This is the second article in a three-part series examining the realities of methamphetamine use in Oakland, and efforts to address this growing public health crisis. If you’re new to the story, start with Part One.

In the early 2000s, Katie O’Bryant was a homeless teenager living on the streets of Berkeley and San Francisco. Like many people who use drugs, she found that different substances played very specific roles in her life. 

As someone who was opiate dependent, O’Bryant needed to use heroin to function on a day-to-day basis. But she also took other drugs recreationally to get high and relied on stimulants to balance out heroin’s sedative effects—something that dealers took into account by selling heroin and cocaine as a packaged deal. 

“When I first started doing dope, they used to sell one-on-ones in the mission. All the dope came with coke,” she said, recalling that small balls of black tar heroin would be sold alongside little baggies of powdered cocaine.

Today, O’Bryant works in harm reduction as the Outreach Coordinator for West Oakland Punks with Lunch, a group that provides food, clean needles, and social services to Oakland’s unhoused population, which includes many people who use drugs. She explained that in her work on the streets of Oakland, she sees a lot of poly-substance use—the term that health workers use to describe someone who routinely uses multiple substances. 

“You will so rarely find somebody who is a puritan with their drugs,” she said. “People have favorites, people have necessities, and [people] have recreational things.”

However, the combinations of drugs that O’Bryant encounters on the streets today have evolved since the early 2000s. Now, poly-substance users most commonly rely on the combination of fentanyl and methamphetamine, a synthetic sedative-stimulant pairing that is much stronger, and more dangerous, than the heroin-cocaine amalgam of two decades ago.  

Said O’Bryant, “We just have way stronger meth than we used to have ten years ago. Our whole drug supply is becoming more powerful, more dangerous, and more harmful.” As The Oaklandside previously reported, the rise of unprecedentedly-potent meth and fentanyl has caused increasing harm to the physical and mental health of thousands of people in Alameda County in recent years. 

The effects of these drugs—which include rising behavioral health issues as well as a startling surge in overdoses attributed to methamphetamine use—are especially detrimental for members of Oakland’s unhoused population who use meth. People who experience homelessness not only find practical utility in meth’s stimulating effects, and therefore are at a greater risk of developing methamphetamine use disorder, but they also confront significant barriers when it comes to accessing health care and treatment for substance use disorder. 

Meth use is nuanced and complex, especially for people experiencing homelessness

One common assumption about homelessness is that meth abuse pushes individuals onto the street, causing their homelessness. But this doesn’t match up with what health workers see among many of the homeless in cities like Oakland. Rather, some people experiencing homelessness start to use meth because they become unhoused and are looking for a tool to help them confront the challenges that come with living unsheltered.

Sidney Siu, a case manager with Downtown Streets Team, an outreach and employment placement organization for people experiencing homelessness in Oakland and other California cities, explained this phenomenon. 

“Many people who use substances like methamphetamine on the streets have actually started using because they became unhoused,” she said.

Siu ties that pattern to the cost-of-living crisis, although she emphasized that there is no single reason that people become unhoused.

“It isn’t incorrect to assume that substance use is a factor, but it is incorrect to assume that substance use is the main factor because the main factor is a lack of affordable housing,” she said. “It isn’t a straight line.”

In areas with large unhoused populations, like Oakland, meth serves a utilitarian purpose. When an unhoused person is living on the street or in an encampment, the stimulant offers a form of protection through heightened awareness. It also helps to curb hunger, and balances out the sedative effects of other commonly abused substances like opioids or benzodiazepines.

The size of Oakland’s unhoused population nearly doubled in the five years between 2017 and 2022, surpassing 5,000 last spring. The city’s rising rate of homelessness, which largely affects Oakland’s Black residents, has been attributed to the pandemic, structural racism, and a lack of affordable housing. 

Doctors who treat unhoused people and people with substance use disorder have noticed a correlation between meth use and homelessness. “[People] use meth to stay awake and not get assaulted when they’re sleeping outside,” said Dr. Erik Anderson, an emergency and addiction medicine specialist at Oakland’s Highland Hospital. 

