Nearly 60% of all drug overdose deaths in San Francisco and four of its neighboring counties involved fentanyl last year, new data shows. And while San Francisco has the highest per capita fatal OD rate, 57% of the region’s 1,510 overdose deaths occurred outside the city.
The 2022 data was obtained exclusively by The Standard from county coroners and medical examiners in San Francisco, San Mateo, Alameda, Santa Clara and Marin counties. Together, the statistics indicate that the multipronged efforts across Bay Area counties to fight the fentanyl crisis are failing.
San Francisco remains the epicenter of the Bay Area overdose crisis: 647 people died from accidental overdoses in 2022, the majority of which involved fentanyl. The city’s preliminary count of fatal overdoses from January through April this year shows ODs have killed 268 people versus 196 over the same period last year. If overdoses continue at this rate, San Francisco will see its deadliest overdose year ever.
Hundreds more died by fatal overdose in nearby counties in 2022: 373 in Santa Clara County, 355 in Alameda County and 54 in Marin County. In San Mateo County, 81 people died of overdoses between January and November 2022. (December data is not yet available.)
“The drug supply, and drug use, doesn’t recognize geographic, county lines,” said Mary Sylla, director of overdose prevention policy at the National Harm Reduction Coalition. While it's San Francisco's deadly overdose crisis that dominates headlines, the surrounding Bay Area counties are also hard-hit and may be less prepared to deal with the problem, she said.
Most counties have adopted a version of the harm-reduction approach, pushing outreach campaigns educating people on the dangers of fentanyl, providing addiction treatment programs and expanding Narcan supply to reverse overdoses.
However, some say the counties’ health care systems are not ready to counter fentanyl’s potency and ubiquity in the Bay Area drug supply.
“The systems of care that were in place, pre-fentanyl, were just not up to the task of a fentanyl epidemic,” said Josh Luftig, co-founder of California Bridge (CA Bridge), which works with hospitals to establish low-barrier addiction treatment in emergency rooms.
The Crisis in Santa Clara County
Overall, Santa Clara County recorded 373 total accidental drug overdoses last year, which included deaths from non-opiate substances like alcohol and cocaine. Fatal opioid overdoses—which count deaths from drugs like fentanyl, codeine, morphine and hydrocodone—in Santa Clara County more than doubled between 2019 and 2022, reaching a high of 167 accidental opioid-related fatalities last year.
“Those numbers are lives—and those lives lost are what is driving our work on this,” said Otto Lee, a county supervisor who spearheaded numerous bills to combat fentanyl. The issue is personal to Lee, who lost a 29-year-old cousin to an overdose.
Santa Clara was the only Bay Area county out of the five analyzed where fentanyl was not linked to the majority of all overdose deaths in 2022. However, of the opioid-related overdoses last year, roughly 82% were linked to fentanyl. The deadly synthetic opioid spread rapidly throughout the South Bay drug supply in recent years, and between 2019 and 2022, fentanyl-linked overdoses increased fivefold in Santa Clara County.
“We had to start talking about [the overdose crisis]. It was so in our faces, and we were that frontline,” said Reb Close, an emergency medicine physician based in Monterey and an associate at CA Bridge.
“As much as many would try to pretend like [opioid use] was somewhere else—NIMBY kind of business—those of us that are in the rooms with the patient, trying to revive people from overdoses, we were seeing it,” Close added.
Santa Clara declared drug overdoses a public health emergency in January 2022, promising to “cut the red tape” and devote more resources to the crisis. Youth drug use has further forced health officials’ hands: Santa Clara County supervisors carved out $135,000 in funding to provide naloxone, the opioid overdose antidote drug, to schools in September, after some high-profile overdoses by teenagers using fentanyl-laced drugs.
The county has also launched a series of overdose prevention campaigns in recent years: The “Expect Fentanyl” slogan was plastered across the city in 2021, in direct response to a spike in overdoses the Santa Clara County Medical Examiner-Coroner's Office attributed to fentanyl-laced narcotics and pills.
