The Fentanyl Fold

(photo by Stephen Lam/The Chronicle)

That fentanyl is a modern-day plague is a well known fact--in 2024 San Francisco had 635 drug overdose deaths, of which over 70% included fentanyl--yet much remains unknown about the deadly opioid. For example, why do fentanyl users contort themselves into an unusual standing position?

Dr. Daniel Ciccarone, UCSF professor of addiction medicine, said what he calls the “nod” is a common side effect of opioid use.

“It’s not much different than the experience of being in a boring lecture and falling asleep,” Ciccarone said. “It’s a version of losing consciousness. But not to the point of losing consciousness –– they’re still conscious.”

These nods have always happened to varying degrees with other opioids, particularly heroin. The nods with fentanyl, however, seem to be more extreme, Ciccarone noted. And it’s often a sign that a person has taken too strong a dose, he said.

“What you’re witnessing is the balance point between passing out –– when you lose all muscular control and are on the floor –– versus some small remnant of consciousness that is keeping the person upright,” he said.

Fentanyl, which can be up to 50 times more potent than heroin, can induce this “low point of consciousness,” which is believed to be euphoric, Ciccarone said.

“As opioids get stronger, the nod gets deeper,” he said. “The dials are just being turned down. Consciousness, breathing, muscular control are going down … and this is just one of the visible signs of it.”

Repeated positioning in the fold can itself cause severe health problems:

UCSF orthopedic surgeon Dr. Alexos Theologis, who specializes in the spine, said some people probably slump because of muscular issues. But going into the fentanyl fold position too much over a long period of time can cause severe damage to the spine, neck and back muscles, he added.

Theologis said there’s nothing in the use of fentanyl itself that will cause people spinal problems, but such prolonged folding can lead to chronic issues.

“The postures I see … are very, very disabling,” Theologis said. “We have studies that demonstrate these postural changes (are) … among the most disabling medical conditions anybody can experience. It’s similar to cancer treatment and pain associated with cancer.”

Whatever one may think of President Trump, his stated goal to eliminate fentanyl from the streets of big cities will help the most wretched who live among us.