Today a story was released that provides reasons why Fentanyl users fold over after taking the drug.

One doctor says “UCSF professor of addiction medicine Dr. Daniel Ciccarone said what he calls the “nod” … 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.” That claim is sort of accurate, but what does it really mean? But why does loss of muscular control cause the users to fold? Why don’t they just lay down? Why don’t they sit down? Why don’t they assume some other position? Why specifically do they fold over? Another doctor says basically the same thing “UCSF orthopedic surgeon Dr. Alexos Theologis, who specializes in the spine, said some people probably slump because of muscular issues.”. Once again the question is why do users fold over? Why not take some other position because of these “muscular issues”. What these doctors are doing is giving a very broad reason that is sort of correct as far as it goes, but the explanations provide no specifics.

Here’s why fentanyl users on S.F.’s streets are bent over

It’s become a ubiquitous sign of the fentanyl crisis unfolding on San Francisco’s streets: scores of seemingly comatose drug users slumped over in extreme positions.

Examples of the so-called “fentanyl fold” have been plastered on social media for years as San Francisco continues to try to get a grip on a highly visible opioid epidemic that claimed the lives of more than 800 people last year.

The effects of fentanyl can be deadly, and prolonged use can cause long-term health problems for users, even if they quit. But the reason for the fentanyl user’s distinctive fold witnessed across urban America has been elusive and difficult to explain.

The Chronicle spoke to fentanyl users and medical professionals in an effort to better understand this particular effect of fentanyl use.

A fentanyl user for the past two years, Jeff Barlow tried to explain why users tend to double over in such extreme angles.

During the fold, Barlow said, “your brain and body are at odds.”

Barlow, sitting last week outside the San Francisco Public Library in the Civic Center, gestured to a man nodding off after taking a hit of the deadly substance. He told the Chronicle that the drug puts you in a “sleep-dream state” and often “you don’t even know you’re like that.”

“It’s like falling asleep in class,” said Barlow, 50. “You blink your eyes and 20 minutes go by. You’re kind of half-in and half-out of consciousness.”

Barlow became addicted to opioids in 2001 after a doctor prescribed him painkillers following an operation. He’s overdosed on fentanyl 14 times, and his partner, Karie Williams — who is not a user — has saved him with Narcan many times.

UCSF professor of addiction medicine Dr. Daniel Ciccarone 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.”

Frederick Smith, 43, said he finds himself in the “fent fold” about two or three minutes after taking a hit of fentanyl. The position has made his knee and foot problems worse. He said he’s in excruciating pain because he doesn’t realize he is in that position until it starts to hurt his body –– so he does more fentanyl.

“I take it because it helps with the pain on my knee and my foot,” he said. “But it makes everything worse.”

Fentanyl user Alan Vetter has also found himself in the loop of pain and pain relief. He smoked a cigarette as the sun baked the Tenderloin sidewalk in front of him.

When asked about the “fentanyl fold,” he said, “You mean that?” referring to a man next to him who was standing but doubled over at the waist.

“I see it every day.”

Vetter said he has used fentanyl for about a year and a half and has found himself in that extreme bent-over position countless times. For him the drug was the only way he could get relief for his injured back and hernia.

“That’s the only way you get relief,” he said of the drug. “I start getting my back cramping and I get sleepy, so I just start to nod off. Next thing I know I’m almost on the floor.”

Vetter said people who use fentanyl end up in those positions so much that “you end up losing control of your body” and get “stuck there.”

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,” Dr. 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.”

He said the fentanyl fold falls into the umbrella of a severe spinal deformity that can cause functional disability and can drive mental anguish. He said he’s not sure whether it’s 100% reversible, but physical therapy and surgery can help people regain their ability to remain upright after spinal deformity.

“A lot of us see it walking or driving on the street, and it’s very recognizable,” he said. “It’s difficult to understand what is causing it, but it’s important for the public to understand it and build awareness.”