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Politics & Policy

San Francisco reverses hundreds of overdoses a month: what happens next?

A person lies in an ambulance. Their face is out of frame.
A person is treated in the back of an ambulance at the intersection of Seventh and Market streets in San Francisco on Oct. 16, 2023. The intersection is known for its open-air drug trade, where fentanyl and other narcotics are bought and sold. | Source: Loren Elliott for The Standard

Casper Green, a homeless man in San Francisco who struggles with addiction, says he was 10 years old when he first overdosed on drugs. Miraculously, he survived with little recollection of what happened. Since then, Green, who now uses fentanyl, claims he would have died four more times—if it hadn’t been for the overdose-reversal medication Narcan.

For many people, a near-fatal overdose would serve as a wake-up call to change their behavior. But for Green, and for an untold number of other people using drugs on San Francisco’s streets, an overdose is more likely to send them deeper into the cycle of addiction.

“You just OD’d, and you’d think, ‘Maybe I shouldn’t do this drug no more,’” Green told The Standard. “But it makes you want to get high again.”

Once Narcan—the brand name for the opioid antagonist naloxone—is administered after an overdose, a drug user’s brain quickly stops feeling the effect of any opioid they ingested, according to physician and University of California San Francisco addiction expert Ayesha Appa. That rapid de-escalation of the high sends victims into a state that’s known as “feeling sick.”

“There’s this emotional roller coaster,” Appa said. “Some people have described to me being grateful to be alive. … It can also be really traumatic.”

San Francisco has embraced Narcan as a tool to combat an overdose crisis that reached unprecedented levels in 2023. A record-breaking 752 people died of drug overdoses through the end of November. (City data for December is not yet available.) 

Between January and September 2023, the Department of Public Health distributed 106,168 doses of Narcan, according to city data. Over the first seven months of last year, ambulances in the city responded to 3,497 likely overdoses, according to data provided by the Department of Emergency Management. Narcan is also available at pharmacies without a prescription.

Paramedics attend to a person on a stretcher beside an ambulance on a city street at dusk.
A person who overdosed is wheeled away on a stretcher toward an ambulance by emergency medical technicians on Willow Street in San Francisco's Tenderloin neighborhood. | Source: Nick Otto for The Standard

The Department of Public Health said in a statement that it’s working aggressively to make drug treatment more available by expanding hours at its Downtown drop-in center, adding hundreds of new treatment beds and broadening access to withdrawal medications.

But what happens after a potentially deadly overdose is reversed is a fraught public health question.

When city paramedics respond to an overdose call, there is no requirement to take the person to a hospital if the person refuses, is capable of understanding their decision and is considered not a danger to themselves or others, according to city policy reviewed by The Standard. Ordinary citizens who reverse an overdose are also not required to contact local health authorities.

The city’s Street Overdose Response Team—a program made up of a paramedic, a clinician and peer counselors tasked with connecting overdose survivors to medical care—followed up with survivors 36% of the time between October 2021 and June 2023, according to the most recent publicly available data.

Of 1,439 interactions the response team had with overdose survivors during that period, 5% of victims were referred to withdrawal management, 42% were “assisted with services” and 56% were provided harm reduction education. A total of 13% were prescribed buprenorphine, a withdrawal management drug, and 15% were already using the medication.

The health department noted in a statement that other street care teams provide ongoing support to homeless people with the goal of connecting them to treatment.

A nonfatal overdose may be the strongest indicator that a person is at high risk of facing serious harm from their drug use. At the same time, mishandling the moments following their revival can erode a victim’s trust in the medical system, making them less likely to seek help in the future.

Rob Weber, a longtime San Francisco drug user, said he accidentally overdosed on fentanyl about a year ago after he used a stranger’s crack pipe near the main branch of the San Francisco Public Library. He recalled waking up in San Francisco General Hospital with chest pain but said hospital staff rushed him back to his homeless shelter in an Uber. He said no health officials ever contacted him to follow up.

