SF needs safe consumption sites
At 50 to 100 times more powerful than heroin, fentanyl, a synthetic opioid, can be lethal if one miscalculates its potency. Eighty-nine people died from fentanyl overdoses in San Francisco last year. But nearly 1,700 opioid overdoses were reversed via the Narcan disseminated by the city.

D-Nice’s hands are shaking, so I take the matchbook and light the barbecue for him. The coals catch and he quickly hoists a metal, pizza-sized plate of mashed, second-hand enchiladas atop the flame. He empties a jar of Lay’s French onion dip onto the now-sizzling mound of food, and scoops up the resultant concoction with slices of wheat bread. 

It’s 2 p.m. on a Wednesday and we’re huddled between a parked car on Capp Street and a tarp draped over a pair of squat, wheeled carts stacked with D-Nice’s worldly possessions — clothes, food, electronics, a framed map of the world. In this compact space there’s just enough room for the grill and a beach chair. D-Nice eats his lunch, but he doesn’t enjoy it: His last encounter with the San Francisco Police Department, he says, resulted in a bag being carted off, and his diabetes medication was in there. “And now,” he says, “everything tastes like salt.” 

And, with the grill lit and food served, we can talk about fentanyl. Or, as a pair of other homeless people on Capp referred to it, “that drug that’s stronger than heroin” — 50 to 100 times stronger, in fact — and “that new drug that’ll kill ya.” 

In fact, per data released by the Department of Public Health last week, 89 San Franciscans died of fentanyl overdoses in 2018 — a 300-percent jump since just 2016 and more than any other opioid. Per the medical examiner, 39 people overdosed on fentanyl in just the first quarter of 2019 alone. That number will, all but certainly, rise with further analysis. When extrapolated, it’s not unreasonable to anticipate that hundreds of San Franciscans will die from fentanyl use this year. 

And D-Nice would know. 

“Fentanyl knocked me on my back for nine hours,” he said. “I just sniffed a tiny piece — dust! It wasn’t shit! And it knocked me on my back. I woke up hella turnt and it was like that for three fucking days. And that is an experience I don’t want to experience again.” 

D-Nice says he’s personally revived four people who overdosed on fentanyl using the Narcan kits widely disseminated throughout the city. But he couldn’t be there for Melanie. 

“I had a girlfriend. She shoulda been on the cover of a magazine, she was so fine,” he says. “She usually did heroin but she switched to fentanyl. She got off the streets, she got inside. And she overdosed in the fucking bathroom.” 

He sighs. “That fucked me up. That really fucked me up. That girl loved me to death.” He glances around at the bubbling plate of meat and sauce, the tarps, his scattered ephemera on the dirty pavement. “And I woulda had a place to stay.”  

Kristen Marshall, who heads up the DOPE project, says that policies that push homeless and vulnerable people into solitary and/or secretive drug-use have been disastrous.

Coverage of the growing fentanyl epidemic often mirrors the stories, decades ago, about killer bees closing in on California: An unstoppable, deadly force that has wrought havoc elsewhere is coming! Be afraid! Be very afraid! 

Fear is not unwarranted. San Francisco’s numbers, as grim as they are, are still dwarfed by those from the East Coast and Midwest. And yet, to put things in a local context, Fentanyl killed nearly four times as many San Franciscans in 2018 as automobile-on-pedestrian collisions. 

These numbers pain Kristen Marshall because, to her, they’re not numbers. They’re people. They’re her community. Marshall runs the city-funded Drug Overdose Prevention & Education (DOPE) Project. She’s the woman overseeing the dissemination of those Narcan kits like the ones D-Nice used to likely save the lives of four people. In this city, she says with experience, when someone shouts “I need Narcan!” people come running. And when there’s no Narcan? “Those motherfuckers get real quiet and everyone else scatters,” says D-Nice. 

The natural reaction to stories about growing numbers of fentanyl deaths is a primal scream of WE NEED TO DO SOMETHING! Marshall would like you to know: WE ARE.

The city disseminated some 30,000 doses of Narcan (naloxone) last year, in intravenous form like this vial or in nasal spray bottles. Some 1,658 opioid overdoses were reversed.

