Fatal overdose in San Francisco–are we making headway on solving the problem?

Fatal accidental drug overdoses have been at an all-time high in San Francisco since 2020, the start of the Covid pandemic. Every year since, we’ve lost between 600 and 800 community members–more than 3,700 people total–a stunning loss reaching into every community in our city. Just this year–from January to the end of June–more than 350 people have lost their lives to accidental overdose.

Despite concerted efforts by community members, community organizations, the Department of Public Health, and city officials to distribute overdose prevention supplies, educate community members on overdose awareness, and ramp up substance use treatment referrals the number of fatal overdoses anticipated for 2025 are stubbornly set to outpace those seen in the previous year. 

“We know what works to reduce drug overdose. And we know what increases people’s vulnerability to drug overdose. We just need to do more of what works, and less of what harms,” said Andrew Reynolds, director of health access for people who use drugs at SFAF. 

Widespread distribution of the overdose reversal naloxone, paired with overdose response training, is essential–and something the city and community partners do exceedingly well. Yearly, San Francisco distributes around 150,00 doses of naloxone–to general community members, providers, first responders, and city workers, but primarily to people who use drugs and their communities. (Note: this metric shows the doses distributed to organizations and programs, not doses provided to people who use substances.)

“It shouldn’t be overlooked that people who use drugs are doing the vast majority of overdose reversals in San Francisco, said Laura Thomas, SFAF’s senior director of HIV and harm reduction policy. “At SFAF, we provide more than 45,000 doses of naloxone to our communities, and we have more than 6,000 reversals reported back to us. Our communities are caring for each other, and doing difficult work to respond to this worsening public health crisis.” 

“Our teams at SFAF–and at partner organizations–do an excellent job at meeting people who use substances where they are to deliver compassionate health services including overdose prevention and response,” said Reynolds. “Unfortunately, our work is complicated and challenged by shifting public perceptions of our work. We’re here to help, and we do a lot of good serving some of our city’s most disenfranchised communities, but we navigate situations that can have adverse consequences for the healthcare and naloxone we provide.” 

The persistence of fentanyl in our city’s drug supply is often identified as causing the spike in fatal overdoses seen since the mid-2010s, when this powerful synthetic drug replaced tar heroin as the primary opioid available in illicit drug markets across the West Coast. (Fentanyl is involved in nearly 75% of fatal overdoses, often in combination with other substances including meth and cocaine.)

“Not everyone who overdoses on fentanyl was intending to use fentanyl,” said Thomas, citing research by Alexander Bazazi, MD, PhD, from UCSF. “In one study in San Francisco, more than 40% of fentanyl overdoses happened among people who didn’t know they were consuming fentanyl. Fentanyl may be showing up in cocaine or meth supplies. Or maybe someone shares a pipe with someone–and there’s still fentanyl residue in the pipe. This fact highlights the importance of drug checking services, which give people more information about what they’re consuming.” 

San Francisco AIDS Foundation provides just such a drug checking service–allowing people to have their samples tested by a technician in order to make informed decisions. 

“Every day, I’m able to have one-on-one conversations with people who are taking steps to be more in control of their health,” said Roxie Corrigan, drug checking technician with SFAF. “In addition to providing detailed information about the components in a person’s sample, I’m also able to have personal conversations with people about their goals and their health.

The capacity of the drug checking program–the only one in San Francisco that uses point-of-care with FTIR technology–is extremely limited, noted Corrigan. 

“We’d love to be able to say that this program is giving all of San Francisco an informed picture of the drug supply, which could go a long way in helping people avoid unintentional overdose,” said Corrigan. “Imagine if there were no surprises for people who were expecting a particular substance, but who unintentionally consume fentanyl or some other substance. We would certainly benefit from a more extensive program that’s accessible to people in areas across the city. That would mean much more funding for FTIR machines, technicians, and other support staff.” 

San Francisco has also invested in expanding access to drug treatment. (When provided and accessible to people who are ready to make a change to their substance use, treatment services are beneficial and can complement overdose prevention strategies. When they are coercive, forced, or used as a penalty in the criminal legal system, they can counterintuitively lead to higher risk of overdose.)  

Thomas pointed to the new availability of late-night access to buprenorphine (a medication assisted treatment for opioid use disorder) as an innovative program that addresses challenges related to treatment connection. 

“I think our city is doing some things right to expand the ways in which people can access and get connected to treatment. Unfortunately, that’s been paired with backing away from some of the most essential evidence-based practices, like safe consumption sites, that we know reduce overdose,” said Thomas.  

Early in her tenure, San Francisco Mayor London Breed publicly supported the creation of safe consumption sites as a strategy to combat the overdose crisis. Implemented in cities around the world, evidence for their effectiveness in preventing overdose (and success in preventing public drugs use and street-level disorder) is robust and well-documented. But near the end of her time as Mayor, she backed away from her support of safe consumption in favor of harsher criminal-legal efforts to “crack down” on people who use substances. Public and city support for safe consumption sites has not returned, even as other cities including Los Angeles have continued to explore their possibilities. 

“There’s so much the city could be doing to change the situation that we’re facing. We have the solutions to this problem, but we need to be able to use them,” said Thomas. “Until then, we will continue to advocate for policies and programs that support the health and wellbeing of all people who use substances in San Francisco. These people are our neighbors, they are our loved ones, they are our community. They are us.”  

Trainings, information, and get access to naloxone

Get info & resources from the San Francisco Department of Public Health.