Second-chance city: San Francisco’s plan to reduce overdose crisis

Programs aim to provide bars, venues with drugs that can prevent death

For bartenders and bouncers across San Francisco’s nightlife scene, keeping people safe often means more than just a quick ID and vaccine card check. It also can mean saving someone from a fatal overdose.

“I was bartending the other day, and our door guy came over and said he saved someone’s life with this,” said James Shane, who works at Emperor Norton’s BoozeLand in the Tenderloin, while pointing to a box of naloxone, a medication that can reverse opioid overdoses.

Shane was among eight other bartenders and restaurant owners who recently attended a free training course in the Mission on how to administer naloxone, also referred to as Narcan. The 30-minute workshop was led by the Drug Overdose Prevention and Education (DOPE) Project, a program of the Harm Reduction Coalition, which distributes naloxone throughout The City and is funded by the Department of Public Health (SFDPH).

San Francisco has since 2003 funded efforts to get naloxone into the hands of people who use drugs. But as overdose deaths have continued to soar since the pandemic, The City has simultaneously seen an increased need for the life-saving medicine, according to Eileen Loughran, a health community programs coordinator for SFDPH.

As overdose deaths remain at historic highs, however, city leaders are now pressing ahead with bold and controversial plans to crack down on outdoor drug dealing and use. They hope to address parts of the opioid crisis that Narcan alone can’t, including behavioral health treatment, housing, community and much more.

Kristen Marshall of Drug Overdose Prevention Education leads a training on the use of Narcan for bartenders and restaurant owners at Mission Bowling Club. (Craig Lee/The Examiner)

Kristen Marshall of Drug Overdose Prevention Education leads a training on the use of Narcan for bartenders and restaurant owners at Mission Bowling Club. (Craig Lee/The Examiner)

More than 6,000 overdoses were reversed in San Francisco in 2021 with naloxone alone, compared with 4,300 last year, according to data provided by the DOPE project and SFDPH. Both years mark a giant leap from 2019, when 2,605 overdose reversals were reported.

At the same time, overdose deaths reached 545 between January and October, inching near the 711 total number of overdose deaths reported in 2020, according to data from the chief medical examiner.

“Everything is increasing, and all of this was very predictable,” said Kristen Marshall, who oversees the DOPE project in San Francisco. “Stronger drugs just amplify the risk that’s already there. You add COVID and the isolation and chaos of a global pandemic on top of that, and it hits the same community that experiences those issues the hardest.”

In addition to bars and restaurants that opt to carry it, naloxone is also provided at places such as the Community Behavioral Health Services Pharmacy at 1380 Howard St. It’s also often carried by first responders in San Francisco, including some law enforcement officers.

Ali Heller, right, of FentCheck talks with wine director Christopher Potter, left, and bartender Alex Duke at the Patio wine bar in the Marina District about carrying Narcan in their bar. (Craig Lee/The Examiner)

Ali Heller, right, of FentCheck talks with wine director Christopher Potter, left, and bartender Alex Duke at the Patio wine bar in the Marina District about carrying Narcan in their bar. (Craig Lee/The Examiner)

Many places are plagued by the same challenges facing San Francisco that contribute to substance use disorder and overdose deaths, including unstable housing, food insecurity and massive economic inequality. But few cities invest in preventing and reversing overdoses at the same level as San Francisco, which runs the largest single-city naloxone distribution program in the country.

Harm reduction strategies in San Francisco extend beyond overdose reversal kits, ranging from clean syringe access and disposal sites to services at the Community Behavioral Health Services Pharmacy to The City’s newly-formed Street Overdose Response Team.

Providing Narcan does not increase drug use or lead to riskier drug use, studies have shown, and it’s not possible to get high or overdose on the medicine itself.

Rather, overdose reversals often are painful and traumatic for those experiencing them. Individuals can wake up confused, disoriented and angry. They can also feel sick from immediate withdrawal.

“Coming back from the brink of death is not a fun thing. The added stigma that can come from an overdose increases the negative impact of that experience,” said Juliana DePietro, interim deputy director of programs for Glide, a nonprofit that provides a range of homeless services, including harm reduction, mobile vaccination, medical care, food and social activities.

Still, flooding communities with the medicine is a crucial step from a public health perspective on simply saving lives. Under the right timing and circumstances, it can provide a step toward treatment. “Someone can only make a change in their life if they are alive,” said Loughran.