Her $258,000-a-year outfit, funded and working closely with the Department of Public Health, last year distributed nearly 30,000 Narcan doses in this city. By a highly conservative count, 1,658 overdoses were reversed. Through April of this year, at least 735 overdoses were reversed. But we do more. 

The city already provides drug-users with test strips that indicate whether fentanyl is within other drugs — and, because fentanyl is so powerful, even a little bit in, say, meth or heroin can be lethal. But fentanyl has gone from being the MSG of drugs, tossed into other materials, to being a substance people seek out on its own. 

So the DOPE Project also oversees regular testing of the city’s fentanyl supply to gauge just what drug users are putting into their bodies. The purity of the supply can vary greatly from week to week — from, say, 4 percent fentanyl by volume to 34 percent. 

When, as D-Nice noted, even “dust” can incapacitate you for hours or days — or worse — this kind of variability is dangerous. In June, Marshall says, a sudden spike in the concentration of San Francisco’s fentanyl supply led to 10 deaths in one week. These numbers — these people’s deaths — do not register on the annual tallies. Not yet. 

The DOPE project can get the word out about unstable supplies in 24 hours or fewer. It’s not high tech: It’s word-of-mouth, boots-on-the-ground, Baker Street Irregulars-type messaging. 

So, these are the types of things we can do as a city. And, to a large extent, they are working. Yes, more people are dying of fentanyl, but more are being saved. Even by the most conservative estimates, for every person who died of an opioid overdose in 2018 — 177, per the DPH — 10 or more were revived. Fentanyl is not cyanide. San Francisco has proven this. We have also proven that it is both cost-effective and a massive life-saver to distribute Narcan far and wide and make it a ubiquitous part of the city’s drug-using landscape rather than allow drug-users to die on the streets and get emergency responders involved in each and every incident. 

Fentanyl is killing lots of San Franciscans. But, argues Marshall, so are this city’s homeless policies. And she feels like she’s working against both of them. 

A tent encampment on 16th and Shotwell Streets, December 2016. Photo by Brian Rinker.

A bit of mathematical levity: While $258,000, the DOPE Project’s yearly budget, would be a lot of money if, say, presented in a wheelbarrow, it represents the amount the city of San Francisco spends in 11 minutes. It is, roughly, one-fifth what the city spends yearly on toilet paper. Distributing Narcan is, again, a money-saver when compared to the costs of administering emergency treatment to dying drug-users (separate and apart from the issue of saving thousands of lives). 

But it’s not cost-beneficial (or life-saving-beneficial) if people have their Narcan taken from them. Last year, 102 homeless individuals reported that — like D-Nice with his diabetes medication — their Narcan was appropriated by cops or Public Works employees. By May of this year, 86 such reports had already been registered. 

So, that’s a problem. As are homeless policies that, however justifiable for other reasons, push unhoused people out of communities and into solitude. Per a 2003 paper analyzing this city’s heroin deaths, a full 68 percent of overdose victims died alone. 

San Francisco isn’t always the most promethean of cities, but instilling Narcan into the culture over the past 16 years was a good and innovative thing. If you overdose within a group, there’s a better than decent chance someone is going to have a kit, underwent the five minutes of training it takes to use one, and will revive you. 

But if the homeless are being shunted out of communal encampments and know the way to avoid contact with authorities is to stay out of groups; if the lucky recipients of housing are placed into Single-Room Occupancy hotel rooms — and if one’s continued housing is contingent on not getting caught using drugs — people are being placed in situations that all but demand solitary, clandestine drug use. D-Nice’s Melanie purportedly died in the bathroom. “Most people die not outside but in supportive housing,” says Marshall. “Treatment on demand” options in this city, she continues, are highly limited. 

Last week’s federally coordinated drug action in the Tenderloin, in addition to carrying the whiff of an immigration crackdown masquerading as a narcotics raid, left the city’s drug users strung out and even more susceptible to overdosing, Marshall adds.

Speaking of the feds swooping down on San Francisco, if this city were able to legally establish a safe injection center of the sort Mayor London Breed campaigned on, that would be a huge help. “That is an ongoing effort,” says Dr. Phillip Coffin, the Department of Public Health’s director of substance use research. “That would definitely be one of the things we’d like to do to help the situation.” 

