As demographic data on the coronavirus pandemic continues to trickle in, an indisputable narrative of health inequity is emerging. Low-income communities and people of color are disproportionately affected by the virus. In San Francisco, the thousands of unhoused people living on the streets or in crowded shelters are particularly at risk of catching the disease.
But COVID-19 isn’t the only health crisis on providers’ minds right now. Drug overdoses — which killed 330 people in San Francisco in 2019 — are currently on the rise across the country. There are many factors at play: the potency of street drugs is always inconsistent, but shifting supply chains can exacerbate the problem, making it harder for users to predict the strength of a given dose. As people are isolated in homes or hotel rooms there’s a higher likelihood that they’ll use alone, with nobody around to administer the overdose-reversal drug Narcan (also called naloxone), which can revive people who take a large dose of opioids, such as heroin or fentanyl. And resources are scarce; a study done at the end of March showed that 43 percent of needle exchanges had closed at least one of their sites, limiting the availability of life-saving supplies like Narcan, clean needles, and test strips that can determine if a drug contains fentanyl.
The impact of the societal changes due to COVID-19 could be catastrophic for people who use drugs. But while other cities across North America report skyrocketing overdose rates, San Francisco has once again managed to stay ahead of the curve. The number of overdoses has steadily increased citywide for years, but there has not been a noticeable surge in deaths since the shelter-in-place order launched in mid-March.
The reason for this is fairly simple: providers saw the shelter-in-place order coming, and reacted accordingly, rapidly changing their programs and strategies.
One such program is the Drug Overdose Prevention and Education (DOPE) Project, which distributes nearly all of San Francisco’s Narcan. In 2019, the DOPE Project recorded 2,604 overdose reversals citywide, the majority of which were administered by people who use drugs. Getting Narcan into the hands of people who use is a proven method to save lives, so when DOPE Project Manager Kristen Marshall heard about the shut down, she moved fast.
“It was a scramble,” Marshall tells SF Weekly. “San Francisco’s entire Narcan supply is stored in Oakland. We had no idea if we were going to lose access to buildings. I looked at my two staff members and said, ‘We need to get all of our supplies to San Francisco right now.’”
It took three car loads to get all of the organization’s Narcan across the Bay Bridge and into San Francisco, where it’s currently being stored in a basement in the Tenderloin. From there, the struggle became logistical. As sites across the city reduced hours, Marshall compiled a new list of providers and a plan for distribution, an effort she says took about two weeks. It’s been a challenge.
“The moves you have to take to reduce your risk [of COVID-19] is paradoxical to what we recommend for people to reduce their risk of overdose,” Marshall says, referencing the common overdose prevention mantra of using with a friend. But stopping overdoses shouldn’t come with the risk of contracting the virus. “We want people to be safe from everything.”
One organization that has changed the way it distributes Narcan and other safe drug use supplies during the pandemic is GLIDE. The social service provider operates out of a multi-story building in the Tenderloin that was shut down during the shelter-in-place mandate, but it still manages to reach people who use drugs.
Senior Director of Programs Kenneth Kim says that the staff got to work early, creating a plan on March 13, the day before the shut down was enforced. “GLIDE took steps early to expand our harm reduction hours and outreach, fearing that a lockdown might lead to increased overdoses and disease transmissions by hindering our ability to distribute supplies and Narcan,” Kim says.
It was a tricky balance to identify ways to protect staff, but still serve the community. The organization’s syringe supply program, which used to exist on the fifth floor, now operates from behind a table in the lobby doorway Monday through Friday, from 9 a.m. to 5 p.m., with rapid HIV, hepatitis C, and STI testing available each afternoon. Outreach volunteers have ramped up outreach, visiting people in encampments to offer supplies.
But nonprofits aren’t the only ones ramping up their efforts. The Tenderloin police station has increased the number of beat officers who carry Narcan, with successful results. As fewer people are walking the streets, it’s less likely someone will witness and be able to reverse an overdose, so police have stepped in. Captain Carl Fabbri tells SF Weekly that officers reversed 30 overdoses between March 17 and May 5 — a 500 percent increase over the same period in 2019. Of these, 28 occurred on the streets, one in a park, and one in a Muni underground station.
While the response on the streets has shifted, a whole other tactic is being employed inside single-room-occupancy hotels, where many vulnerable people experiencing homelessness are being temporarily housed — many for the first time in years. This alone is dangerous; people who live in SROs are 19 times more likely to die of an overdose. With that in mind, the city’s Department of Public Health has teamed up with the DOPE Project and the AIDS Foundation to address their specific needs.
“Guests entering isolation and quarantine, who must be indoors throughout their stay, are screened multiple times to determine what substances they would be uncomfortable without and whether they’d like support to reduce or stop their use,” explains DPH spokesperson Jenna Lane. “This period in our care has allowed some people to connect for the first time with addiction treatment and harm reduction therapy. For guests in recovery, DPH provides behavioral health support to maintain their sobriety through the stress of the isolation and quarantine period.”
In addition to trained personnel, Narcan, syringes, and overdose reversal guides are made easily accessible in many of these SROs, so that people can help themselves to the tools they need to stay safe while using.
The combination of all these efforts appears to be working. Marshall says she’s been closely monitoring the numbers emerging from the Medical Examiner’s office. They’re not conclusive; forensic toxicology tests are still being conducted, and it will likely take weeks before we have any clear data on the impact COVID-19 has had on overdoses. But so far, Marshall says there has not been the surge in overdose fatalities that other cities across the country are reporting during the pandemic. Jacksonville, FL has seen 20 percent more overdose-related calls in March. Ohio’s Franklin County saw an average of 12 overdoses per day in April. But San Francisco isn’t having a significant spike.
“Every week when I check in the rate [of overdoses] has not shifted,” Marshall says. “Had San Francisco’s harm reduction programs not been laying down the foundation, getting people Narcan, getting people supplies, it would have been beyond catastrophic. But people were prepared. They have access to the supplies they need to reverse overdoses and stay safe.”