A Radical Reversal

San Francisco has one of the lowest fatal-overdose rates in the U.S. Here's why.

Early on the morning of Feb. 22, several hours before sunrise, a security guard at the Urban School on Page Street found three men sheltered in the arched doorways of the elite private academy. He couldn’t wake them, and when paramedics arrived, they pronounced the trio dead at the scene. Several hours later, the three were identified as David Clark, 31, Adam Wilson, 36, and Michael Campbell, 32 — the latter of whom was known by his friends as Pan. The friends, who all lived in the Haight, had allegedly found a baggie of drugs on the ground as they left a liquor store. Assuming it was ketamine, they smoked it, not knowing it contained fatal levels of fentanyl.

Within hours of receiving their bodies, Dr. Luke Rodda of the San Francisco Medical Examiner’s office called the Drug Overdose Prevention and Education (DOPE) Project, a subset of the nationwide Harm Reduction Coalition, to let them know about the suspicious overdoses. The DOPE Project immediately printed out flyers warning drug users that fentanyl was making the rounds, and within a couple hours they’d been posted at food banks, needle-exchange sites, and medical clinics. The Department of Public Health sent out a press release. As people who use drugs got word, the news spread across the city like wildfire.

The fast response was striking, but it wasn’t isolated: It’s the result of a carefully oiled machine, a 15-year collaboration between the city and a slew of community organizations.

Syringe Access Coordinator Anna McConnell holds a bottle of Naloxone (Narcan) at the needle exchange tables in the lobby of Glide in 2015. (Photo: Mike Koozmin)

At the center of San Francisco’s battle against these fatal overdoses is one drug: Narcan. Packaged under the generic name naloxone, Narcan was developed to reverse opioid overdoses while they’re in process. When someone has taken too much of an opiate, their breathing slows, and may eventually cease, resulting in death. When Narcan is administered — either in a nasal spray or an intramuscular injection — the opioids are knocked out of the brain’s receptors. If applied early on in the overdose, Narcan immediately stops the effects, bringing the person to consciousness.

It’s a small window of time, made smaller by the rise of fentanyl, a dangerously fast-working opiate that can be deadly even in tiny amounts. In order to reverse an overdose, you have to recognize the signs early on — and in a society that shames and criminalizes drug users, pushing them to use in bathrooms, alleys, and abandoned properties, it’s often the case that the only person around to recognize and reverse an overdose is another drug user.

With that in mind, getting Narcan and overdose education into the hands of people who use drugs is key to preventing fatal overdoses.

Unlike much of the rest of the country, San Francisco learned this early on. In 2003, the DPH commissioned a local study on Narcan’s success in reversing overdoses. Since then — throughout economic recessions, changes in leadership, and the rise of fentanyl — it’s managed to provide Narcan to San Franciscans for free. (Over the counter, the drug can cost up to $130.) In 15 years, thousands of overdoses have been reversed by friends, passersby, or nonprofit public health workers.

The success is linked to one transparent tactic. Early on, the DPH was smart enough to realize it couldn’t achieve the task of reversing overdoses alone: It needed a slew of badass organizations and people to step up to the plate.

The DOPE Project had been active in San Francisco for two years when the DPH began supplying Narcan to drug users through an already-established needle-exchange program. Initially, nurse practitioners would volunteer at needle exchanges, training visitors how to recognize overdose symptoms and how to administer the drug. It was a formal prescription process, requiring someone with medical training on hand — but in 2010, the city changed its policy, allowing those who’d undergone formal training for Narcan administration to distribute the drug directly to those who wanted it, without a medical professional.

This opened everything up. No longer limited to medical staffs’ schedules, the DOPE Project collaborated closely with DPH, expanded Narcan’s accessibility beyond needle-exchange sites, and launched a massive effort to deploy Narcan trainers.

Today, more than 120 Narcan teachers have completed the training program. They have subsequently taught 10,414 others in San Francisco how to recognize an overdose and administer the overdose medication. In addition, Narcan can be found at more than 15 locations throughout the city, from pop-up needle-exchanges to food banks.

A mural in Boston advises users to pick up Narcan. (Photo: Caity Bernard)

The numbers speak to the success of this network. In 2010, when DPH relaxed its Narcan prescription program, 62 potentially fatal overdoses were reversed. In 2011, that number doubled to 125. In 2012, it was 274. Each year, the number has increased by 50 to 100 percent, climbing steadily to where we are today;  In 2017, 1,247 community-dispensed Narcan overdose reversals took place — more than three a day, on average. This figure doesn’t even include those administered by the San Francisco Police Department or paramedics.

As the number of overdose reversals climbs, the number of people who die from overdoses every year has stayed fairly constant since 2014 — around 100 to 125.