But we can’t. Establishing such a center would enable Attorney General Bill Barr to ride into this city on a white steed, Teddy Roosevelt-style, and undertake the GOP base-gratifying move of prosecuting San Franciscans for enabling drug-users to use drugs. 

So, we’ll keep doing what we’re already doing. Both the good and the bad. 

But for this city investing several months’ worth of toilet paper money in Narcan and outreach, San Francisco would be awash with dead fentanyl victims. We’re doing good things, but we could do more if we prioritized this issue. We could do more if the unintended consequences of city homeless policies were frankly addressed. 

We could do more if drug users and homeless people dying was considered a critical issue. 

Until that time, expect the body count to increase. And expect those who deign to pay attention to ask, with increasing urgency, what can be done? 

Joe Eskenazi

Joe was born in San Francisco, raised in the Bay Area, and attended U.C. Berkeley. He never left. “Your humble narrator” was a writer and columnist for SF Weekly from 2007 to 2015, and a senior...

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29 Comments

  1. I’ve also said that San Francisco isn’t doing enough for its drug users. $12 Billion budget and people still have to shoot up and smoke their stuff on the street. Unbelievable.

  2. I feel SF is doing way too much. It’s clear people dont want to get off this drug… I mean look at the chick who got off the streets and into housing and still died. She had no intent to ever get clean. Why waste money and time and medications on people who refuse rehab, and lie to get a place to privately shoot up. No thanks. Cut the funding and let the people survive if fit and die off if not. It will prevent people from coming here to do drugs and think its okay. Why fund addiction?

    1. come on Bob, addiction is a disease that literally changes your brain. let’s have compassion for people who are suffering. “let people die on the street” is neither an option for a City to take, or moral, and it won’t do anything to clean up the mess of addicts and dealers we have.

      1. Besides compassion when do we also get conservatorship and mandatory rehab? Or is the answer to not letting them die quickly on the streets to instead let them die slowly?

  3. Did this article really say that providing housing is bad for people who choose to use drugs?

    And how about people work at getting off the drug rather than us making sure there’s an endless supply of Narcan?

  4. Good. Take them out. I moved out of sf a few weeks ago because of the homeless. Maybe since the city isn’t doing anything this drug will wipe out those deserving of it.

    1. “Good. Take them out. I moved out of sf a few weeks ago because of the homeless. Maybe since the city isn’t doing anything this drug will wipe out those deserving of it.”

      Care to say that with a real name attached?

    2. Yeow…really Oppzorro? We are happy to see you go then. Those of us who have been here awhile have learned empathy and working with communities to fix problems. If you can’t have compassion for those that need understanding, it would be great if you could take your tech job elsewhere.

      1. Interesting claim about fixing problems given the problem is worse than I’ve seen in decades, and the stats back this up.

  5. Yes, the article does say that supportive housing is bad for people who (choose) to use drugs, directly and by inference:

    “Per a 2003 paper analyzing this city’s heroin deaths, a full 68 percent of overdose victims died alone.”

    “If you overdose within a group, there’s a better than decent chance someone is going to have a kit, underwent the five minutes of training it takes to use one, and will revive you.”

    “But if the homeless are being shunted out of communal encampments and know the way to avoid contact with authorities is to stay out of groups; if the lucky recipients of housing are placed into Single-Room Occupancy hotel rooms; and if one’s continued housing is contingent on not getting caught using drugs — people are being placed in situations that all but demand solitary, clandestine drug use. D-Nice’s Melanie purportedly died in the bathroom. “Most people die not outside but in supportive housing,” says Marshall.”

    1. I thought it was resplendently clear from both the story and the passage you highlighted but, for those who missed the point: Failing to take into account people’s real-life behaviors can have drastic and unintended consequences in the real world. Life is multifaceted, and while getting someone off the street is hard to argue against, failing to adequately account for people’s drug use and providing little in the way of alternatives — treatment on demand doesn’t really exist in this city — can, again, have drastic and unintended consequences.

      JE

      1. Joe,

        I missed the point in your article that talked about people taking account for their own real life behaviors If someones real world multifaceted life is shooting up and then only surviving because of an endless supply of Narcan being readily available I don’t think there are going to be any unintended consequences.
        (thank you for the phrases above I took from you).

