Meth: San Francisco’s drug crisis within a drug crisis

To combat fatal overdoses, The City must address its dire methamphetamine problem

On a sunny morning in San Francisco, Billy Lemon makes the rounds through a cafe at the Castro Country Club. A barista serves up drinks and light conversation, two people chat over a coffee and someone else types away on a laptop.

It boasts all the charm of a neighborhood coffee shop, but there’s much more going on behind every cup served. To place an order, guests walk through the cafe’s pristine Victorian building, past a living room where meetings are held daily for people in recovery from methamphetamine addiction. And Lemon is among them.

“That first experience (of doing meth) is fantastic and you could try to replicate that for years, usually to no avail,” said Lemon. “So you wind up doing more, more frequently. What used to be fun becomes fun with consequences, and it’s then just consequences, and before you know it you’re in jail. That was my case.”

Overdose rates in San Francisco have ballooned in recent years with the arrival of fentanyl, a synthetic opioid 50 times more powerful than heroin. But the majority of fentanyl-related overdoses in The City involve a mixture of substances.

Call it what you want: ice, Tina, crystal, speed, crank. In San Francisco, methamphetamine is often part of a deadly concoction. Yet it’s rarely part of the public conversation as The City reckons with a spiraling overdose crisis. Advocates say that must change if we want to have a chance of successfully addressing the problem.

“Meth is the most used substance available,” said Laura Guzman, senior director at the Harm Reduction Coalition, a national overdose prevention organization that works with the San Francisco Department of Public Health. “We aren’t talking about it, and that’s probably because it requires a much more complex solution. We haven’t developed good spaces and treatment for people who use meth.”

Over half of the 645 overdose deaths in San Francisco in 2021 involved methamphetamine, according to data from the Office of the Medical Examiner. In January 2022 alone, 26 out of 46 overdose deaths were meth-related while 28 involved fentanyl, often in combination.

While overdoses on meth alone are rare, deaths in San Francisco linked to the substance increased by more than 700% since 2008, according to a city report. Nearly half of psychiatric emergency room admissions at San Francisco General Hospital from 2017-2018 involved meth, the report found, and 90% of individuals with at least eight psychiatric holds had used only methamphetamine.

“People are co-using meth and heroin and fentanyl,” said Guzman. “There is a large number of people who use meth where treatment is scarce, if available at all.”

‘A full assault’

Lemon can remember clearly the first time he tried meth. It was around 1998, during his senior year at San Francisco State University after he had recently come out as gay.

“I was trying to balance being freshly out and what that means, and school and work. Someone said ‘Let’s go to the EndUp and dance all night,’” Lemon said. “It was amazing.”

A few years later, Lemon lost his bartending gig and went on unemployment, and from there, he said, “it snowballed.” On meth, Lemon could stay up for hours on end exploring his new community and identity with the help of a powerful social lubricant. It allowed him to silence the shame he had carried while feeling like his bubbly, energetic self again.

“It is really complementary to a lot of gay men’s sexual prowess,” said Lemon. “It lowers your inhibitions, and for a lot of gay men that grew up in a generation where we weren’t comfortable in our sexuality, like myself in particular, it allows us to experiment and feel less inhibited.”

But the fun eventually faded. Lemon began dealing large amounts of methamphetamine and other drugs. He went from having his own apartment to living with friends who used drugs also to completely relying on others for housing.

“It got to a point where I was couch surfing and as long as I had dope I was housed,” said Lemon. “There are a lot of folks who are homeless and are addicts just trying to stay warm.”

Lemon was arrested multiple times, and in 2009, faced serious time in prison. He had hit an all-time low. That’s when a bizarre miracle of sorts happened. At the time, San Francisco was dealing with illicit drug sales within The City’s own ranks. An investigation found a former lab technician at the police department stole and used some of the cocaine she was supposed to analyze. Then-District Attorney Kamala Harris subsequently dismissed hundreds of cases that relied on evidence that came through the lab.

One of the cases to get tossed was Lemon’s. At that point, he decided he was ready to make a change.

“I went to residential and inpatient rehab and a ton of 12-step meetings,” he said. “For me, it had to be a full assault. I had to use every opportunity.”

Now eight years sober, Lemon sees lives like his change every day as executive director of the Castro Country Club, a sober gathering place for the LGBTQ+ community. In addition to 12-step meetings, the facility runs a Peet’s cafe where people in recovery, some of whom have been out of work for years, can learn barista skills. For many of the patrons, meth had been a huge part of their lives.

“It’s easily produced. It doesn’t cost a lot,” said Lemon. “It allows you to stay up longer and do more.”

The Castro Country Club offers a glimpse of what the flip side of an otherwise horrific spike in drug overdoses across San Francisco could look like. But safe spaces for meth users are scarce here. Even more rare are treatment options to lead someone through recovery.

“It is absolutely possible to recover and get long-term sobriety. I see it every day,” said Lemon. “The missing component for a lot of folks when they decide to get sober is the opportunity to build a community of support.”

A crisis in the shadows

Compared with fentanyl, which began taking over drug markets in San Francisco around 2018, meth has a longer history in The City. It first became popular in the 1990s in New York City and eventually seeped into San Francisco. Partygoers flocked to the stimulant for its ability to produce feelings of euphoria, confidence and increased sex drive.

