Are The City’s overdose treatments working? It’s impossible to tell

As drug crisis grows more urgent, experts say there’s a murky path ahead

While the number of overdose deaths declined in San Francisco’s most recent tally, other indicators of progress reveal The City is still far from getting a grasp on its most urgent health crisis.

There were 50 fewer overdose deaths linked to opioids, cocaine or methamphetamine in 2021 compared with 2020, when overdose deaths reached an all-time high of 700, according to data from the San Francisco Department of Public Health. The past year marked the first decline in overdose deaths since 2018.

But other recent city data show overdose reversals are climbing, while substance use treatment admissions have been on the decline for years. The simultaneous trends point to a complicated picture of limited treatment options during the pandemic, a deadlier drug supply that requires fast-acting reversals, and a growing number of individuals treated each year with addiction medications outside publicly funded programs.

The findings come at a time when San Francisco is focusing renewed attention and resources on a long-brewing crisis and the public discourse over its strategies. A Tenderloin Linkage Center that opened in January appears to highlight the challenge. In its first week, the center connected just 3% of clients to treatment services. Meanwhile, other proposals for sobering centers, safe drug consumption sites and supportive housing remain held up in bureaucratic delays.

Mayor London Breed recently announced the decrease in overdose deaths, praising prevention strategies that have been implemented over the last two years, including a Street Overdose Response Team, an overdose prevention program in single-room-occupancy buildings, an overhaul of San Francisco’s mental health care system, and adding 150 overdose reversal medicine stations across shelter-in-place sites for the homeless.

“We must look ahead and build on the progress we have,” she said. “We know that we still have a long way to go, but we must act aggressively to ensure that every resident receives the support and services they so desperately need.”

Moving ahead may be the only choice, but it’s not a simple one. And those tasked with examining The City’s data say it’s too soon to know which specific interventions might be helping.

“It’s hard to say on a case-by-case level, and to attribute (the decline in deaths) to any one intervention requires a big sample size and very, very complicated analyses,” said Phillip Coffin, director of Substance Use Research at the San Francisco Department of Public Health, who authored a recent report on The City’s substance use trends. “I couldn’t do that scientifically with the data sets we have currently.”

What is clear, Coffin said, is that San Francisco is now leaning in to fight an overdose crisis that’s much different from where The City was even just prior to the onset of the pandemic.

As deaths have dipped, overdose reversals have skyrocketed from 2,600 in 2019 to nearly 8,200 in 2021, according to data from the Drug Overdose Prevention and Education (DOPE) Project, which is part of the Harm Reduction Coalition and funded by the San Francisco Department of Public Health.

The growing number of reversals is possibly due to an expansive effort in San Francisco to increase the distribution of naloxone, a short-acting opioid antagonist.

Broadly, overdose trends in San Francisco signal that “interventions work, but we are starting on a much higher baseline,” said Coffin. “We have such a larger place to start with that impact feels less satisfying, but it’s equally important because every single life matters.”

Bigger problems, tougher solutions

For individuals who survive a drug overdose, what happens next isn’t clear.

Opioid treatment has increased each year in San Francisco since 2018, but the overall number of admissions to treatment programs for other substances has dropped from 10,273 in 2015 to 6,707 in 2020, according to the city report.

“Honestly, it’s a little bit discouraging,” Coffin said, referring to the decline in substance use treatment for meth in particular. Out of the 650 drug overdose deaths in 2021, 348 involved methamphetamine, according to city data.

Lockdowns in 2020 made it more difficult for many people to stay connected to treatment programs. But other challenges have been creeping up since 2015, including a more potent and deadly drug supply and an increasingly unaffordable housing market. The decline was also likely related to a growing number of people receiving buprenorphine, an opioid treatment medicine, outside The City’s treatment programs, Coffin said.

“The reality is: The drug trend is changing and people’s conditions are not changing,” said Laura Guzman, a senior director at the Harm Reduction Coalition. “People use more when there is more stress. The numbers were really small in San Francisco before 2019, but we didn’t have this deepening of poverty and the added challenge of fentanyl.”

Guzman emphasized that getting people in the door, even if they aren’t ready to accept services, is part of a long and very personal process of changing behavior.

“You might have folks seeking treatment for opiates, but that does not change the reality that people are still on the streets using drugs, and poor people are impacted the most,” Guzman said. “We can’t prevent all people from overdoses, but we can create conditions for people to live and change their lives.”

Life at the linkage center

One of the primary intervention strategies that has come under the microscope recently is the Tenderloin Linkage Center at United Nations Plaza. The multistory building and fenced-off outdoor area intend to act as a navigation center primarily for individuals who are experiencing homelessness and substance use disorders. Organizations such as HealthRight360 and The City’s Homeless Outreach Team are on site to connect people with services such as housing or drug treatment.

In the first week since the center opened on Jan. 18, only 33 out of 1,180 individuals were successfully linked to other health and social services.

At the same time, three overdoses were reversed and no lives were lost, according to a city report released last week detailing elements of Breed’s Tenderloin Emergency Intervention Plan, which launched in December and allowed The City to bypass certain zoning rules to open the linkage site swiftly.

Breed’s delivery of the emergency plan was notably brash. She described the open-air drug sales and use in the Tenderloin as “bullsh*t” and said drug users outside would be pushed into treatment or face jail time.

Recent reports, however, have confirmed that substances are being consumed on site and overdose reversals have taken place at the linkage center, showing a more complicated response that is actually playing out on the ground.

News that drugs are being used at the center has since sparked backlash, with some addiction experts pointing to how it could be triggering for individuals who are seeking treatment. Others argue it’s a necessary part of getting people who struggle with addiction through the door.

The City is simultaneously working on a supervised drug consumption site and sobering sites, which are slated to open this year.

“The lack of spaces for people to be in S.F. has been a huge problem for overdose prevention efforts, whether it’s a drop-in center or a safe consumption site or sobering site — any of these things is a huge value for overdose prevention,” said Coffin. “The best way to prevent overdose deaths is for people not to use in isolated settings. The vast majority of deaths are from people using alone.”

The strategy already has been implemented and saved countless lives in countries such as Canada and Portugal, which decriminalized personal possession of drugs and offer supervised consumption sites as just one part of a broad and progressive approach to keeping drug overdoses low.

The U.S. federal government has not yet approved overdose prevention centers that allow drug use, but the idea is already in action in places like New York City, which opened a safe consumption site in December that has so far had zero overdose deaths. Rhode Island recently passed a law that will allow people to use illegal drugs in a supervised environment.

“We should be throwing everything we have to this crisis,” said Gary McCoy, director of policy and public affairs at HealthRight 360, which has been working with the linkage center. “There will be many solutions.”

Correction: This story previously stated more than 6,000 overdose reversals took place in 2021. It has been updated to reflect a more accurate estimate, 8,200, according to data from the DOPE project.

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