Edwin Armando Alvarez relaxed in UN Plaza near City Hall on a recent Friday, dragging on a cocaine pipe and recounting some of the times he nearly died from drugs. His first overdose was at age 12, he said, continuing to the most recent one when he awoke in an ambulance after a paramedic gave him three doses of the opioid antidote naloxone and advised: “You’re really lucky.”
Punch line complete, Alvarez turned back to his pipe, identifying in the cocaine resin what he said were yellow flecks of fentanyl, a cheap and powerful synthetic opioid that is often found as an adulterant in street drugs.
“I’m doing my best not to let myself die,” he said. “I keep Narcan on me, and I give it to myself if I feel tired or exhausted.”
Alvarez and others who’ve overdosed multiple times and been revived with Narcan, a brand of naloxone, are easy to find in tents along San Francisco sidewalks, in parks, in doorways, and all-too-often in the morgue. The Standard interviewed seven of them just by strolling around Downtown San Francisco. But they’re all but invisible to city leaders, even though overdoses are currently killing around a dozen people a week in SF.
That's because the city contractor that distributes naloxone, and which the city relies upon for overdose reversal data, collects only limited information about overdose victims. In fact, it stopped keeping track of certain basic healthcare data as of Jan. 1, 2021, according to documents obtained via public records request. The health condition of naloxone recipients, when and where overdose reversals occur, how many people are revived multiple times, or what the long-term prognosis is for naloxone recipients are among the facts not collected.
The failure to obtain basic data is among the most dramatic indications that several years into an overdose epidemic that claimed 1,354 lives during 2020 and 2021—about twice as many as Covid—San Francisco lacks a coordinated public health strategy to address the use of fentanyl, a cheap, powerful opioid that’s smoked, injected and often used as an additive in other drugs.
“There’s no way to make progress without data because you don’t know what the problem is,” said Keith Humphreys, a professor of public mental health and population sciences at Stanford University. “If you don’t have that, any coherent strategy would be based on guessing.”
In a statement, the San Francisco Department of Public Health said the Drug Overdose Prevention and Education (DOPE) Project stopped collecting certain information in order to simplify data collection, improve accuracy, engage with overdose victims, and be able to hand out more naloxone. The most important data, the statement said, is whether or not someone asked for a naloxone refill, which the agency does keep track of.
Andrea Figueroa, project manager of the DOPE Project, added in an email that the idea in reducing data collection was “to streamline and maximize Naloxone distribution.”
Mayor London Breed’s current budget proposal includes $340 million for mental health, substance use and overdose investments between 2020 and 2023. But the steps she has taken so far—including a state of emergency declaration for the Tenderloin District, stepped up security patrols and the opening of a so-called “linkage center” to steer those who use drugs into treatment—fall well short of a comprehensive public health approach, drug policy experts say. The “linkage center” is already slated for closure.
At the same time, the DOPE Project has grown into what its managers say is the largest single-city naloxone distribution program in the country, claiming to have trained more than 13,000 people to administer the drug since it began in 2003. The National Harm Reduction Coalition receives $365,276 for these services during the current fiscal year, part of what the health department said is its larger overdose prevention strategy.
During the first quarter of this year, it recorded 950 halted overdoses, while handing out 3,500 doses of naloxone, likely saving additional lives. As such, the program is a standard-bearer for the city’s commitment to harm reduction, a policy that seeks to protect people’s health as much as possible while not stigmatizing drug use. The idea is to keep people who use alive by not making them wary of healthcare.
The DOPE Project is run by the National Harm Reduction Coalition, a nonprofit committed to fighting the criminalization of drug use and advancing the rights of marginalized and non-white people the organization says have been victims of the war on drugs. Harm reduction advocates are now pushing the city to open so-called safe-consumption sites, where people can use drugs in a supervised environment.
Yet the DOPE Project operates with an agenda apart from other entities involved in the fentanyl problem. Alex Kral, a researcher with the think tank RTI International who has published multiple studies on San Francisco’s fentanyl crisis and the DOPE Project’s work distributing naloxone, was flummoxed when asked if the city has a cohesive strategy to fight drug overdoses.
“That's a good question. I don't have the answer,” he said. But “I think [that] line of questioning is really important.”
Kral said the city has fallen far short of complying with its official policy of providing treatment on demand.
“They don’t have enough treatment slots,” said Kral. “Where are they linking to? Where's all the methadone slots that come at no cost to the user? We need more treatment. And then we need to make sure that there are places for people to go where they're monitored when they're using drugs."
At the time of publication, there were 26 spaces available for short-term residential treatment, 22 spaces available for longer-term programs, and 10 available for detox treatment to help those with substance abuse disorders manage withdrawal systems as they stop using drugs, according to city data. The city provides 500 such beds in total.
Supervisor Dean Preston recently called a special hearing about the lack of a comprehensive plan to fight overdoses.
“The city has no comprehensive plan to address overdoses, despite the extent of the crisis and the tragic loss of so many lives,” he said. “We need to bring city leaders, public health experts and community stakeholders together to chart a path forward to solve this crisis, save lives and prevent further suffering.”
