Biden's Drug Czar Shares Vision for Tackling Overdose Crisis in San Francisco and Beyond

Certain opioid-treatment medications that help fight addiction and prevent overdoses may now be easier to access after the federal government this month loosened restrictions on obtaining them.

The updated rules essentially make permanent the pandemic-era changes that relaxed barriers to treatment, such as no longer requiring some patients to show up in person every day to take methadone and other medications — a change that cities like San Francisco found effective in increasing participation in such programs.

The relaxed rules come as San Francisco reported 806 overdose deaths in 2023 — more than any other year on record, according to updated figures (PDF) from the city’s Office of the Chief Medical Examiner. In January 2024 alone, San Francisco reported 66 overdose deaths, mostly driven by fentanyl, a synthetic opioid about 50 times more potent than heroin.

Federal public health officials are watching the West Coast closely as the overdose crisis in this part of the country intensifies. The Biden administration has so far allocated $83 billion toward treatment programs, an increase of more than 40% over the previous administration’s investment, according to the White House.

On the same day, the Biden administration announced it was loosening restrictions, Dr. Rahul Gupta, director of the Office of National Drug Control Policy (aka “Biden’s drug czar”), spoke to KQED about addressing the opioid epidemic in San Francisco and elsewhere across the country.

The following interview has been modified for clarity and length.

KQED: What could San Francisco do more of to try and stem its current tide of drug overdoses?

Gupta: When we look at these types of epidemics across the country, where we find successful examples is where there’s a really good balance of both expanding treatment, accessing life-saving drugs, like Narcan, which actually are an opioid antagonist and connecting people to treatment. And one of the things that needs to be done is to ensure that naloxone (the generic name for Narcan) is available in more public spaces — malls and schools and restaurants and other offices. But at the same time, also going after the sort of the financial networks of drug trafficking.

Today’s announcement is really about expanding treatment access, removing barriers to treatment, providing more resources in terms of test strips for not just fentanyl but also xylazine, the animal tranquilizer that is now being found more and more mixed with fentanyl, and making the response so much more complicated. The goal here is really to prioritize saving lives, prioritize, getting people the assistance that they need in a not stigmatizing way. And that happens when we treat addiction as a disease.

Where does the administration stand right now on supervised consumption sites, where people can consume illegal drugs in a sterile, supervised environment? If Biden gets four more years, do you think we’ll see real change on that front?

Let me first talk about the harm-reduction approach that this administration is taking — the first in history to do so. We’ve taken an approach to focus on three specific policies that include getting naloxone into the hands of people. Having opioid overdose reversal medication is really the best way to save lives immediately.

Second is syringe-service programs. The third is drug checking. All three approaches are evidence-based and really supported by decades of data to demonstrate their efficacy. But also, result in cost savings, life savings.

There is federal litigation ongoing at this point (regarding supervised consumption sites), so I’ll stay away from commenting specifically on particular avenues beyond those that we have federal policy behind.

What is important in today’s announcement is to make permanent some of these COVID-era flexibilities, like take-home medications and telehealth provisions. These allow expansion of treatment access to people not only in urban areas but also in rural and marginalized communities because oftentimes, we know that there’s a disparate access to who gets treatment and who doesn’t get treatment.

For example, people behind bars. We know today there are about 2 million Americans behind bars, and two-thirds are there for something related to drugs. And yet, the treatment in incarceration or in custody is very uneven across the country.

Today’s announcement allows treatment programs within jails and prisons to not (have to) be designated as opioid-treatment providers. They can be a clinic and still be able to provide those lifesaving treatments.

I’ve spoken to incarcerated people who have told me about smuggling life-saving medications like buprenorphine into prisons. So, is this change aimed at addressing that?

Yes. It is a top priority for the president to make sure we are doing something about these tens of thousands of people that are dying right after reentry each year. The Centers for Medicare & Medicaid Services is now allowing Medicaid waivers for states to apply to be able to allow treatment in custody 90 days before release. The whole idea here is to get people treatment when they are reentering society, so then they’re able to again get those vocational opportunities, educational opportunities, economic opportunities.

Has California applied for that waiver?

Yes. California was the first one to apply and has already received that waiver. We’re working closely with the state on implementation.

Given the abundance of the illicit drug supply right now, when can we expect to see the current crisis to change? What are your projections?

Last November, President Biden met with President Xi Jinping from the People’s Republic of China at the APEC summit in San Francisco, and Xi made a commitment to address the fentanyl supply chain.

Our team just returned from Beijing this week. We are confident that if (cooperation) continues forward, the supply of those chemicals that ultimately end up being turned into fentanyl in Mexico will be disrupted. So it’s going to be important for us to continue to hold those individual governments accountable.

As we address this, we still have to focus on the public health side of this at the same time. So, it’s important to view these as two sides of the same coin. And this is not like an overnight thing. It takes a while for these actions and policy changes to have effect.

At the same time, we’re seeing people overdosing and dying. So, we have to continue with the public health efforts while addressing the supply side.