Unhoused and housed people use meth alongside other addictive and commonly abused substances like heroin, fentanyl, and alcohol. Poly-substance use increases an individual’s risk of experiencing overdose. Sometimes a person is purposefully consuming two different drugs in combination, often to balance out one drug’s effects with another, but unintentional polysubstance use is also common, notably with people who consume adulterated substances, such as meth laced with fentanyl. 

“It’s easy to fall into the tracks of ‘let’s talk about meth, let’s talk about opioids.’ But these things are so related. There isn’t a group of people that just uses heroin, or just uses fentanyl, or just uses meth,” said Anderson.

Intentional poly-substance use often stems from an individual looking for different effects that a single substance alone can’t offer. For people experiencing homelessness, the effects that various drugs can offer—relief, escape, stimulation, heightened awareness—can feel necessary in order to survive the realities of life on the streets. 

“People have been using heroin in Oakland for like 50 years. So, there are a lot of people who know how to use heroin safely. Meth is newer and more chaotic and does something totally different to your body.”

Dr. Erik Anderson, emergency and addiction medicine specialist at Oakland’s Highland Hospital.

Engaging with multiple substances extends up the ladder to substance production and distribution, too. Law enforcement officers and Oakland DEA case files tell us that the groups responsible for dealing meth in Alameda County are the same ones that are distributing heroin, fentanyl, and other controlled substances. 

“It’s not tidy,” said Dr. Andrew Herring, an emergency medicine doctor and director of research at Highland Hospital. In 2017, Herring founded Alameda Health System’s Bridge Clinic at Highland Hospital—an innovative program for patients with substance use disorder in the heart of Oakland that is highly accessible by design. Herring expanded that vision to help create the state-wide CA Bridge program in 2018 to assist hospitals around California in developing effective addiction medicine programs. 

Herring explained that the effects of drugs like fentanyl and meth are understandably valuable in challenging circumstances—even hypothetical ones. “Let’s say it is a zombie apocalypse. What would you want in your little survival pack?” he asked. “You’d want an incredibly potent and powerful painkiller,” he said, referring to opioids. “And [you’d want] something that helps you stay up at night, be more intelligent, have a higher IQ, and be stronger and faster,” he said of meth. “I mean, it’s really an amazing performance-enhancing drug.”

Finding utility in multiple drugs associated with substance use disorder is not a practice unique to people who are unhoused. “There’s a reason that every military will have both some sort of stimulant and some sort of opioid,” said Herring. “It’s not irrational.”

Still, the continuous need to balance out the effects of a sedative with a stimulant, and vice versa, can create a cycle that perpetuates addiction. Sarah Windels, a founding member of CA Bridge, explained that among unhoused people, that cycle often takes the form of opioid use during the day and methamphetamine use at night. 

“If you think about somebody who is already living on the street because of their opioid use disorder, they need to stay awake at night to guard themselves and safe keep their belongings,” she said.

As a result, people experiencing homelessness in Oakland are at a greater risk of overdosing from methamphetamine. According to the Alameda County Homeless Mortality Report, overdoses among Oakland’s homeless population were “increasingly due to psychostimulants such as methamphetamine” between 2018 and 2020.

Oakland’s meth crisis disproportionally affects people of color

The spread of cheap and highly-potent meth impacts Oakland in a way that reflects existing social and racial inequities. 

The high overdose mortality rate experienced by Black people in Oakland who use meth mirrors the disproportional impact that the opioid crisis has had on the city’s communities of color. “This disparity is real and has been getting worse in the past couple of years,” said Anderson.

Alameda County’s Black population faces a much higher risk of overdosing on a psychostimulant such as meth compared to the county’s white residents, according to data gathered by the state Department of Public Health. And the rate of overdose deaths among Black people locally is climbing at a faster pace than it is for white people who use meth. 