But some experts say that the region’s health care system has been too slow to respond to the ballooning numbers of fentanyl-linked deaths.
“In the South Bay and the Peninsula, there was a perception that the drug crisis was something that was happening in [San Francisco’s] Tenderloin, and that there weren't patients in these towns using fentanyl,” said Elizabeth Keating, clinical program director for CA Bridge. “We still heard a lot of hospitals saying, ‘Oh, well, those patients don't come here,’ or ‘We don't see those kinds of people in the hospital.’”
The Crisis in San Mateo County
San Mateo County saw 134 fatal overdoses in 2021—a record—but deaths appear to have dropped significantly in 2022.
A comparison of overdoses between January and November 2021 and the same period in 2022 showed San Mateo’s fatal overdoses dropped 33%. The county did not provide data for December 2022.
Yet, the share of fentanyl-linked deaths appear to be rising in San Mateo. The county documented 81 fatal accidental overdoses between January and November last year, 62% involving fentanyl. Just over half—53%—of 2021’s fatal accidental overdoses involved the synthetic opioid, by comparison.
San Mateo County’s health department has sought to reduce overdose deaths by producing safe-use pamphlets and pushing for naloxone distribution in public spaces like libraries. Alarmed by the rash of teenagers overdosing in neighboring Santa Clara, the department has expanded outreach to youth in recent months.
“We didn’t want to wait for this to become a problem of overdoses. We have seen what is happening in other schools,” said Patricia Love, the executive director at the San Mateo County Office of Education. “Having [naloxone kits] available for after-school programs is basically a preventative measure.”
Health officials said that some schools in Santa Clara County were initially reluctant to offer naloxone. By contrast, San Mateo County’s Coalition for Safe Schools and Communities campaigned to distribute the overdose antidote despite having fewer 2022 teenage overdoses than Santa Clara, a campaign Love said has been successful.
San Mateo schools now carry overdose “toolkits” that include naloxone and information pamphlets, Love said.
Still, Bay Area counties should have been more proactive about the youth crisis earlier, said Luftig, the co-founder of CA Bridge, who is also a physician’s assistant based at Highland Hospital in Oakland.
“If we’re looking back at the adolescent crisis we’re having, if it wasn’t substance use disorder, this would be headline news every day,” he said, in reference to what’s unfolding in South Bay counties. “It's so upsetting that there's a health care condition that is plaguing the youth in our community and driving fatalities up [...] and we're not up in arms every day about this.”
The Crisis in Alameda County
Alameda County had 355 residents die of overdoses last year, representing an 11% increase in overdoses from 2020 (detailed 2021 data was not available). The rise of fentanyl in the drug supply has largely driven the fatalities, with the opioid accounting for roughly 63% of the county’s deadly overdoses last year.
Alameda County’s opioid and fentanyl overdose rates in 2022 were more than double what the county saw in 2020. There were roughly 12 fentanyl-related overdoses for every 100,000 Alameda County residents in the third quarter of 2022, compared with the rate of 6.4 fentanyl overdoses per 100,000 residents recorded in the first quarter of 2020.
Luftig said that Alameda County’s HIV Education and Prevention Project, which formed in 1992 in response to the spread of HIV via shared syringes, first led the county’s public health efforts. The project has long been responsible for the county’s harm-reduction programming, distributing naloxone and working with coalitions like CA Bridge to expand treatment options.
“They’ve been in this space for far longer than we have doing harm reduction,” Luftig said. “But historically, the syringe exchanges and these community-based organizations have not had low-barrier access to treatment—that piece has been missing,” he said in reference to the lack of programs offering buprenorphine and other medications to help people transition off drugs.
Overdoses nevertheless continue to hit Alameda County hard: After San Francisco, the county had the second-highest share of fentanyl-linked overdoses in 2022, and public health experts in Oakland say an alarming rise in methamphetamine use exacerbated the overdose crisis in recent months.