“I didn’t even know where I was, but they just wanted me out of there,” Weber said. “There’s a lot of people in the medical field who have a disdain for people who use drugs.”

Some overdose survivors said they were simply left on the city’s streets after being revived. Others recalled waking up in a hospital and quickly taking the bus, or hitching a ride, to the closest drug dealer.

“Imagine people around you yelling at you, and you don’t know how to react,” said Brian Rain, who said he’s overdosed five times on fentanyl. “You realize that you could’ve died. But you need your drugs.”

‘A Deep, Dark Hole’

Some drug users said the profound discomfort of their withdrawals overshadowed the implications of their close call with death. Rather than contemplate the consequences of their drug use at that moment, they said the pain of withdrawals sent them into a frantic search for their next high, a feeling they called “getting well.”

“I remember coming out of it, not understanding what happened and just being horribly sick,” Green said. “It’d be better to be dead than sick.”

A study conducted in Massachusetts in 2020 found that 5.5% of people who were revived from overdoses in the hospital died within a year of the incident. About 67% of those deaths came from a subsequent opioid overdose.

According to Appa, an opioid overdose effectively causes a person’s body to forget to breathe on its own. She said Narcan works by quickly emptying the brain’s receptors of opioids, allowing bodily functions to continue but causing severe withdrawals.

“Reversing overdoses is not what we want. Optimally, what we want is preventing the overdose in the first place,” Appa said. “The cumulative effects of [lack of oxygen] on the brain are obviously not great.”

Even hours after an overdose is reversed with Narcan, the brain may be unable to feel the effects of opioids fully. It’s not until long after he gets high again, Green said, that he realizes the gravity of his brush with death.

“There’s no light at the end of the tunnel. There’s nothing,” Green said. “It’s scary.” 

A man in layers with a hood, a beard, and a concerned expression sits before a peeling red wall.
Matthew Ortega said he had an out-of-body experience due to Narcan. | Source: David Sjostedt/The Standard

Matthew Ortega, a 43-year-old homeless man from Humboldt County, told The Standard he had an out-of-body experience when he was brought back from an overdose last year. 

Ortega said he believes he was given too many doses of Narcan, sending his mind and body into shock.

“It’s not a game. It’s not some cool fun thing to do,” Ortega said. “It felt like I was being ripped out of a deep, dark hole.”

Ortega said the experience ultimately made him more careful with his drug use. Still, he’s struggled to stop using drugs completely, due to chronic pain caused by a degenerative bone disease in his spine.  

For some, the lack of successful interventions with overdose survivors points to a need for more coercive tactics. In October, Mayor London Breed issued an executive order to quickly implement new state legislation that broadens the use of conservatorship to include people with severe drug addiction.

Breed is also backing a March ballot measure to screen some welfare recipients for drug use before granting them cash payments.

Others say the overdose crisis points to a need for designated spaces, known as safe-consumption sites, where people can use drugs under the supervision of people trained to reverse overdoses and find other services when they are ready for treatment.

“One clear type of program that we’re missing, that seems obviously important and beneficial, would be a safe-consumption site,” Appa said. 

Blue storage bins with medical supplies, labeled with numbers and percentages.
Tools and resources available to guests of the now-closed safe-consumption site Tenderloin Center on Market Street in San Francisco are pictured on June 2, 2022. | Source: Camille Cohen/The Standard

The city operated such a facility called the Tenderloin Center for 11 months in 2022, reversing 333 overdoses during its tenure, according to city data. However, the site, which cost $22 million, closed as critics alleged it attracted drug use and other criminal behavior to the area. Plans to open smaller similar facilities have since hit a standstill over legal and funding issues.

Rain told The Standard he overdosed twice at the Tenderloin Center and found the experience less traumatic than the other times he awoke from overdoses in an ambulance.

“Nobody wants to go to the hospital,” Rain said. “At least [at the Tenderloin Center] they weren’t all freaking out.”