Reversal to recovery

What happens to those who survive an overdose is now a real-time experiment among city leaders who recently announced a plan to crack down on drug dealing and possibly use as well.

“We are a city that prides ourselves on second chances,” Mayor London Breed said during a recent press conference. But “our compassion should not be confused for weakness or indifference.”

On Friday, Breed declared a 90-day state of emergency in the Tenderloin, comparing the crisis level to that of the COVID-19 pandemic. The move waives rules around contract procurement and planning codes to allow The City to open a site that would aim to connect people with behavioral health services and housing programs.

The announcement follows a plan released last week that will increase police presence in the Tenderloin and requires users on the street to seek support or face jail time.

“The situation in the Tenderloin is an emergency and it calls for an emergency response,” said Breed. “We will use that focus and coordination to disrupt the illegal activity in the neighborhood, to get people the treatment and support they need, and to make the Tenderloin a safer, more livable place for the families and children who call the neighborhood home.”

The mayor’s more recent rhetoric contrasts with Breed’s stance in 2020. Last year, she redirected funds from law enforcement to support the African American community and launched programs such as the Street Crisis Response Team, which started in November 2020 as an alternative to police to respond to mental health and substance use crises on the streets.

It remains to be seen how the various approaches will work together. Harm reduction advocates warn that many who struggle with addiction and homelessness have had negative and sometimes violent experiences with social services and hospitals.

But even those who disagree on solutions can often find common ground around the growing need to connect those struggling with substance use disorder with treatment. DePietro says that’s where The City’s safe consumption site can be crucial to providing a safe place to use drugs as well as immediate connections to medical, social and rehabilitation services. The idea is to provide a controlled space where people can use drugs under the supervision of health care professionals, who can reverse overdoses and connect people to other services they may need.

“This (safe consumption site) could combat so many of the issues of stigma, criminalization and safety, and just ensuring people are not going to be penalized for their use so they don’t have to use in isolation, which is incredibly dangerous,” said DePietro.

Overdose deaths tragically have impacted communities across The City, but the majority in San Francisco remain among extremely low-income and unhoused drug users, leading most experts to agree that long-term solutions will require a mix of supportive housing, health care and anti-poverty initiatives, according to Marshall and DePietro.

“The work that is being done to address the overdose crisis is important on so many levels,” said DePietro. “A large part of that is reducing isolation and stigma around drug use, building community with people who use drugs and providing a safe place to speak with providers and case managers about anything they are concerned about and changing behavior around.”

Still, neither the mayor’s enforcement blitz in the Tenderloin nor the safe consumption site will be a cure-all for The City’s longstanding tensions around policing drug use and homelessness.

“Behavior change has to be driven by where an individual is,” said DePietro. “That doesn’t just relate to the number of treatment beds available, but how they have experienced treatment in the past.”

‘Second-chance’ city

In the meantime, more bars and venues are stocking their emergency kits and bathrooms with naloxone, especially ahead of holidays such as New Year Eve.

Mission Bowling Club owner Molly Bradshaw hosted the recent Narcan training workshop at her business on Monday, after someone recently walked in during an overdose crisis looking for Narcan. But the venue had run out of the supply it had on hand from prior to the pandemic.

“I want people to feel comfortable and safe here, or just to feel comfortable to ask for help if they need it. We have a wonderful community here and we want to be there for our unhoused neighbors, too,” said Bradshaw, who has an academic background in public health. “We can’t do everything, but I wanted to learn more about this and I feel more empowered from it.”

Other efforts, like one program called FentCheck, have stepped in to offer bars and venues free naloxone and fentanyl test strips, which can determine if the opioid is present in a drug supply. Oakland residents Alison Heller and Dean Shold launched the nonprofit after losing friends and loved ones to drug overdoses, and now distribute supplies to dozens of establishments in Oakland, San Francisco and New York City.

“Every day I go to venues and knock on doors and give them the option of having Narcan,” Heller said on a recent walk through the Marina, where she was asking bar workers if they wanted free supplies. “Bartenders tell me there’s no rule or rhyme or reason for who is grabbing these. Some venues you might not suspect to have that kind of engagement.”

Robbed shopkeeper says San Francisco is so broken it needs Batman

The Deli Board’s Adam Mesnick is sick and tired of SOMA crime

Chinatown community optimistic but ‘very nervous’ as Lunar New Year approaches

‘It is going to be a real test. We are all kind of holding our breath a little bit’

The climate challenge facing S.F.’s next Assemblymember

Where do the four candidates stand? The Examiner parsed their platforms