In an emailed statement, the Department of Public Health said the city does have a “comprehensive multi-pronged plan to prevent overdose.” It involves educating people about overdoses, handing out naloxone, providing addiction treatment, and combating the view that taking illegal drugs is shameful. The city also has programs to train paramedics in helping overdose victims seek services, providing a day shelter for those who are addicted, and working to coordinate various treatment and housing services, the statement said.
The statement did not include data showing whether or not its programs were successful. But the health department said in a January press release that a decline in overdose deaths from 2021 to 2020 of about 13% may represent a “leveling off” of deaths “with the support of new City investments in substance use treatment, mental health, housing and other services.”
According to the National Association of County and City Health Officials, a comprehensive response to the opioid epidemic should begin with monitoring and surveillance to collect information guiding “public health investigation and response.” Once so armed, such a policy could guide access to services for prevention, treatment and recovery, according to the association’s guide for local health officials. The program also includes harm reduction strategies.
Until last year, the DOPE Project collected data on naloxone recipients’ drug use, overdose history, the type of drugs they overdosed on, and where the overdose occurred, reporting the numbers to the city every three months.
But in March of 2021, the Harm Reduction Coalition told the city it had stopped asking about these things. The idea, according to a memo obtained through a public records request, was to streamline naloxone distribution and make the process easier for the uninitiated.
As the DOPE Project was reducing its collection of health data, it was also making controversial policy claims to city health officials, underscoring the extent to which the various city agencies responding to the fentanyl problem often work at cross-purposes.
Police seizures of drugs, far from being a helpful step in combating addiction, were cited by the DOPE Project as a cause of overdoses—the idea being that fentanyl shortages cause jonesing among those suffering from addiction, leading them to accidentally overdose when finally getting a dose from an unfamiliar supply.
“These overdoses are the result of a chaotic and unpredictable street market, especially as federal operations continue to target the Tenderloin and people living in poverty,” asserted a 2021 “Trainings & Announcements” memo sent from the Dope Project to the health department.
The DOPE Project has issued a number of such warnings, including one to city healthcare leaders after federal agents conducted a raid in December 2020 advising of “major street supply disruptions as early as this weekend and into next week. We believe the hardest hit communities will be people experiencing homelessness and extreme poverty in the Tenderloin, South of Market, and Mission neighborhoods.”
Police Chief Bill Scott, meanwhile, has called for funds to hire more officers, stating that “the investment of personnel to address [drug overdoses], is just as important as the investment of personnel to address shootings, stabbings and other types of violent crime that leads to murder.”
Academic studies have produced scant evidence for the view that police raids reduce drug use and therefore overdoses. Nor is there a large body of evidence for the opposite, that such raids worsen fentanyl overdose rates in San Francisco.
The Standard asked the health department whether the city believes, as a matter of policy, that police actions taking fentanyl off the street are harmful. The department did not answer the question, but said in a statement that it had sent flyers to the police department describing drug treatment services, with the idea that officers could hand them out to people who use.
The police department did not respond to multiple inquiries about what its policy is when officers encounter someone who is overdosing, but did send data showing that officers reversed 145 overdoses in 2021.
The DOPE Project has also disputed the widely held view that people have been overdosing on adulterated cocaine, heroin or methamphetamine, without realizing they’d also ingested fentanyl.
In the December 2020 memo, a former DOPE Project manager wrote that there was “NO evidence whatsoever of widespread instances of fentanyl contaminating other drug supplies, like methamphetamine or cocaine,” instead blaming such claims on “false law enforcement narratives.”
Another DOPE Project memo added: “white powders and rocks all look the same and the War on Drugs creates an even more unpredictable market.”
Laura Guzman, director of capacity building and community mobilization at the National Harm Reduction Coalition, said in an email that the San Francisco Medical Examiner’s toxicology reports haven’t been able to prove somebody’s death was due to taking drugs tainted with fentanyl, meaning there was no proof of contamination. She did acknowledge that a March incident in the Mission that claimed three lives showed strong evidence of unintentional overdose.
An analysis by The Standard of two years of overdose data obtained from the San Francisco Medical Examiner’s office via records requests found that 64% of San Francisco drug overdoses during 2020 and 2021 involved fentanyl along with at least one other drug.
Of the half-dozen multiple-overdose victims The Standard talked to, most say they expect to overdose again, with hopes they’ll be revived with yet another dose of naloxone. It’s possible that there are thousands of them—dead people walking.
When Alvarez overdosed that first time at age 12, he said he was distraught over his parents' split and took all the pills in his stepfather’s bathroom cabinet, hoping to die.
Nowadays, when he overdoses, he says it’s unintentional. He just wants to do his coke without the fentanyl, but has overdosed by accident because it’s cut with fentanyl. With his stash of naloxone, Alvarez says he’s revived his friends, family members and strangers on the street from potentially fatal overdoses.
After an overdose, he said, he’s elated to have yet again survived and to have another opportunity to raise his nine-year-old son.
“I’m like: ‘Thank you, God. Thank you, God. Oh my God.’”
Additional research by Hayden Fargo.
David Sjostedt can be reached at firstname.lastname@example.org