees the same trend. She told those present at the first forum that fentanyl has basically supplanted heroin altogether as the opioid of choice.
In 2022, EMS services responded to 8 opioid-related incidents in Eastham, between one and 4 in Wellfleet, 6 in Truro, and 11 in Provincetown, according to state data. Wellfleet also saw one overdose-related death in 2022.
Dan Gates, the executive director of ASGCC, said these numbers could be underestimates because of the way overdoses are reported. He said so far this year, Wellfleet, Truro, and Provincetown have each seen one fatal opioid overdose.
Regular opioid users tend to be aware that fentanyl is present in their drugs and develop a tolerance. But, Gates said, “what’s been really a shift in the last year in particular is the presence of fentanyl in other substances.”
ASGCC says it is identifying fentanyl in more and more non-opioid drugs, especially stimulants. Morrison said that “most every substance” the group tests that is not an opioid still registers trace amounts of fentanyl.
According to Traci Green, who heads the Opioid Policy Research Collaborative at Brandeis University, about 15 to 20 percent of powdered stimulants — particularly cocaine — in Massachusetts are testing positive for fentanyl.
Though Green didn’t have Cape-specific numbers, she said drug use on the Cape tends to be seasonal, with more recreational or experimental use in the summer. “When there is more powder coke, we definitely see more powder fentanyl coming in at the same time, and that’s when things are very vulnerable to contamination,” Green said.
Gates said the presence of fentanyl in non-opioids creates new risk factors for stimulant users or people who may only occasionally use drugs at parties or clubs and who wouldn’t necessarily think they could be ingesting fentanyl.
“So, suddenly someone, some Saturday night, is at a bar, and someone offers them a line, and they think, ‘Oh, why not,’ ” Gates said. “And they don’t realize they’re at risk of an overdose.”
A New Drug Appears
Powers, who also conducts drug testing, said she thinks the presence of fentanyl in cocaine is overblown and said she’s rarely found fentanyl in methamphetamine samples. But she — and those at ASGCC — raised concerns about a new drug beginning to pop up alongside fentanyl in the drug supply: xylazine.
A powerful animal sedative, xylazine is paired with fentanyl in some pills, Powers said. She said that while the drug is far more common in Boston, “it’s trickling in” to the Cape’s drug supply. Xylazine complicates harm reduction efforts, Powers said, because it can create serious skin wounds or cause infection.
Powers also said she has seen MDMA, GHB, and ketamine — all popular party drugs, particularly within the queer community — test positive for fentanyl “sporadically over the last four years.
“The drug supply is contaminated and adulterated, and it’s not a clean supply, so you don’t know what you’re getting,” she said. “That’s why drug testing is so important to try to see what’s in the drugs that people are using.”
ASGCC has partnered with Outer Cape Community Solutions to purchase NaloxBoxes containing free Narcan and place them at various locations in town over the coming weeks, including at town hall and the MacMillan Pier bathrooms. Gates, at the forum in June, likened them to “lending libraries” for Narcan.
Katie Ledoux, a former ASGCC staff member who now co-manages The Underground in Provincetown, said she has given her staff Narcan and fentanyl test strips for anybody who they know might be using drugs. For her, this practice stems from principles of harm reduction, which recognize the reality of drug use and aim to minimize its negative effects.
“I don’t want anybody doing drugs in my bar, but I’m also not ignorant of the fact that it’s happening,” Ledoux said.
For Kavlouskas-Noyes, it’s a question of being able to handle an overdose the moment it happens.
“If someone’s going to be at risk coming into my establishment,” Kavlouskas-Noyes said, “I definitely want to be prepared, because rescue can’t always zip down Commercial Street. I figure that short window between response and when they could get here could make a big difference.”
In Provincetown, Gates said, the risk can lie in non-opioid users who take an occasional pill or bump of cocaine — the “weekend warriors” who might not know about Narcan or have access to it in their social networks. The window to reverse an overdose can be just minutes, and a friend, bartender, or even a total stranger with Narcan can make the difference.
“The point,” Gates said, “is to get it out to as many people as possible.”