Paramedic Isaac James (left) and counselor Chantel Hernandez-Coleman, members of the Street Overdose Response Team, speak with two people sitting on the street in the South of Market neighborhood in San Francisco on Sept. 3, 2024. As San Francisco scales back some harm reduction programs and stages police raids of open-air drug markets, a group of UCSF doctors says such public health strategies are vital.
(Beth LaBerge/KQED)
As San Francisco scales back some harm reduction programs amid the city’s crackdown on open-air drug markets, UCSF doctors are raising concerns and emphasizing the integral role that such public health strategies play in keeping drug users safe.
Harm reduction, which aims to mitigate the risks of death and long-term damage associated with drug use, has spurred increasingly polarized debate between coalitions that support and oppose the strategy. However, doctors and policy experts say increasing collaboration is the best way to ensure public health for the whole city.
“Harm reduction and treatment are like part and parcel of each other,” Dr. Ayesha Appa, an assistant professor of medicine at UCSF, said during a town hall on Thursday hosted by the Treatment on Demand Coalition.
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She said that for one of her patients, “having relationships with people who are offering safer-use supplies allowed him to feel valued and then think, ‘I’m worth something. I can do this,’” and get on methadone, a medication used to treat opioid addiction.
November’s election results, though, show a city growing more concerned with getting drugs and drug users off the streets and out of public view.
A harm reduction program representative speaks with people on a popular alleyway in the Tenderloin neighborhood to hand out Narcan, fentanyl detection packets and tinfoil to those who need them as a part of drug addiction outreach in San Francisco. (Nick Otto/Washington Post via Getty Images)
New Mayor Daniel Lurie campaigned on public safety, saying the city needed to crack down on open-air drug markets. He and other candidates running against incumbent London Breed criticized some of her efforts focused on harm reduction, including the shuttered Tenderloin Center, which was the city’s first publicly run overdose prevention site.
In Breed’s latter years as mayor, she moved away from a harm-reduction approach to the drug crisis, which progressive politicians had embraced. And in District 5, which includes the Tenderloin, voters ousted their progressive supervisor in favor of a more moderate leader.
“You have a city that moved in a pragmatic direction – a lot of people are clearly unhappy with a number of things in the city, but a big part of what they’re unhappy about is drugs, homelessness, disorder, crime,” said Keith Humphreys, a drug policy expert and professor of psychiatry at Stanford University.
Activists and nonprofits who have advocated for harsher crackdowns on public drug use — and criticized the city for making it too “easy” for people to use drugs — joined Lurie during his first month in office to introduce his “Fentanyl State of Emergency Ordinance.”
“We’ve seen people suffering in the name of compassion and body autonomy, and it has to end,” said Gina McDonald, the co-founder of Mothers Against Drug Addiction and Deaths, who hosted the rally. “We believe that this fentanyl state of emergency ordinance is a state of emergency. It’s a five-alarm fire that needs to be mitigated.”
The legislation gained wide approval from the Board of Supervisors, with only a single vote against it.
In March, Lurie released more details on how he plans to use his expanded powers under the ordinance, which includes increasing treatment availability, clearing open-air drug markets and “reassess[ing] policies for distribution of fentanyl smoking supplies” — a service provided by some city-funded nonprofits that had drawn controversy.
He’s also worked with law enforcement to set up a mobile police command unit at the 16th Street BART station in the Mission, and overnight police raids at prominent drug markets have increased.
Meanwhile, Supervisor Matt Dorsey introduced the “Recovery First Ordinance” at the end of February, which would make entirely stopping illicit drug use and attaining long-term treatment “the primary objective of the city’s drug policy.” In a post on the social media platform X on Friday criticizing the UCSF doctors, Dorsey wrote that abstinence-only approaches to ending drug use include medication-assisted treatments.
The push toward recovery-focused drug policy has been unpopular with harm reduction advocates, who say reducing efforts to give out safer smoking supplies like foil and pipes is “misguided.”
A recent study from independent scientific research organization RTI International found that increased drug seizures by law enforcement also increased opioid overdose mortality. But Humphreys said what it fails to account for is the public health of non-drug users.
A psychiatric clinical pharmacist with the San Francisco Department of Public Health packs a backpack with harm reduction supplies before making deliveries to SROs and Permanent Supportive Housing in San Francisco on March 23, 2023. (Beth LaBerge/KQED)
“The purpose of taking drug dealers off the street is not to change the overdose rate,” he told KQED. “The purpose is to make neighborhoods safe for families and get drug dealers off the streets.”
He said an integrated public health approach — which the city has been working on for years but continues to need more of — would combine a nighttime bust by police with onsite harm reduction services, for example.
“In Europe, in cities that have closed down open-air things, the police and the public health people work side by side,” he told KQED. “Police will say we’re closing down this open-air drug corner and the dealers are ours and the users are yours.”
“They will arrest the people … but then drive the methadone vans saying, ‘Who wants treatment, who needs clean needles right here?’ They use it as an opportunity to engage people into care because your dealer’s gone, but you know you could get to treatment right this second.”
The four UCSF doctors who spoke about the importance of harm reduction on Thursday stressed the importance of linking harm reduction and treatment services by offering them in the same spaces and making the on-ramp to treatment less intimidating for drug users.
They said that reducing the distribution of safer drug supplies and medications that treat opioid addiction will make people less safe.
“I live in the city, I have kids … so that allows me to understand people who say, ‘Why the hell are you handing out opioids to people with opioid use disorder …handing out supplies to people that help them use drugs?’” said Dr. Scott Steiger, a professor in the departments of Medicine and Psychiatry and Behavioral Sciences at UCSF. “I could wave a magic wand and stop all of that, but we can’t.
“This particular city has done this before and is very good at figuring out ways to be more inclusive, to bring people back into the larger community who are otherwise stigmatized or outsiders.”
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