At the end of 2021, the rate of psychostimulant deaths among Alameda County’s Black population was 13.71 per 100,000 people, a 63% increase from the 2020 rate of 8.1. That same year, the rate for white people in the county was 9.23 per 100,000, marking an increase of 55% from 2020’s rate of 5.94.

Viewed over a slightly longer timeframe, the unequal impact of meth on Black people is startling. 

For 2018, there were 6 psychostimulant deaths among Black users in Alameda County, with a rate of 3.53 per 100,000. By the end of the second quarter of 2022, the 12-month running number had shot up to 47—an increase of nearly 700% in just five years. “I mean, you don’t have to squint. Just pull up that chart. Literally, African American mortality has gone up seven times since 2018,” said Herring. 

And yet, more white people in Oakland use meth than do Black people according to hospitalization data. The fact that despite that disparity, Oakland’s Black residents are dying at a higher rate, indicates that other factors are at play, such as socio-economic inequities that fall along racial lines and expose more Black people to poverty, homelessness, addiction, and lack of access to adequate health care.

The layering of social inequities in Oakland that disproportionally affect communities of color makes it that much harder for Black people who use meth to receive equal access to addiction medicine care. “You can’t have untreated substance use disorder, untreated homelessness, untreated psychiatric diseases, and then expect someone to fully engage in treatment,” said Anderson. 

In Oakland and across the state, meth’s disproportional impact upon communities of color appears to have been exacerbated by the racial health disparities laid bare by the COVID-19 pandemic. 

Across California, meth’s overdose mortality rate among Black people, especially men, saw a noticeable spike after the onset of the COVID-19 pandemic in 2020. At the end of 2019, the rate of psychostimulant-induced overdose death for Black Californians was around 12.33 per 100,000. Two years later, at the close of 2021, that number had more than doubled at 27.62.

Caring for people with methamphetamine use disorder presents unique medical challenges

In his work at Highland Hospital, Dr. Erik Anderson often has discussions with patients who tell him about changes in the properties of street drugs. But while patients will give him details about changes in the local heroin supply—especially when it comes to the presence of fentanyl in the drug—he is unable to glean the same information about new directions in meth production and distribution. People who use meth are less inclined to discuss these matters.

Still, Anderson and other physicians are aware of so-called “new-meth,” an unprecedentedly potent version of the drug created using an older method known as P2P, which you can read more about in our previous reporting. 

“You can read about how manufacturing is different, mass supply, that sort of thing, but I don’t feel like patients report that to me quite as often,” Anderson said. He suggested that physicians may need to ask stimulant users about the changing meth scene more directly. “Maybe we’re not talking to people enough about it,” he said.

Having those conversations may be challenging, in part because people who use meth can develop chronic behavioral issues and symptoms of psychosis that make it difficult to engage in productive conversations and stable treatment.

“It’s certainly a harder thing to understand and harder to engage with patients about,” said Anderson of meth’s changing role in Oakland. 

The drugs’ effects on people make it hard to get a clear picture of the changing methamphetamine scene, which differentiates it from other substances also known to be addictive and dangerous. 

“If you’re only using heroin daily, it’s dangerous and it’s a disease we need to take really seriously,” said Anderson. “[But] it’s a different ballgame if you’re using meth daily; it’s more chaotic and unstable.” 

“People have been using heroin in Oakland for like 50 years. So, there are a lot of people who know how to use heroin safely. Meth is newer and more chaotic and does something totally different to your body,” he said.

Part of what Anderson is referring to is meth’s effects on the brain. Opioids have psychological consequences, most notably limiting the brain’s ability to experience pleasure and manage pain on its own. However, meth—especially new meth—causes symptoms more akin to psychosis, making it challenging for physicians to communicate meaningfully with many patients. 

