Almost every time Edwin Armando Alvarez overdosed on fentanyl, he said he awoke grateful to be alive. But on March 9, alone in his residential hotel room in San Francisco’s Tenderloin, he didn’t wake up. He died at 53, lying on his apartment floor among cockroaches, moldy food and heaps of trash.

A week before he died, he called his daughter, Genoveva Alvarez-Arroyo, expressing a desire to escape the life he found himself in. He started using fentanyl while living on San Francisco’s streets, and the city had placed him in housing just blocks from where drug dealers hawked the deadly opioid. 

“I know I can really, really beat this,” Alvarez said in his final voicemail to his daughter. “I try and try and try.”

Alvarez-Arroyo said she knew her dad as a talented artist and as an exceedingly tidy person. He painted several murals across the city and was known by friends as “Smiley” for his positive attitude. 

“He was the best dad ever,” said Alvarez-Arroyo, who lives in Oakland. “Then he started to change. It got bad. Like really, really bad. I've never seen him like that before. … Living down there didn't help him at all.” 

Alvarez was one of at least 85 people who fatally overdosed in San Francisco’s housing for formerly homeless people this year by July 31, according to data from the Chief Medical Examiner’s Office analyzed by The Standard.

Inside taxpayer-funded supportive housing, nearly three people died of overdoses every week on average in the first seven months of this year, according to the medical examiner’s data.

The city’s leaders and largest homelessness nonprofits appear to be undercounting the loss of life from drugs in the city-funded housing units. In a statement, Mayor London Breed’s office said it counted 67 reports of accidental drug overdoses in its supportive housing buildings last fiscal year, which ran from July 2022 to June 2023. Breed’s office said 51% of those overdoses were reversed, while 31% had an “unknown outcome” and just 18% resulted in a “known fatality.” 

That would bring the number of “known” deaths to roughly 12 people over the course of the year.

The medical examiner’s data shows at least 17 people died by July 31 this year inside the buildings of a single housing provider, Episcopal Community Services. Representatives of the organization told The Standard they are unable to track the number of overdose deaths in their facilities due to a lack of staff. 

Another 19 people died inside buildings run by the Tenderloin Housing Clinic, whose executive director, Randy Shaw, said his organization isn't told how its clients die. 

The Department of Homelessness and Supportive Housing said Breed’s data comes from critical incident reports collected from housing providers. But because the cause of death often isn’t determined until months later, many fatal overdoses go uncaptured in the reports. 

“I don’t have the capacity to chase the coroner,” said Lauren Hall, executive director of the nonprofit housing provider Delivering Innovation in Supportive Housing. “I really think the data collection is something that the city is trying to figure out because everybody wants to know the number.”

The homelessness department has a $713 million budget this fiscal year, and 59% of the department’s budget over the next two years is allocated to housing. The city’s budget for behavioral health services sits at $592 million, according to a January presentation.

In a statement, Breed’s office and the Department of Public Health pointed to increased investments in treatment as well as outreach teams and overdose prevention measures aimed at improving the health outcomes of drug users in supportive housing units. The health department said it distributed more than 73,000 doses of the overdose reversal medication naloxone this year while providing addiction and mental health care to 25,000 people annually.

“The accidental overdose death rate in San Francisco is alarmingly high, and would be even higher if not for our many efforts,” the health department’s statement read. “We continue to work urgently, in many areas, to respond to this situation with the goal of saving lives.”

A record number of 563 people citywide lost their lives to overdoses by August this year, according to preliminary data from the medical examiner’s office. 

In January, the city opened a state-of-the-art, six-story building at 1064 Mission St. with the capacity to house 256 formerly homeless people. The building’s website promised it would serve as a national model “to help San Francisco’s most vulnerable, chronically homeless neighbors achieve housing stability, improve health outcomes, and lead stronger, more independent lives.”

Within a week and a half of the building’s opening, two people fatally overdosed in its rooms. 

Critics of the city’s current policies say the death toll illuminates the risks of taking people straight from the streets and shelters and placing them into isolated housing units. Others say the city must invest more in measures to assist people in reversing overdoses inside the buildings.

Chris Callandrillo, chief operating officer for Episcopal Community Services, told The Standard the nonprofit is working to train its residents and stock the overdose reversal medication Narcan on every floor of its buildings. 