That’s still too many, yet San Francisco’s overdose mortality rate is one of the lowest in the nation. Milwaukee, which has 300,000 fewer people than S.F., had 343 overdose fatalities in 2016. Philadelphia had 907. New York City had 1,374. In San Francisco, there were only 105 — a number that could have been exponentially higher, had 883 overdoses not been reversed that year. Without Narcan, we would have seen nearly a thousand opioid deaths on our streets in 2016 alone.

“We have achieved an extremely high level of people carrying naloxone, partly because of our program structure which allows people to access it in all areas,” Eliza Wheeler, the Overdose Response Strategist at the Harm Reduction Coalition, tells SF Weekly. Drug users can find Narcan upon release from the San Francisco County Jail, at Glide Memorial Church, at syringe-exchange sites, API Wellness, the Mission Neighborhood Resource Center, and St. James Infirmary. The network enables people moving through the city’s diverse range of services to pick up or refill Narcan kits as needed, for free, no questions asked.

The cost of such an operation is much lower than one would anticipate. According to DPH, the annual budget for staff, material, and supplies totals only $203,958 annually.

Graffiti in San Francisco by the artist 169. (Photo: stilsayn)

While mainstream media is quick to judge drug users, they are the life-saving, Narcan-wielding heroes in this story.

Well before Narcan was available at 15 locations around the city, word got around that it was a medicine that could draw you back from the brink. Decades ago, Orlando Chavez took the matter into his own hands.

“I can remember in the ’70s, that we didn’t have a needle exchange. We had nowhere to get Narcan,” he says. “We realized we could get into hospitals and steal it. I found a hospital in my neighborhood where the back door wasn’t very protected, and I was in and out of there like a house mouse. I’d draw it up [into the needle], and place it above my medicine chest in easy reach.

“It’s a beautiful thing to see how things have changed,” he adds. “I guess we were doing harm-reduction back then — but didn’t know what to call it.”

So successful has San Francisco been that Narcan is in almost every city drug user’s vocabulary and arsenal. In March 2017, nine people using crack cocaine laced with fentanyl overdosed at a hotel on Sixth Street. Thanks to a rapid community response, eight of them were given Narcan, and lived. Only one person died.

At a public community meeting in late March, more than two dozen drug users gathered to discuss drugs, overdoses, and share their stories. In between each personal anecdote, there was often a piece of advice for others in the room.

“I’ve used Narcan a lot with other people,” said a woman in her 20s named Jessica. “In the last three months, I’ve been around 12 overdoses. Seven of them I Narcan-ed myself. Two of them passed away. But a lot of them are still here because I had it.

“Make sure you get the same consistency [of drug] if you can,” she told the crowd. “And don’t use alone.”

The loss of life is fairly easy to quantify in numbers, and it’s easy to focus on the saves. But the ripple effects a death it has on a community are far-reaching. When Clark, Wilson, and Pan died outside the Urban School, it marked the beginning of a devastating month-long period for the Haight in which 15 people subsequently lost their lives. Pan, in particular, was well-loved.

Mary Howe, executive director of the Homeless Youth Alliance, knew Pan well, and says he was extremely kind, funny, and humble.

“He really looked out for his friends,” she said. He’d also overcome adversity, having spent nine months in the hospital re-learning how to walk after being hit by an Uber driver. According to Howe, he wasn’t a regular drug user.

In the weeks after the deaths, Howe says more people have been coming in to get their drugs tested — but the reason why hangs heavy over the neighborhood.

“I’ve been doing this work for so many years, and I’ve never had three people die like that, especially from smoking,” she said.

A 2013 Clarion Alley mural by artists Erin Amelia Ruch and Mike Reger depicts the superhero Narcania saving lives.

Fentanyl’s presence in San Francisco is dark, but its deadly effects have contributed to the current availability of Narcan. Never before has the need for an overdose reversal been so profound. The powerful opiate can be found in almost anything these days — from heroin to methamphetamine to homemade Xanax. Fentanyl gives users a very strong high, and it’s so fast-acting that in extreme circumstances someone could overdose while a needle is still in their arm.

Fentanyl has pushed the unpredictability of street drugs into a whole new category, and people who use were the first to notice its devastating effects.

“When fentanyl showed up with a bang in 2015, the Syringe Access Collaborative — in partnership with the DOPE Project and the DPH — responded very quickly,” Kristen Marshall, a project manager at DOPE, told a crowd at an Overdose in S.F. Community Conversation on March 29. “The reason we were able to do that is because you all trusted us enough to show up at our doors and say, ‘This is happening, we are scared, what do we do?’ We worked together on getting naloxone out into the community, and then you all took care of the rest.”