        Your story is resplendently clear that addicts who don’t want to get clean are a drain on our society no matter how much we try to help them.

        1. You’re welcome for the new vocabulary. Have fun with it. But try not to forget the apostrophes and hyphens. You can borrow some of them, too.

          Best,

          JE

    2. I think you make a point. But the article isn’t about housing or how to cure a drug addiction. The article accepts the fact of drug addiction and promotes the establishment of “safe injection sites” to reduce overdose deaths. Perhaps the article is also obliquely making a case for legalization(and regulation) of drug use to make it safer.

      To make a analogy. Say the topic was women dying from hemorrhage after performing self abortions because they were doing it alone in their residence. If the article promoted “safe abortion sites”(medical clinics), that couldn’t reasonably be interpreted as saying housing was bad for women.

  6. Ya, well I have pity for these folks is Narcann just giving them a chance to reload? More drugs, not life I mean. How much money has to be devoted to people that are either unwilling to contribute to society and those moneys are taken from other people (seniors, children regards to parks, education, etc). And how many of these drifters have been here less than a month, year, 5 years even…. it might be ok if they’re somehow contributing (pickup litter, don’t commit petty crime (car break ins)… it’s a complex problem: which the only answer (and is NOT working) is to continue to pour money down a black hole.

  7. I’m pretty well acclimated to what’s going down in the Tenderloin these days.

    However last week, while on the way to an appointment at the Tenderloin Housing Clinic, what I saw
    reached a new level of …. shock. The sheer numbers were overwhelming.

    Perhaps skid row in LA may be this bad but it is hard to imagine anywhere else in the developed world where such misery would be accepted by the governing class or the governed.

    It is interesting to note there is daren’t a word or critical examination of the policy of distributing millions of free needles by the bucket full over these many years by any local media.
    That I can recall – anyway.

    Perhaps the 20,000 volt 3rd rail of AIDS prevention prohibits investigation of how a needle exchange program morphed into junkie oblivion.

    Or, as evidenced by the lack of meaningful challenge to the political status quo, are the vast multitudes of strung out humanity just a new normal evolution of San Francisco culture endorsed by the majority of voters?

    1. Carlos, the CA Department of Public Health officially supports syringe access:
      https://www.cdph.ca.gov/Programs/CID/DOA/pages/oa_prev_needle_exchange_syringe.aspx

      here is a NY Times investigation into why these programs work:
      https://www.nytimes.com/2016/09/05/upshot/politics-are-tricky-but-science-is-clear-needle-exchanges-work.html

      syringe access is san francisco is not debated not because its a third rail of discussion – its because the research has proven this is effective public health policy. removing syringe access won’t make the junkies in the TL disappear, it will ultimately lead to worse public health issues, more ambulance calls, etc etc.

      1. Seth, both your links reference needle “exchange” programs. Something science and studies have shown to both rational and effective. No arguments there.

        In San Francisco we give away millions of needles a year on demand to anybody. There is no functional “exchange” program.

        One of the points in my comment was – why are there no critical examinations of how the San Francisco needle exchange program morphed into the San Francisco needle give away program. What happened and why?

        And what are the unintended consequences?
        Which at this point, I speculate, can be answered with a trip to the corner of Hyde and Turk.

        A cynical person might observe our newly acquired San Francisco values are saving thousands of people from the scourge of AIDS and hep C by being a partner and enabler in the continued torment of these folks via their addictions to extremely dangerous substances.

        Substances, which stand a pretty good chance of killing them.
        But then again we save all those bucks by not having to provide long term AIDS and hep C treatments.

        1. Carlos, I dont know about any long-term studies about needle “exchange” versus needle “distribution. The CDC makes it clear that clean needle access is a benefit to public health:
          https://www.cdc.gov/policy/hst/hi5/cleansyringes/index.html

          This article from an SF AIDS Foundation doctor states some reasons why a city would choose distribution over one-for-one exchange:
          https://www.sfaf.org/collections/beta/we-say-needle-exchange-but-open-access-not-one-for-one-exchange-is-best-for-health/

          my understanding is, the more clean needles that are available for injection drug users, the lower the risk of blood-borne diseases being transmitted because dirty needles are less likely to be used. you are correct that we “save bucks” but not having to treat long term AIDS/HIV and Hep patients if we can reduce infections.

          my hope is that our harm reduction efforts are met with an equal amount of staff/time investment on getting folks clean and sober. That is a very challenging aspect of this work though.

