Paul Harkin, director of harm reduction at GLIDE, hands out narcan, fentanyl detection packets and tinfoil to drug users in an alley in San Francisco's Tenderloin neighborhood on Feb. 3, 2020. To reduce overdose deaths, a report released Tuesday calls for stronger coordination among San Francisco’s law enforcement, public health and other agencies tackling the crisis. (Nick Otto for the Washington Post via Getty Images)
One outgoing supervisor is calling on the city to harmonize public health and law enforcement’s approach to the overdose crisis.
Although overdose deaths have dipped 20% to date this year compared to 2023, San Francisco continues to face an epidemic-level drug overdose crisis. Supervisor Dean Preston, who lost his reelection bid earlier this month, released a report on Tuesday that offers a blueprint for how San Francisco can emulate an approach used in Zurich, Switzerland – one of San Francisco’s sister cities that similarly struggled with an opioid crisis in the 1990s, but has since become an international model for overdose prevention and reducing drug-related crimes.
“This is making sure the Department of Public Health, the Police Department, homeless services and others at the table are actually pursuing a unified approach, and we do not have anything like that in San Francisco right now,” Preston told KQED. “My hope is that this is a top priority for not only the new mayor but for incoming supervisors also.”
After implementing a “Four Pillars Strategy” that unites prevention, treatment, harm reduction and law enforcement, overdose deaths in Zurich decreased by 50% from 1991 to 2010, according to Stanford Social Innovation Review, along with a 65% decrease in HIV infections, and 80% decrease in new heroin users.
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UCSF addiction expert Daniel Ciccarone has studied safe consumption sites in Zurich and around the globe. He said the report offers a “rational, clear-minded policy analysis that the city needs for this crisis.”
“The beauty of this report is it gives us an opportunity to look at evidence-based approaches and move the city forward,” he said. “There is no good ‘Plan B.’ Relying on police interventions is not sustainable, and bribing or threatening people into treatment does not work.”
Several differences could make implementation look different between San Francisco and Zurich, including that the Swiss city is about half the size of San Francisco, has a smaller homeless population, and has more medication-assisted treatment options legally available.
Inspired by the success in Zurich, Preston requested that the city’s Budget and Legislative Analyst office produce the report on how San Francisco might replicate that success.
Supervisor Dean Preston speaks to a local resident at a bus stop at McAllister and Divisadero in San Francisco on June 13, 2024, while campaigning for reelection to the Board of Supervisors District 5. (Beth LaBerge/KQED)
“Do we need to do exactly everything that Zurich has done? No. But the defining feature of their Four Pillars approach is that all of these relevant departments are working on each pillar,” he said. “They don’t just work to put Band-Aids on a situation or reactive crisis response. They actually have both a short and long-term plan for success, and that’s what this city has really been lacking.”
At the top of the report’s recommendations is a call for all departments working on overdose issues to coordinate – a seemingly simple task but one that the city has struggled to achieve throughout the current overdose crisis. For example, when the city opened up a temporary overdose prevention center in 2022, police fined some drug users for carrying publicly-funded harm reduction supplies that were provided at the site.
Mayor-elect Daniel Lurie plans to initiate a state of emergency for the fentanyl crisis when he takes office in January, which Preston said could be an opportunity to implement the report’s recommendations.
However, it’s unclear exactly what the incoming mayor will do with the emergency powers. Lurie ran on a platform of increasing drug treatment availability, improving behavioral health interventions and creating more supportive housing, as well as using ankle monitors on first-time drug dealers.
“I am in the process of setting up a meeting with Mayor-elect Lurie to go over this,” Preston said. “A culture shift needs to happen, but it’s all doable. And one of the problems right now is we just are not pursuing a unified approach to solve this crisis.”
People wait in line to get into the Tenderloin Linkage Center in San Francisco on Feb. 8, 2022. (Beth LaBerge)
Lurie wouldn’t be the first to declare a state of emergency, which allows the city to bypass certain bureaucratic steps to release and direct urgently needed resources. In December 2021, Mayor London Breed declared an emergency in the Tenderloin, a neighborhood with the highest rate of overdose deaths in the city. It allowed Breed to call in federal law enforcement agencies to help slow the flow of fentanyl into the city and arrest drug dealers.
During her emergency order, the city temporarily opened up a safe consumption site in 2022, called the Tenderloin Center, a medically supervised space where drug users could get off the street and get free meals, showers and other basic necessities. More than 300 people visited the center daily, and health professionals reversed 100% of overdoses that occurred on-site.
The safe consumption site was intended to be temporary, and the city closed it after about 10 months following public criticism and scrutiny from local businesses who complained about long lines outside extending into United Nations Plaza.
That same year, San Francisco released an Overdose Prevention Plan that called for opening up replacement centers in more dispersed wellness hubs around the city. However, today, efforts to open such centers remain at a standstill and political willpower to make them happen has waned in anticipation of President Donald Trump’s second term.
The Budget and Legislative Analyst’s report also recommends that the city open up safe consumption sites and coordinate with law enforcement to help people move safely indoors and reduce drug use in public spaces.
Meanwhile, the report also calls for expanding medication-assisted treatment, like buprenorphine, which helps curb cravings and withdrawal symptoms for people struggling with opioid addiction. The city has increased access to this type of therapy by reducing barriers, such as providing medication treatment on demand to residents in permanent supportive housing and expanding the city’s behavioral health pharmacy hours.
“We’re starting to see more people accept treatment, whether it’s abstinence-based, buprenorphine or methadone,” Mayor London Breed told reporters at a Monday press conference about the city’s overdose response. “The people are out there doing the work and making sure that folks know it’s not a one-size-fits-all.”
According to the report, about 75% of Zurich residents with opioid addiction take medication for opioid use disorder. But in San Francisco, only about 25% of people struggling with opioid use disorder are connected to medication-assisted treatments, according to the BLA report.
That’s partly because many people struggling with opioid addiction may not know that the treatment options exist, said San Francisco resident Juliana Gurrola Nuño, who is now part of the city’s public health campaign promoting available drug treatment and stories of San Franciscans who benefitted from recovery services.
“There are services available to help you start your recovery journey, even if it’s just taking the first small step. But not every person struggling with addiction knows about these resources,” she told reporters at the news conference. “I know that when I was in my addiction, I had no idea of any of these services. I want to change that.”
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