Often, doctors struggle to determine whether behavioral issues are being brought on by the drug, or exist independently. In Highland’s Emergency Department, Anderson and his colleagues frequently see psychosis as a predominant feature of either meth intoxication or chronic meth use. “It’s tough to know what the driver is,” Anderson said. “Is it meth or is it a psychiatric disorder?” 

To Anderson, that distinction is often a false dichotomy: because meth lacks an effective medical treatment, a patient’s psychiatric symptoms will be treated the same as they would in a patient without substance use disorder. 

“It’s possible and often is true that some patients have an underlying psychotic disorder like schizophrenia, and it’s hard to know which one is predominant,” he said. “[That] makes the treatment much more complex.” 

Difficulties when it comes to effective behavioral treatment are intensified by the fact that, unlike opioid use disorder, methamphetamine use disorder has no chemical treatment options. 

“With opioids, buprenorphine and methadone are so wildly effective,” said Anderson, referring to the two drugs that help to counteract opioid addiction. “I probably would say they are the most effective medicines we have in all of healthcare for [reducing] mortality and for patients having quality back in their life.”

Katie O’Bryant of West Oakland Punks with Lunch received a combination of methadone, buprenorphine, and naltrexone as well as behavioral therapies to treat her heroin addiction. While she found that the medications caused her discomfort, she also credits them with having saved her life—but they were only one piece of that process. Getting access to housing, behavioral care, and other services in addition to medication-assisted treatment was critical.  

By way of contrast, in Oakland and across the country, medical treatments for meth addiction are either minimally effective or still being tested in clinical trials. 

Addiction professionals agree that the most effective treatments for substance use disorder rely heavily on both medical and behavioral therapies. Without being able to offer a substance that can counteract a patient’s addiction—and possibly curb their symptoms of psychosis, even temporarily—physicians are unable to offer effective behavioral health support such as therapy.

“If we treat any substance use disorder, we think about what medications can be used and what behavioral health support we can offer. Those are the two core things. And for meth, there’s not a good treatment option [through] medicines,” Anderson said. 

When a person is withdrawing from an opioid such as fentanyl, they can be quickly stabilized and directed to care. The same option does not exist for meth. Therefore, when a patient is experiencing meth-induced psychological symptoms, they are more likely to fall through the cracks. 

“The difficult part is linking those patients [to services], and especially the more severe cases who have complex social barriers to care,” Anderson said of patients who use meth and are unhoused. “If you’re in that situation, it’s really hard to connect to services that are effective.”

In the absence of an effective therapeutic medicine, health workers do the best they can

On the streets, outreach workers are confronted with the behavioral challenges presented by people who use meth – which they say are getting more pronounced. 

For O’Bryant, the worsening behavioral symptoms mark a shift from the effects of meth that she saw as a young person living on the street. “I’m seeing way worse psychiatric problems,” she said. “And I’m seeing it faster, and seeing a lot more shit that may be irreversible.” 

While the number of people with worsening psychiatric symptoms as a result of chronic meth use is increasing, not everyone experiences such severe effects. 

“It’s a spectrum of disease like anything else,” said Anderson. “Some people use it and have fewer problems. Some people have tremendous problems.”

For O’Bryant, who has worked in outreach for over two decades, understanding that substance use disorder varies from individual to individual is crucial to fixing the problem. 

“We need to have more individualized treatment,” she said. “I think the idea that there’s a blanket cure for any of these things that will work for everybody…really lacks an understanding of how people and substances work.”

At Punks with Lunch, O’Bryant and her colleagues work hard to be client-centered. That means asking people what has been effective for them in the past and listening to folks’ ideas of which approaches might work well with their lives and abilities.  

Still, she firmly believes that there is a universal benefit to offering reliable housing and access to mental health services that will help to stabilize most people who use drugs, including meth. 

“People understand their own experience and themselves way better than you ever could,” she said. 

This is the second piece in a three-part series on methamphetamine use in Oakland. Next, we’ll cover the novel initiatives underway to help treat meth use disorder, which could include an experimental trial taking place at the Wilma Chan Highland Hospital Campus.