Recently, harm-reduction workers in San Francisco began handing out a new tool for drug users: fentanyl test strips. The highly sensitive tests can detect even the tiniest traces of fentanyl. Armed with that education, people can either dispose of the drugs, use a smaller amount, dispense it more slowly, or make sure a buddy nearby has Narcan, in case things go south.

Fentanyl test strips hit the streets in S.F. in August 2017, and the DOPE Project has closely monitored the results. Between August and January, nearly 250 surveys from people who’d used them have been turned in at syringe-access sites, presenting useful data for harm reduction researchers. Of the drugs tested, 78 percent of the speed or methamphetamine samples tested came back positive for fentanyl, as did 67 percent of the crack cocaine samples. Of those who had positive results, 92 percent of them shared the information with their community.

“Knowing what’s in a product helps people make good decisions,” Marshall said. “Right now, we’re working on a more robust protocol, where we’d actually pull samples from the street, submit them to a lab, and give them all the exact percentage and rundown of everything that’s in that product, and then post them weekly at access points. Then you can say, ‘Ha! The black-tar heroin being sold against the Phoenix wall near Ellis is actually 80 percent heroin, and like 1 percent some garbage pill, and then a bunch of balsamic vinegar. Cool.’

“Welcome to the free market and capitalism,” Marshall added. “You have the right to know as a consumer what you’re buying.”

Howe has already created a hyper-local version of that. Every month, she drafts a small flyer for the neighborhood with the test results of all the drugs tested through HYA. “In the last four months, this is what we have learned just from the Haight site,” it reads,” before listing how much of each sample of drug tested positive for fentanyl. For heroin, 47 of 76 samples tested positive. Fifteen of 23 crack samples did. At the bottom, it’s tallied up.

“This means 62 percent of drugs testing positive for Fentanyl,” she writes.

The already-established network of Narcan distributors, the constant education that the DOPE Project and its partners offer to drug users, and the test strips mean that as the rest of the nation struggles to react to the sharp spike in fentanyl, it hasn’t necessarily resulted in a higher death rate in San Francisco.

The DPH is tracking that closely. In 2014, eight of the 211 overdose deaths were from fentanyl. The following year, 11 of 101 fatalities were fentanyl-related, In 2016, it was 22 of 105.

So far we haven’t seen an overall increase in mortality, just a shift in causal opioids,” Rachael Kagan, spokesperson for the DPH, says. “This might be attributable to quick access to methadone and buprenorphine and widespread naloxone access.

“But,” she notes, “that could certainly happen any time, as other cities on the East Coast with solid programming have been devastated by fentanyl.”

In the meantime, word about the test strips is spreading.

Jen, who lives in an SRO, has a neighbor who’s overdosed eight times. At the Overdose in S.F. Community Conversation, Jen told the crowd she went crazy the last time, as a Narcan injection didn’t reverse his overdose and paramedics had to be called.

“Later, I had a talk with him, and I got him to understand how scary fentanyl is,” she said. “He now uses the strips. He tests it before he uses it, and he takes it back [to the dealer] if it has it. He takes it really seriously, and he’s doing really good now.”

The national hysteria around fentanyl and the opioid crisis has reached epic proportions, with nary a publication or politician missing an opportunity to address the issue.

Last week, the new director of the Center for Disease Control and Prevention called opioid drug use “the public health crisis of our time,” pledging to “bring it to its knees.”

President Donald Trump has compared opioid use to his late brother’s alcoholism, saying he plans to launch an ad campaign targeted at youth that will disclose “the devastation and ruination [drugs cause] people and people’s lives.” He’s also proposed an additional $400 million for the Drug Enforcement Administration, to criminalize those dealing and using drugs.

Even pop culture has hopped on the opioid bandwagon, treating it more like a trend than a health crisis. A recent Salon headline offered readers tips on “How Exercise Can Help Tackle the Overdose Crisis.” An emotional listicle from POPSUGAR came out late last year on “5 Things Growing Up With an Addict Taught Me.” There’s even a television series in the works, which Deadline describes as “an original dramatic TV series based on the story of the pharmaceutical company at the center of the crisis and the family behind it.”

There are innumerable issues with all of this: Trump launching a campaign to shame drug users, his commitment to filling prisons with dealers, and the click-bait headlines that easily skirt by the human intricacies behind the “opioid crisis.” But what is most frustrating to those who’ve worked in harm reduction for years is that this “epidemic” is only now getting attention.

“There is nothing new about what is happening right now,” Marshall said. “People have been dying from drug use and the War on Drugs for years. The only reason we’re calling for compassionate treatment is because the visibility right now is that white folks and affluent folks are dying from drug use.”

She has a point. Opioid overdoses are decimating entire communities in the Midwest. The CDC reports that from July 2016 to September 2017, there was a 70 percent spike in opioid overdoses in the middle of the country. Major national publications have run massive photo essays in which every person featured was white.

