Fewer people on track to die of overdoses in San Francisco in 2022: What changed?

The country’s overdose crisis is perhaps not so evident anywhere as it is in San Francisco, where more than 1,000 people have died of a fatal drug overdose since January last year. But year-end data shows that the rate of these overdoses is actually declining in the city.

A total of 556 people in San Francisco died of fatal drug overdoses as of the end of November, a 13% decline from 2021’s 641 total accidental fatal overdoses, according to data from the Medical Examiner’s Office. Estimates show the city will likely end the year with about 600 overdose fatalities.

If the rate of overdoses continues, it will be the second year in a row that the city has reported a decline in overall overdose deaths. Last year, 2021, was the first to break the decade-long streak of worsening fatal overdose statistics.

While these numbers may signal some hope for San Francisco, the city’s handling of the drug crisis this year has constantly shifted: Between a July drug crackdown and the opening of the city’s first unofficial safe consumption site called the Tenderloin Center, San Francisco oscillated between harm reduction and criminal punishment in its approach to the crisis.

At times, the two approaches conflicted, sometimes in spite of city leaders hoping to find a winning balance between them. So what actually worked?

The health department put increasing access to treatment and harm-reduction services at the top of its 2022 Overdose Plan, signaling the city’s long-standing harm reduction and public health-forward approach to the drug crisis.

But in the face of anecdotal reports of patients being turned away from treatment and a widespread behavioral health worker shortage, legislators are concerned that the health department may not be meeting its long-standing goal of offering “treatment on demand.”

San Francisco has seen a steady decline of drug addiction treatment admissions while overdoses have exploded since 2015, a phenomenon that health leaders attribute to an evolving outpatient-style approach to addiction treatment, as well as new state policies that require patients to attend longterm treatment in their cities of origin. 

And though San Francisco has historically touted its role as a leader in the harm-reduction movement, the recent closure of the Tenderloin Center has made some critics skeptical that Mayor London Breed will continue to prioritize public health measures to fight the fentanyl plague.

Advocates say that safe consumption sites, where people can use drugs under supervision, are crucial to an overdose prevention plan.

A total of 333 overdoses were reversed at the Tenderloin Center in the last year, and the rate at which it intervened in these crises only picked up in the months leading up to its December closure. It saw over 124,000 visits across its 11-month open period, averaging roughly 400 per day. By comparison, Emergency Medical Services (EMS) reversed roughly 132 overdoses during this same time period.

In the last year, the Tenderloin Center quickly became a central hub for distributing naloxone—often called by the brand name of its delivery device, Narcan—a drug that can reverse an opioid overdose. Over 15,500 doses have been distributed in the last year, both by the Tenderloin Center and city outreach teams.

Phillip Coffin, director of the Center on Substance Abuse, estimated that roughly 1% of the city’s 4,600 overdose reversals would have led to death.

In the roughly 10 months that the Tenderloin Center was open, the city saw around the same amount of fatal overdoses as the 10 months prior to the center’s launch, causing some legislators to question its effectiveness. 

San Francisco saw 505 overdoses between March and December 2021—and roughly the same number between January and October this year, when the Tenderloin Center was open. 

But most of the city’s overdose deaths occurred among people with a fixed residence in the city, and at least 246 residents within city-funded permanent supportive housing facilities died from overdoses during 2020 and 2021.

A string of fentanyl lacings and subsequent fatal overdoses in March, for example, prompted the city to issue a health alert, and a mass overdose on Christmas Day led to six non-fatal overdoses—events that may add to the city’s growing overdose count, but happened among portions of the population that wouldn’t likely use the Tenderloin Center. 

Critics of the Tenderloin Center also say that even though it provided crucial health services, the “linkage”—the site was originally called the “Tenderloin Linkage Center”—concept was essentially defunct. Fewer than 1% of visits to the site resulted in a “completed linkage” to behavioral health programs, and 281 requests for those services went unfulfilled.

And data from the city shows that fatal overdoses are decreasing in neighborhoods across San Francisco at roughly the same rate, including in the Tenderloin—despite the fact that the blighted Downtown neighborhood had access to a safe consumption site.  

Nonetheless, the Tenderloin saw 111 fatal overdoses in 2022 (as of the end of November), representing almost 20% of all fatal overdoses in the city. Though the Tenderloin witnessed a disproportionately high number of overdose deaths compared with other neighborhoods, the share of fatal overdoses happening in the Tenderloin remained the same between 2021 and 2022. 

While San Francisco has largely pushed for a health-forward approach to the overdose crisis, many residents and some legislators have pushed for greater law enforcement against drug dealers and users on the streets.

During a summer drug crackdown, San Francisco police began citing and arresting drug users—not just dealers—as part of a federally funded strategy to disrupt the drug markets that dominate pockets of Downtown. In September, District Attorney Brooke Jenkins announced a five-strike policy that aimed to coerce repeat offenders into treatment.

But did it work? 

Arrests and citations relating to narcotics (drug violations, possession or related money offenses, for example) increased in 2022, far outpacing pandemic levels. In 2021, police cited 459 narcotics-related incidents. But throughout the past year, narcotics-related arrests or citations quickly piled up, topping 1,200 incidents for a 169% year-over-year increase.

“We want people who are addicted to get help,” SF Police Chief Bill Scott told The Standard in July. “I very much understand harm reduction. But we have to disrupt this activity because the bottom line is it’s going unabated.”

At the same time, drug overdoses and reversals continued to surge. The Tenderloin Center’s overdose reversals peaked in early August, and the use of naloxone services—both by the center and the Department of Public Health—increased slightly from July through September.

Overdose deaths showed no signs of slowing in the summer either, and remained consistent in the months leading up to the end of the year.

Harm-reduction experts say that these punitive measures are “wildly counterproductive” to reducing overdose deaths, and stand in the face of more recent efforts to back risk management programs and reduce drug stigmatization.

Some experts contend that San Francisco’s declining overdose fatalities is simply a sign of the city’s emergence from the deadly pandemic lockdown surges of 2020 and early 2021.

Though fentanyl had slowly added to the city’s overdose death rate for several years prior, the city started experiencing record-breaking death tolls from the drug in May 2020. The city then averaged 68 overdose deaths per month between May 2020 through February 2021, but has dropped to an average of 51 overdose deaths per month in the time since.

During the Covid lockdowns, people were more likely to use in isolation, and there were less pedestrians roaming the streets to reverse potentially fatal overdoses. But the true determinant of the decrease may never totally be understood.

“Some of that peak we saw in 2020, was due to isolation from Covid,” Coffin of the Center on Substance Abuse, said. “But I would hope that the intensification and expansion of programs and innovative services that we've rolled out have also contributed to the decline.”

Editor's Note: This story has been updated to further clarify that the rate of overdoses in 2022 is on track to be lower than last year's total, though the final end-of-year numbers are not yet in.