Callandrillo said the rise of fentanyl has also intensified the need for sober living environments as well as competent case managers. Whereas case managers used to focus on eviction protection, they are now forced to confront life-threatening drug use, he said.

“Fentanyl shifted the paradigm,” Callandrillo said. 

As part of a policy called “housing first,” the city has long worked to remove barriers people face in acquiring housing. That means removing requirements such as drug treatment and sobriety mandates. The city has served as a national model for the policy, according to proponents, providing subsidized homes for over 10,000 people at a time. 

Now, some social service providers at the forefront of the homelessness crisis say fentanyl is forcing them to contemplate ways to evolve the policy. In September, Breed informally proposed legislation that would force some welfare recipients to undergo drug screenings.

The city typically admits people into housing using a process called Coordinated Entry, which evaluates applicants based on the chronicity of their homelessness and their level of vulnerability if left living on the streets.

Callandrillo said 80% of tenants in one of Episcopal Community Services’ buildings acknowledged having a drug addiction, while roughly 65% said their drug use was a serious impediment in their lives. 

Shaw, of the Tenderloin Housing Clinic, said he wants the city to require tenants of supportive housing to participate in case management and other services. 

“Housing first wasn’t created with the threat of fentanyl,” Shaw said. “The circumstances have changed.”

Other providers said they don’t want to see the city create requirements that could lead to more evictions. Instead, they argue the current model would benefit from a greater investment in voluntary treatment and other preventative measures. 

Hall, of Delivering Innovation in Supportive Housing, said her organization has seen success in training tenants to reverse overdoses. She pointed to a program that pays and trains some tenants to respond to overdoses at the Minna Lee hotel, which hasn’t seen a fatal overdose since Feb. 2021.

“It’s not so much a question of ‘what do we do?’ but ‘how are we going to get the funding?’” Hall said.

Susan Lefeever, a 49-year-old resident at the Minna Lee, told The Standard she’s reversed three overdoses since becoming a peer overdose responder two years ago. She said the tenants feel more comfortable coming to her than the building's staff. 

Daniel Ciccarone, an addiction science researcher at the University of California San Francisco, spoke highly of preventative measures such as installing alarm buttons, like Life Alert systems for older adults, in the tenants’ rooms.

Ciccarone said rooms where people live in isolation, by their very nature, are likely to heighten the risk of a person with addiction fatally overdosing.  

“Addiction is connected to loneliness,” Ciccarone said. “We have to be cognizant that our supportive housing often adds to loneliness.” 

Alvarez-Arroyo said she wishes the city had more forcefully guided her father into treatment. She said despite the best intentions of caseworkers and other staff, the city made it too easy to obtain drugs and too difficult to pursue recovery.

The Standard reported in September that roughly half of people who sought treatment from the city’s largest drug detox center this spring weren't admitted. However, the city said many of those who weren’t admitted were taken to other facilities or left on their own accord.

In his final voicemail to his daughter, Alvarez said he had just participated in a class on how to reverse overdoses.

“I swear to God, he had nine lives. But that was his 10th,” Alvarez-Arroyo said. “He needed help, and he was crying when he couldn't do it on his own.”

Larry Hunt, famed Market Street “bucket man” who appeared in the Will Smith movie Pursuit of Happyness, was another one of the dozens of drug overdose deaths in supportive housing this year. 

His wife, Cheryl Martin, told The Standard in June that Hunt had long struggled with depression. But when the pandemic brought his sidewalk drumming career to a halt, he began to truly suffer.

“I guess God needed him in the choir in heaven,” Martin said at the time. 

After years of living outside or in shelters, formerly homeless tenants may be unprepared to live on their own indoors. On the other hand, it can be nearly impossible to recover from addiction while living on the streets. 

“They send people to these places to die,” said one supportive housing resident, Elizabeth Intinarelli. “They shouldn’t be alone. They don’t know how to take care of themselves.”

Friends and family of Alvarez told The Standard he never learned to adjust to living on his own inside after he started using fentanyl.

Alvarez told The Standard in a June interview that he had overdosed multiple times without intervention and he hoped to one day recover from his addiction to father his 9-year-old son.

“His biggest dream was that his family would come together,” Alvarez-Arroyo said.

“He was a loving, caring dad, and then I watched him deteriorate.”