Next Steps: San Francisco’s Overdose Response

London Breed
6 min readSep 28, 2022

During COVID, San Francisco saw more deaths from overdoses than we did from COVID-19. This is both a testament to the City’s comprehensive response to COVID, as well as the significant challenges we are facing as Fentanyl has flooded our City.

In San Francisco, we reached a record high of over 700 fatal overdoses in 2020. Last year we saw a drop down to under 650 based on preliminary data, and this year we have seen around 390 overdoses so far, which would put us on pace for another small annual decrease. Which is to say, that though the numbers are better than they were, they are still way too high. Too many people are dying. And too many people are on our streets using drugs and suffering from addiction.

Today, the Department of Public Health released its 2022 Overdose Prevention Plan. This plan pushes forward a number of initiatives to connect people to treatment and improve how we deliver services to those on the street. The goals are to prevent overdoses and to get people off the street and into the care that will help them get better. It also targets the significant disparities we see in overdoses, including a disproportionate impact on the African-American community.

SFDPH’s Overdose Prevention Plan focuses on four areas:

  • Increase availability and accessibility of the continuum of substance use services
  • Strengthen community engagement and social support for people at high risk for overdose
  • Implement a “whole City” approach to overdose prevention
  • Track overdose trends and related drug use metrics to measure success and inform program development and change

Within those areas are key steps that will help us to bring down overdoses and get more people into treatment and services. Read more about the 2022 Overdose Prevention Plan here.

The plan sets some key immediate objectives, which includes steps like opening 70 new residential step-down beds in the next year, significantly increasing the amount of Narcan (which is used to reverse overdoses) on our streets, and increasing the number of people in Medically Assisted Treatment (MAT) by 20%, which means they have access to medication called buprenorphine that has proven effective at getting people off opioids, even Fentanyl.

These are just a few of the real tangible things we can do right now.

Transitioning the Tenderloin Center

Another part of that Overdose Prevention Plan is our effort to transition the services at the Tenderloin Center (TLC), which is scheduled to close in December. Opened as part of the City’s Tenderloin Emergency Response, the TLC has provided badly needed support while also drawing some criticism, some of which has been fair, some of which has been counterproductive.

With the Tenderloin Center, we tried something new. We brought together all of our services into one place with no real barriers to get people off the street and try to connect them to everything from the basics like a shower or some food to housing and treatment. When you do try something new, it’s not always going to work perfectly. There were good programs, and people received help.

For example, one person who regularly visited the TLC, lost his wife to an overdose. He came to the TLC ready to take his first step and said he wanted to do it to be there for his children. One of the service navigators at the TLC went with him to make sure he got his methadone detox treatment. Unfortunately, he disappeared for a while and had relapsed and was ashamed. But when he did show back up to say he was ready to work towards sobriety, he worked with one of our health navigators who set everything up so that he could enter residential treatment. He was escorted to get his medication refills and transported directly to treatment.

So yes, there has been success. But there were also some challenges and the TLC didn’t do everything we wanted it to do.

Every day, the Tenderloin Center has welcomed people off of the streets in need of connections to services and support.

But now the questions are — what did we learn from this experience and what are we doing next?

Well, we did learn that when we offer a place for people to get help off the streets, it needs to be easy to access. Sustaining critical services, with no threshold to entry, where and when people need it is an important intervention to prevent overdoses. We also learned that having one large site became a significant logistical challenge and concentrated impacts in one area. It’s a lot to ask of City and non-profit staff, and it’s a lot to ask of our neighborhoods. So we are adapting.

Wellness Hubs

Our next step is to take those no-barrier services, and to create much smaller Wellness Hubs in the community. These sites will provide coordinated services and access to help as the Tenderloin Center (TLC), but in more than one location where people need it the most. We are going to start with two new sites, the first of which will open as the TLC closes. We will evaluate these sites as they open, with plans to add more in the future.

These sites will have specialized teams to help those who are seeking support for treatment, to receive it at any-time including direct connections to a variety of treatment programs. If someone wants to get off the streets and get help, they will have a local option, with no challenges to entry. As with the TLC, our goal is to help people and to learn and adapt as we go.

San Franciscans believe in giving people help, but no one neighborhood should be responsible for that. Our communities have been engaged with the TLC, and we will work with them on next steps. We want residents to provide input into the design of these sites. In return, we want everyone in the neighborhood, from those seeking help to those who have small businesses and small children to feel a sense of safety and well-being so we’ll be investing in tools like ambassadors that have shown great success in our Tenderloin and Mid-Market neighborhoods.

Commitment At Every Level

This work builds on strategic investments in our street response teams, shelter beds, treatment beds, and housing. These investments are designed to create a range of solutions that can get people off the streets, into safe settings, and ultimately — stability.

And this is happening. For example, on any given day, we are supporting 3,600 people in shelter, and housing just under 12,000 people in in this City who were formerly homeless or on the streets. And over the last year, over 1,000 people engaged in medication assisted treatment through buprenorphine to treat opioid use disorder and more than 2,700 people enrolled into opioid treatment programs.

To keep this momentum going, San Francisco is adding resources for those on our streets every day. We are completing our plan to add 1,000 shelter beds back to the system over the last three months. We’re now two-thirds of the way to adding 400 additional treatment beds. And we are in the middle of the largest expansion of permanent supportive housing in decades, creating almost 3,000 new supportive housing placements in the last two years.

The Baldwin Navigation Center, opened in August 2020, is ramping up to provide shelter to 180 people experiencing unsheltered homelessness on the street.
A room at the Baldwin Navigation Center.

We’re also coordinating with every single City department to show up and do what it takes to keep the streets healthy and safe. In the Tenderloin alone, we haul away 100 tons of trash weekly. Our enforcement activities have taken roughly 70 pounds of Fentanyl off the streets this year, which is remarkable when it takes just 2 milligrams to cause a fatal overdose.

Every community deserves to be clean and safe, and we expect people to help us meet that standard. Selling drugs is not legal. Public drug use is not acceptable. And stealing, destroying property, arson isn’t acceptable either. We are working with every option at our disposal, including enforcement, to do more to hold people accountable and get them the help they need while creating neighborhoods that are safe for everyone.