It’s unquestionable that opioid use is increasing, but it’s not a new issue. While the rest of the country catches up, San Francisco has modeled a successful method for preventing overdose deaths since way back in 2003.

We like to think that our city was the first at everything. In this case, bragging rights are somewhat just. While it wasn’t the first city to attack fatal opioid overdoses from a harm reduction perspective, S.F. is one of the first to be very good at it.

An excerpt from the education cartoon “Naloxone Breaking the Stigma” by Van Asher.

Fentanyl  and the subsequent near-obsessive media coverage of it  — is also having a long-overdue effect on how city residents at large respond to the opioid crisis. San Francisco is no stranger to epidemics, and the queer community in particular has long understood the importance of a community-based, harm-reduction model. The city’s response to the AIDS crisis cannot be downplayed as a segue into how successful it’s been combatting opioid overdoses.

“We know that harm-reduction works,” says Kagan. “In the AIDS crisis, stopping the spread of HIV through needle exchange was an innovation that has since become a global best practice. When people come into syringe access sites, they dispose of used needles, test their drugs for fentanyl, learn how to use naloxone, and gain access to services and information to improve their health and wellbeing. Our progress in the fight against HIV/AIDS reflects the total commitment of the community to work together for a single purpose.”

This collective caretaking mentality is now extending to overdose prevention. No longer are people who use drugs and paramedics the only ones to carry Narcan. Politicians, librarians, business owners, and everyday people now have it on them. (Full disclosure: I carry it daily.)

“If you’re in Downtown S.F. and you ask for Narcan, five people will come running,” Wheeler says.

Nightlife venues, which have long carried tubs of condoms to prevent the transmission of HIV and other sexually transmitted diseases, are also catching up. The Stud was the first business to ask the DOPE Project to train its staff.

“We didn’t have a scare, or anything like that,” says Rachel Ryan, a member of the collective that owns The Stud. “The reality is that not only are some of our patrons likely recreational drug users, but our neighborhood is full of people living on the street who are opioid users. Being engaged members of the community and looking out for your neighbors is, to me, the most basic, Mr. Rogers kind of mentality.”

Since the training, the bar has posted signs all over the bar alerting patrons that the staff carries Narcan. The nasal spray — which Ryan points out is “as easy to administer as allergy medication” — is easily visible behind the counter.

The Stud is taking the lead in more ways than one: Ryan has been talking to other bars and nightclubs about getting their employees trained. She’s planning to bring Marshall from the DOPE Project back for another training, and inviting other people from the industry in.

“We’re in the business of big ideas,” she says.

It’s not an easy feat: Even in San Francisco, the stigma of opiates, the fear of liability, and the longstanding prejudice against drug users mean the utopian possibility of every nightlife business carrying Narcan is probably pretty far off.

It’s only getting easier for people who use drugs to access Narcan, however. Residents at Zuckerberg San Francisco General Hospital have launched a pilot program in which Narcan is handed out to every internal medicine patient who’s been prescribed opiates, and to anyone admitted who says they use drugs.

“We offer treatment for patients, but we also know that not everyone is going to stop using,” Dr. Marlene Martin, an addiction specialist at ZSFGH, tells SF Weekly.When you tell someone with diabetes that if they have to stop eating sugar, you know that’s not going to happen right away. You provide them with insulin, and you counsel them. We do the same with people who use drugs. We have to empower patients with education, harm reduction, and naloxone. Hopefully, that also means they use more safely.”

And the DOPE Project continues to scale up every year. Each year, they plan to add more programs to their list, making Narcan even easier to procure.

“Our goal is a public-health model of saturation,” Wheeler says. “You reduce the burden of flu by giving flu shots. We reduce overdoses by distributing naloxone.”

Nuala Sawyer is SF Weekly’s news editor.
nsawyer@sfweekly.com |  @TheBestNuala

Where to Get Narcan

For non-drug users, Narcan can be obtained at any pharmacy, without a prescription. The CMHS Pharmacy at 1380 Howard St. has a particularly well-trained staff. Advocates suggest that you don’t visit sites that cater to drug users out of respect for their privacy and to maintain the publicly funded supply.

For those who do use drugs and would like Narcan, it is available at any syringe access site in S.F. For a list, can call Kristen Marshall from the DOPE Project,(628) 225-2801 or, check in with any of these sites (call for their schedules):

SFAF Syringe Access Services: 415-487-8043  
Homeless Youth Alliance/SFNE: 415-630-0744 
St. James Infirmary: 415-312-6306  
Glide Harm Reduction Services: 415-674-5180 
SF Drug Users Union: 415-990-3827

Narcan and fentanyl test strips can are also available at any needle-exchange site.

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