If I Were Mayor

Over the past decade, the opioid crisis has urgently and significantly impacted San Francisco, leading to a disturbing surge in opioid-related deaths. In the last year alone, as reported by the city’s Department of Public Health, there were 806 overdose deaths, a stark increase from 647 deaths in 2022.

The first wave of this epidemic is believed to have started in the 1990s when opioids were overprescribed as painkillers driven by major pharmaceutical companies. The next wave began in 2010 due to an increase in heroin-related overdoses. The third wave, starting in 2013 (up until today), was caused by synthetic opioids, mainly illicitly manufactured fentanyl. Fentanyl is 50 times more potent than heroin, (1) and it accounted for 81.02% of the overdose deaths in San Francisco in 2023.

To address this issue, Governor Newsom instituted a 97 million dollar budget for the 2023-24 fiscal year. This budget encompasses $79 million for a naloxone distribution project, $10 million for grants for education, testing, recovery, and support services, $4 million to make test strips more available, and $3.5 million for overdose medication for all middle and high schools. He has also set aside $30 million to expand the California National Guard to prevent drug trafficking. (2)

Newsom’s budget focuses on education and reducing the number of deaths through overdose prevention. His plan focuses on improving the services that are already in place instead of ideating new solutions. The $10 million budget for education, testing, recovery, and support services was available through application to all non-profit residential substance use disorder treatment facilities. Twenty-five clinics were chosen to receive funds to support establishing or enhancing their Medications for Addiction Treatment (MAT) services in 2018.

The measures demonstrate the priorities of the state of California, which include reducing the opioid overdose death rates and increasing the availability of essential services. However, these strategies are insufficient for three main reasons.

Firstly, the current measures do not sufficiently address the need for sustainable recovery. Without tackling the socioeconomic factors that contribute to addiction, individuals may relapse even after receiving treatment. To create lasting change, San Francisco must address these underlying issues. When people continue to struggle in their circumstances, substance use will continue. With 8,323 homeless individuals in San Francisco as of the 2024 PIT Count and a 7.3% increase in homelessness between 2022 and 2024, stable housing and employment opportunities are crucial to preventing relapse and supporting sustained recovery.

Second, the outreach methods are not fully available to everyone in need despite the efforts to expand services and improve accessibility. These issues include documentation requirements and administrative delays, which have deterred individuals’ attempts to seek treatment. A 1999 study conducted by J. Porter, for example, discovered that long-term heroin injectors in Puerto Rico recognized psychological, institutional, and cultural difficulties in entering treatment. One crucial structural obstacle that affected all heroin injectors was identified as the waiting period between detoxifications and “rehabs” and the first waiting period for treatment. (3)

Lastly, these measures lack coordination and a cohesive strategy among stakeholders. Multiple agencies, non-profits, and governmental bodies operate independently, often without sufficient communication or data-sharing mechanisms. Due to the lack of communication and data-sharing mechanisms, these facilities often operate independently. This leads to a duplication of efforts, such as multiple centers offering similar outpatient treatments without a cohesive strategy to manage patient transitions between different levels of care. Additionally, gaps in coverage emerge because patients needing to transition from outpatient to residential care may not receive timely referrals, resulting in inefficient use of resources and potential delays in treatment.

To address these issues, I would implement two different strategies.

Firstly, I would implement more efficient harm-reduction measures. Currently, in San Francisco, harm reduction measures include preventing overdoses from being fatal by supporting and broadening overdose prevention services such as naloxone distribution, fentanyl test strips, and drug checking. Additionally, efforts are being made to improve post-overdose outcomes by enhancing targeted overdose response teams and connecting individuals to care.

However, these measures are often isolated and do not contribute to sustained recovery or effectively prevent further overdoses. Without an integrated approach that includes coordinated long-term treatment and recovery support, these efforts fall short of addressing the root causes of addiction and ensuring comprehensive care for individuals at risk.

To lower the rate of overdoses, I would open safe injection sites in key locations around the city where drug usage is the most prevalent, including areas in the Tenderloin and near City Hall. These sites would include sterilized equipment, drug checking, testing for infectious diseases such as HIV, HCV, and other STIs, education on drug use, safe drug practices, and safe sex practices, access to resources such as rehabilitation referrals, addiction treatments, social services such as housing and employment services. Emphasizing community connection through small group sessions and peer support groups can create an environment where
individuals can access the help they need without fear of judgment or stigma.

Creating these centers is essential because providing a non-judgmental space for drug users creates an environment of trust and support that can lead to better engagement with treatment services and long-term recovery. San Francisco currently lacks sufficient harm reduction facilities, leaving many drug users without safe options for using substances and accessing related health services. 

The efficiency of community-centered treatment can be seen in the success of peer support groups in addiction treatment. Research has indicated that the benefits of peer support groups are related to the following: less substance use, treatment engagement, lower risky behaviors related to the hepatitis C virus and the human immunodeficiency virus, and less secondary substance-related behaviors like craving and self-efficacy. (4)

Harm reduction encompasses a wide range of strategies aimed at reducing specific harms. When considering syringe service programs and safe injection sites, it's important to acknowledge their targeted role in providing support to those most vulnerable. Implementing harm reduction measures should prioritize the community's needs and well-being.

The next issue we need to address is: What happens next? Harm reduction is not offered as the solution to the opioid crisis. Our focus should be on making the change sustainable.

Treatment maintenance drugs should be fully legal and accessible to those who need them. These medications, such as methadone and buprenorphine, have been proven to be effective in treating opioid addiction and reducing the risk of relapse and overdose. Currently, accessing these drugs can be challenging due to various legal and regulatory barriers.

In order to address this disparity, Bill AB-1288 sought to improve access to essential medications. The bill prohibited health care service plans and insurers from requiring prior authorization or step therapy (requiring patients to try and fail less expensive treatments before approving the prescribed medication) for specific medications used to treat substance use disorders. Governor Newsom vetoed the bill, providing reasons such as utilization review being important for containing healthcare costs, protecting patients from unexpected billing, and ensuring necessary care, and because it helps prevent fraudulent requests or drug abuse.

However, these issues can be easily mitigated by expanding the naloxone distribution to include buprenorphine and methadone (used for opioid addiction treatment), and long-acting injectable naltrexone (used for opioid addiction treatment and prevention of relapse). These drugs have proven effective in addiction treatment. Methadone, buprenorphine, and naltrexone reduce opioid use, symptoms, infectious disease transmission, and criminal behavior. They increase the likelihood of individuals remaining in treatment, and lower overdose mortality and HIV/HCV transmission. (5)

It's time to move beyond temporary fixes and implement comprehensive, sustainable solutions that support every individual's journey to recovery and well-being.

(1)https://www.assembly.ca.gov/system/files/2023-05/05.24.2023%20Fentanyl%20Select%20Committee%2 0Background_0.pdf
(2)https://www.gov.ca.gov/wp-content/uploads/2023/03/Fentanyl-Opioids-Glossy-Plan_3.20.23.pdf
(3)https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2396562/
(4)https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5047716/
(5)https://nida.nih.gov/publications/research-reports/medications-to-treat-opioid-addiction/efficacymedications-opioid-use-disorder