Of the five core Bay Area counties, lightly populated Marin County unsurprisingly reported some of the lowest counts of overdoses. But the coastal region’s opioid overdoses and fentanyl-linked deaths rose steadily in the last few years, and its per capita opioid overdose death rate was among the highest in the region in 2021.
In January, county officials said that Marin sees more than one fatal overdose and two non-fatal overdoses every week, on average. In 2022, Marin counted 54 fatal overdoses.
Fentanyl accounted for 57% of the county’s fatal overdoses in 2021, according to OD Free Marin—a year later, the synthetic opioid was involved in nearly two-thirds of fatal overdoses.
“The nature of the local opioid crisis has shifted from prescription opioids to fentanyl,” said Dr. Matt Willis, the county public health officer, in January. “New very potent opioids are flooding the illicit market, and we’re seeing more overdoses in every community in Marin. It’s time to take action together.”
Marin health officials, for their part, said they embraced the same slew of harm-reduction efforts touted by other Bay Area counties. In response to rising overdoses, county health officials said they invested in linkage programs to connect users to medication-assisted treatment, such as buprenorphine, which helps diminish the effects of physical dependence to opioids. The county also started training street teams with using Narcan, the brand-name naloxone spray, in early 2022.
“About a year ago, we gave training to the San Rafael Downtown Streets Team staff,” Willis said. “They saved two lives the next week, both young people in their 20s.”
The county recently beefed up its drug surveillance and research efforts. Marin may be the first and only Bay Area county to formally implement a wastewater drug-tracing program, an increasingly popular preventative measure to track how different drugs—including the deadly Narcan-resistant substance xylazine, aka “Tranq”—flow through communities, before overdoses can reveal those trends after the fact.
“When we detected [Tranq], we released a public health advisory to our providers so that it got out to our harm-reduction colleagues and other people in the community as well,” said Haylea Hannah, a principal investigator at Marin’s wastewater project. “It’s giving us objective data to put to some things we’ve been hearing anecdotally for quite a while.”
A Fractured Response to the Crisis
Local lawmakers are growing desperate and increasingly cognizant of the fact that no one county’s health care or criminal justice systems can tackle the overdose crisis alone—especially as fatal overdoses persist and fentanyl trafficking extends across county boundaries.
“The opioid pandemic really doesn’t discriminate, though I think in the public arena, and media, we may see a certain population that seems to be highlighted the most,” said Edwin Poon, deputy director of Santa Clara County’s Behavioral Health Services Department, referring to the primacy of San Francisco's crisis in the news. “In reality, fentanyl abuse and opioid abuse have impacted our community severely since last year.”
Still, experts say there is hope in some of the early attempts for cross-county collaboration.
Wastewater drug tracing, for example, is only officially deployed in Marin County, but Hannah—the investigator at the pilot program in Marin—told The Standard that other California counties are now starting to reach out to the county about that approach. And Santa Clara County officials said they’ve established opioid treatment clinics that can serve residents from neighboring counties, such as San Mateo.
San Francisco’s public health department, for its part, says the city has collaborated with Alameda and Marin counties “on issues related to treatment access, naloxone, other strategies for overdose prevention and, more recently, concerns about xylazine.”
Efforts are also now reaching the state and federal level. San Francisco supervisors called for more federal support to target drug trafficking, while Gov. Gavin Newsom deployed the highway patrol and California National Guard to the city in May. State legislators have passed a slew of bills designed to prevent overdoses, and statewide coalitions, such as those run by the Public Health Initiative, have tried to create addiction treatment networks across the Bay Area.
“No single entity can address this major issue that we are confronting,” said Dr. Mary Maddux-Gonzalez, a physician who works with one of the state’s most prominent coalitions, the California Overdose Prevention Network. “We really need the collaboration of all of these entities in communities to address it.”