  8. People hell bent on getting high will allways find something else to get high with. It never changes. Drug users mostly on their own accord make a decision to use drugs. They choose to to do this. They CHOOSE. Coddling them with Narcan or anything else is not really solving what us a huge problem. The answers to this epidemic of drug use which also increases homelessness because on people on drugs dont really care about anything else you know like working or going to school stuff like that…the answers are not easy and will not be nice and comfy. How do you detox thousands of people? Motivate them later to work and be productive or at least self sufficient? The real truths and answers are not going to be pretty. Incarceration, relocation separation, mental fitness evaluations and if they are unskilled, job training, then housing, then medical care etc.. because there is so much affordable housing in San Fran lol. Starting to get the picture? Billions could be spent on this but if the person is determined to get high at any cost or willing to try the latest new drug what do you do with them. Especially when they get to the point where their brains have been permanently damaged. Aka their brains are fried. I have seen plenty of this and it’s not pretty. They look and act like walking zombies. So once again what to do? I’m guessing more capitulation more free handouts of syringes, Narcan etc….because that is the easy route.

    1. The ultimate in “harm reduction” means giving these drug users decent homes, in the most expensive city in the world, AND giving them “lounges” where they can smoke and inject around other people. Preferably, these “lounges” or “dens” will also have helpful, trained medical professionals in place. And because we are talking about drug users there should be no rules or consequences. Because if they are kicked out, they go back to using on the street, and we all know that ain’t pretty. These facilities should also have amenities like onsite cafeterias, laundry services, and other concierge type stuff. It is just better if we keep these people as healthy and clean as possible. It will actually save us money on the back-end. Yes, this kind of wrap-around harm reduction is expensive. And yes, it will require dozens if not hundreds of large, new specially configured apartment buildings. And yes it will attract drug-users from everywhere. But we’re a compassionate city. If we can’t do this successfully, then it can’t be done.

  9. Junkies got nothing coming. They add nothing to our experience, they only take away our time, trash our city, rob our cars and clog our support systems. They do not deserve our compassion. Just die already, or wake the F up and get clean. Nothing anyone can say or do can ever make any difference to somebody who is looking for death on the installment plan.

  10. Ahh! It’s SFGATE striking again.

    Often I’ll come to an excellent Joe E. story only to find the ugliest of ugly knuckle-draggers going on about retribution or whatnot in the comments. Who are these monsters reading Mission Local?!!

    Answer – dumb knuckle-draggers portaled over from the hotbed of poor takes: SFGATE.com.

    Great work, Joe – your voice is an important one here in the Mission!

    Trolls, etc. – get better, work harder, find Jesus.

  11. Joe, thank you for this story. Thank you for jumping into these comments and engaging with these monstrous human beings. Long live the DOPE project and much love to each and every person surviving the streets of San Francisco.

  12. Man dead of an overdose at 24th and York this morning. Right at Pop’s. All I know is the called him El Guerito. We need to start carrying Narcan andlooking out for our homeless brothers and sisters

  13. Wow Some of the comments here are so cold & out of touch. Are some people under the impression that drug addicts had a good start in life then chose to veer in another direction? Maybe it’s like that for some but not most. Usually in abusive situations as young children, sexually & physically abused by parents/ family / other adults they trusted. Then as teens they escape, end up somewhere on the streets. Not a life they chose! We need to stop blaming drug addicts because it does not help them or anyone. Some people have been using drugs since they were kids and know nothing else. I didn’t know how I felt about this idea of injection sites but after this article I do think it’s a good idea as long as it is just 1 small part /step in the process to help these people. Getting them off the streets is the first step. Maybe these injection sites help keep them alive while they wait for a spot to open in a rehab program. What a blessing this organization is and all the people behind it and all the effort- also to the reporter. More compassion people!

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