“Meth historically has been a significant challenge in the LGBTQ community,” said San Francisco Supervisor Rafael Mandelman, who is gay and called for The City’s methamphetamine task force in 2019.

But meth’s reach intersects myriad communities across San Francisco.

Meth use is most common among white men, the 2019 report found, but negative downstream impacts such as arrests and jail time are more concentrated among Black San Franciscans. The most acutely impacted is the unhoused population, which has increased alongside San Francisco’s overdose crisis.

“In some ways, the meth crisis, which is a huge crisis, gets overshadowed by the opioid crisis,” said Mandelman. “Everyone knows there is a fentanyl crisis, and I’m not sure as many people know that meth is killing hundreds of people in San Francisco each year.”

Unlike fentanyl, a depressant painkiller that makes users feel euphoric and sleepy, meth is more likely to contribute to insomnia, psychotic episodes, and in some cases, violent behavior. For people sharing the sidewalk with someone experiencing a meth-induced episode, it can be a scary and disturbing scene.

“This is playing a role in the crisis on our streets,” said Mandelman. “And that remains issue number one for my constituents.”

Lemon said he began experiencing psychosis towards the end of his years on meth, when he started shooting it intravenously. But that was just one of the threats he faced.

“I was robbed at gunpoint several times. There are also times I can remember waking up in the ER and not knowing how I got there,” he said. “That’s certainly not part of what folks think their adult life will be like.”

Chances for change

Medication-assisted treatment options such as methadone and buprenorphine can treat opioid addiction. But similar therapeutics don’t exist for methamphetamine dependence. And few programs are available to refer people who want help with their meth use.

This winter, San Francisco rapidly erected a new health and social services center at United Nations Plaza where struggling San Franciscans can get a hot meal, take a shower and connect to services and treatment. But compared with opioids, treatment options for methamphetamine users are scant.

“There is no treatment available and accessible and appropriate to treat folks with meth,” said Guzman. “People who use meth want solutions.”

In 2019, San Francisco convened a task force to study its meth challenge and present solutions. One recommendation was to create what later became known as SOMA RISE, a sobering center in the South of Market neighborhood that is slated to open this spring. Unlike the Tenderloin Linkage Center at U.N. Plaza, which serves as a catch-all services site for the unhoused, SOMA RISE will specifically aim to provide a safe space for drug and alcohol users.

At SOMA RISE, intoxicated people on the street will be able to come indoors, rest and access other basic needs such as showers, bathrooms and meals. It’s a key component of Mental Health SF, The City’s landmark mental health program for people who lack insurance or who are experiencing homelessness.

It remains to be seen how the center will handle the scale of San Francisco’s crisis. Skeptics point to Portland, Ore., where a sobering center ran from 1985 to 2020. The city shut it down after health care workers said the site wasn’t equipped to handle the agitated and erratic behavior from a growing number of meth and opioid users.

Yet supporters say sobering and supervised consumption sites, which San Francisco is also preparing to open, are even more necessary as fentanyl has shortened the window of time required to respond to and reverse overdoses.

“Fentanyl is a game-changer. It can kill you instantly and it’s being cut in other illicit drugs, including meth,” said Gary McCoy, who has been sober from meth for 11 years and serves as director of policy and public affairs at HealthRIGHT 360, a medical clinic that will staff SOMA RISE. “Someone who uses meth may not realize there is fentanyl in the drugs they are using.”

Filling a void

One recovery model that has shown evidence of success for some meth users is known as contingency management. The idea is to offer financial rewards in exchange for entering treatment programs, getting sober and finding a recovery community.

The San Francisco AIDS Foundation has advocated for more of this type of intervention after finding success with its own program, the Positive Reinforcement Opportunity Project, or PROP. At the program, LGBTQ+ people who used meth are given gift cards for staying sober. The center says 63% of participants stopped using meth after one year and another 19% reduced their use.

Lemon has also seen contingency management work.

“Part of the meth issue is people become so entrenched in shame. For me, as an ex-dealer who went to rehab with nothing more than the clothes on his back, PROP gave me an opportunity and a gentle nudge,” said Lemon. “For someone who had nothing positive happen to them for quite some time, that win was enough to put some wind behind my sails.”

The strategy has been employed by the Veterans Affairs Administration, and a statewide pilot program is slated to launch in summer to explore contingency management across California, where overdose deaths from stimulants nearly quadrupled over the last decade.

“The foundation of recovery for any substance is having a connection and community around you to be supportive. The bonus of contingency management is it brings folks in,” said McCoy of HealthRIGHT 360. “They can participate in that program and it also allows for other wrap-around services that can be provided including group therapy sessions.”

Still, contingency management is extremely difficult to access if homelessness is a factor. And in San Francisco, it often is.

Moreover, legal hurdles and public opinion have stifled efforts to expand access. In 2021, Gov. Gavin Newsom vetoed a bill by Sen. Scott Wiener (D-San Francisco) that would have legalized contingency management and authorized Medi-Cal to cover it.

Appetite for the model is growing, though. President Joe Biden’s drug policy platform calls for increasing access to evidence-based treatment, including contingency management.

In the meantime, programs like the Castro Country Club will continue to fill a gap.

“I may have gotten sober quicker had I had this opportunity. It’s the reason community spaces are important and the reason brick and mortar spaces are important,” said Lemon. “People need to be able to walk in and be met with compassion and kindness.”

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