San Francisco Chronicle - (Sunday)
How city broke drug death records
2020
The most destructive year in San Francisco’s drug epidemic has ended with 806 people dead from accidental overdoses. About 8 in 10 of those deaths involved fentanyl, the cheap and potent synthetic opioid.
The previous record of 726, set in 2020, followed the COVID-19 outbreak. Overdose deaths in the city had been rising, with an alarming uptick in 2018 as fentanyl became increasingly available.
With the launch of new street teams and intervention programs, overdose deaths in San Francisco decreased the following year. Public health officials were cautiously optimistic. Then came January 2023 and a catastrophic 84 deaths — a new high for the city. That record would be broken again seven months later, according to preliminary 2023 data from the medical examiner’s office.
A bitter debate about how to respond to the tragedy continues to rage, with Mayor London Breed pushing for more police intervention and public health experts favoring harm reduction policies.
How did we get here? Trying to understand what happened requires looking into the past.
January: San Francisco officials face a new reality: The city is unprepared for fentanyl’s devastation. Grappling with the doubling of overdose deaths in 2019, Dr. Luke Rodda at the city Office of the Chief Medical Examiner tells the Chronicle that “we had a feeling through the year that we were seeing more and more deaths, but this is really quite staggering.”
The trend continues in the first month of 2020 when 39 people die from accidental drug overdoses, with 59% of those deaths involving fentanyl. The drug — roughly 50 times more potent than heroin — is a frightening new game changer.
City supervisors pass a
resolution declaring overdoses a “public health crisis” and urging the Department of Public Health to create a plan to address it. Daniel Ciccarone, a UCSF professor who specializes in drug use policy, warns that “fentanyl’s not going away. We have to learn to adapt to it.”
March: Mayor London Breed’s shelter-in-place order shuts down San Francisco. Breed’s health department focuses huge resources on the coronavirus as residents hunker down. The drastic changes mean those struggling with addiction on the streets find a more fractured safety net and more difficulty accessing housing, shelter and treatment services, which are scaled back. Fearing COVID-19,
people on the streets become more isolated.
“We are advising people to remain more isolated, which could paradoxically increase the risk of an overdose being more fatal,” Dr. Phil Coffin, the city’s director of substance use research, tells the Chronicle a few months into the pandemic.
May: Deaths of homeless people skyrocket, likely driven by overdoses, officials say. During an eight-week period ending in late May, deaths of the unhoused spike compared with the prior year. Dr. Barry Zevin, director of the health department’s Street Medicine team, primarily blames the disruption of services and shelter. “It is very painful,” Zevin
tells the Chronicle.
Seeking to protect those on the streets, officials move more than 1,200 mostly unhoused people into shelter-in-place hotels that offer food, health screenings and the overdose reversal drug Narcan. Despite the campaign to bring people inside, tents and open drug use in the Tenderloin surge alarmingly, prompting residents, business owners and what was then known as UC Hastings College of the Law to sue the city in federal court.
October: At least 10 times a day, someone on the brink of death from an overdose is saved with Narcan in the city. That’s according to data released by the DOPE (Drug Overdose Prevention and Education) Project, a city-funded program focused on overdose response. While staggering, the figure is still likely a huge undercount.
The growing distribution of Narcan is an example of how San Francisco and its nonprofit partners are leaning into harm reduction while they still lack enough treatment beds. The strategy can save lives, but critics say the practice enables drug use and doesn’t incentivize people to get into treatment. The debate rages over the next three years.
December: Nearly two people a day die in 2020 from overdoses — then the deadliest year on record in San Francisco. The epidemic cascades across the nation, with a federal health advisory saying overdose deaths accelerated nationwide during the pandemic. San Francisco is now one of the epicenters of the crisis. By the end of 2020, 726 people in the city die of overdoses, more than were
killed by COVID-19. Some experts say the federal government’s lackluster response is partly to blame.
“The whole country is suffering from complete federal failure in dealing with opioids,” Keith Humphreys, a professor of psychiatry at Stanford University, tells the Chronicle.
2021
January: Even as San Francisco police seize record amounts of fentanyl, deaths continue to rise. Police report that they seized more than 12 pounds of fentanyl in 2020, compared with less than 4 pounds the year before — a jump experts say reflects the rise in supply and demand. Chief Bill Scott tells the Chronicle that if the police hadn’t seized such a huge amount of fentanyl, there might have been “even more overdoses.”
July: San Francisco scrambles to add mental health and drug treatment beds, aided by pandemic emergency state and federal funding. Breed touts plans to add 400 beds for
mental health and addiction treatment, with 140 of those open by the end of the year — an 18% jump in capacity. The new beds are in addition to expanded hours at city-run drug treatment and referral facilities.
But these plans are hampered by hiring difficulties: The city has the money to expand services at the Behavioral Health Access Center to seven days a week, but struggles for the next two years to make it happen. The center’s services include methadone and other medication-assisted treatments, which experts say are one of the most effective ways of reducing fatal overdoses.
Hillary Kunins, the city’s behavioral health services director, tells the Chronicle this is part of a nationwide shortage of the behavioral health workforce. “The work is hard,” she says. “But it’s really critical and it can be really fulfilling.” August: San Francisco launches the first overdose-focused street outreach team amid a wave of new teams meant
to cut fatalities and get more people into treatment. The Street Overdose Response Team — staffed by paramedics, behavioral clinicians and peer specialists — responds to more than 100 overdose calls in just the first month. Many more similar street teams launch in the coming months, but some either fail to effectively help vulnerable people struggling with homelessness, addiction and mental illness or fail to track if they’re meeting their goals, an audit later finds.
December: Breed declares a 90-day state of emergency in the Tenderloin, pledging to address the overdose crisis, clean up the neighborhood and get more aggressive with crime. The mayor promises to “make life hell” for drug dealers and open-air users and be less “tolerant of the bulls— that has destroyed our city.” The emergency declaration allows city officials to set up a drop-in center, dubbed the Tenderloin Linkage Center, in U.N. Plaza the next month to provide food and showers as well as referrals to housing and services to homeless people struggling with addiction.
The center, which will be open for the next 11 months, moves 1,000 people to housing or shelter. But fewer than 1% of visits will result in linkages to mental health or drug treatment. Still, by the end of 2021, overdoses are down 13% compared with the previous year. City officials credit the investment in treatment, housing and other services.
2022
January: The Tenderloin Linkage Center draws fire from critics when the public learns that workers there are letting people use drugs in its outdoor plaza — an unofficial supervised consumption site. Breed just two months earlier had