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San Francisco Projected to Reach Highest Overdose Death Toll in 2023

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Names written in chalk appear on the sidewalk in memorial. Candles are also placed on a mat. Packs of chalk are scattered on the ground. The names "Bobby," Connor," and "Steven" can be seen.
A street memorial for people who recently died of drug overdoses is displayed outside of a supervised drug use pop-up site in San Francisco on Aug. 31, 2023. (Martin do Nascimento/KQED)

San Francisco is on track to hit a tragic milestone by the end of the year — with more fatal overdoses projected in 2023 than any on record.

“It is absolutely bleak, but it is not unexpected,” said Alex Kral, an epidemiologist at the independent nonprofit research institute RTI International. “Absent any new huge impactful interventions, I would continue to expect us to get worse for a couple of years until it would stabilize. But stabilized still means bad.”

There were 692 accidental overdose deaths from January to October of this year, with 65 occurring in October, according to the latest medical examiner data released Wednesday.

The new data supports projections made months ago that the city could eclipse its tragic milestone from 2020, when a total of 726 overdose deaths occurred.

Kral has studied drug use and overdoses in San Francisco for nearly 30 years. His estimation that overdose deaths may continue to rise is based on patterns in the East Coast, where fentanyl became more common in the illicit drug supply about 10 years ago, before hitting the West Coast.


On top of a deadlier drug supply, Kral says widening economic inequality, coupled with the region’s severe lack of affordable housing and out-of-reach treatment options, have fueled overdose deaths.

“We have seen on the East Coast that it really took about five years or so for things to continue to skyrocket before leveling off,” Kral said. “In San Francisco, fentanyl didn’t really show up in a large way until 2019, so we are still in year three or four of that huge increase.”

The majority of overdose deaths occurring in San Francisco — and elsewhere across the West Coast — involve fentanyl, an opioid about 50 times stronger than heroin. Many overdose deaths in the report involved combinations of substances with fentanyl, including methamphetamine and cocaine.

In response to rising overdoses, local public health officials have dramatically expanded the availability of buprenorphine and methadone, medications that can curb opioid cravings and withdrawal and help with recovery.

Boxes of Narcan are on a table.
Boxes of Narcan, the overdose prevention drug, at a safe drug use pop-up site created by volunteers with Concerned Public Response in San Francisco on Aug. 31, 2023. (Martin do Nascimento/KQED)

In addition, the widespread distribution of Narcan, a fast-acting medicine that can reverse an opioid overdose, has saved countless lives. The city also plans to add new residential treatment beds in 2024 to its current total of 2,550.

“We must remain nimble in our overdose prevention efforts, including getting more people who use drugs into treatment with medications for opioid use disorder in outpatient and residential treatment settings,” reads a press statement from the Department of Public Health, released after the data was published.

While these public health resources have been growing, Mayor London Breed has also charged local and state law enforcement to crack down harder on drug trafficking as well as increase arrests for public drug use and dealing.

That included bringing in the CalGuard and California Highway Patrol to work with San Francisco police, and this week, she joined 36 other U.S. mayors in asking President Joe Biden for additional support to tackle the drug supply.

“Fentanyl is devastating communities in cities all across our country like no other drug we’ve ever experienced before and this crisis demands additional urgent intervention efforts,” said Mayor Breed in a press statement announcing the federal funding request. “President Biden’s funding request gets at the heart of what we need — more funding for treatment to help those struggling with addiction and to prevent overdoses, and support for public safety and enforcement efforts to hold those accountable who are profiting off this deadly drug.”

Meanwhile, public health advocates have been pushing the city for years to open a supervised consumption site where people can use drugs in a medically supervised setting, and doctors can be available to reverse overdoses and connect users to other social or health services.

More than 200 such facilities operate globally, including in New York City. Rhode Island also plans to open up an overdose prevention center with funding it won from lawsuits against opioid manufacturers.

A sign that reads the Gubbio Project in San Francisco.
A sign for the Gubbio Project, a nonprofit offering services for unhoused people, hangs on the front gate in San Francisco on March 9, 2023. (Beth LaBerge/KQED)

San Francisco ran a safe consumption site in 2022, a year when overdose deaths dipped. There were 333 overdoses reversed at the facility, and no deaths took place. The site drew in hundreds of people a day for meals, showers and overdose prevention help but closed down after 11 months of operation. The city has not reopened a similar site since.

Supervised consumption sites are one aspect of local drug response, along with residential treatment, medication-assisted treatment, abstinence, law enforcement coordination and better access to housing and health care. But they have been hard to open in San Francisco since Gov. Gavin Newsom vetoed a bill allowing the city to pilot them.

Supporters like Lydia Bransten, executive director of the Gubbio Project, said supervised consumption sites could make a significant difference in simply saving lives and slowing the uptick in overdose deaths.

She was one of about a dozen volunteers who ran a pop-up overdose prevention center in August, where two lives were saved from overdoses during the civil disobedience act.

Gubbio Project was also one nonprofit that the city had pegged to privately run safe consumption services last year when the city announced a plan to open so-called “wellness hubs” with various overdose prevention services.

But after months of dragging the idea along with no progress, Bransten said the plan is at a “dead end.”

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“There are a lot of words to run [supervised consumption sites], but nothing to say we will be there for you if something happens legally. That has really put people in a position where they don’t feel safe to be able to do it,” Bransten said.

Her organization offers a space to sleep and gives away hygiene kits to people experiencing homelessness. It also provides wellness services like massages and interfaith chaplains for people who come through its doors in the Mission neighborhood.

Many people who rely on Gubbio’s basic needs services also use drugs, Bransten said. The rising overdose toll has hit the community hard.

“We lost two people in our direct community last month, both of whom had been using drugs for decades and have been in and out of treatment multiple times,” Bransten told KQED. “This is a tragedy that is hitting not only San Francisco but cities around the country, and it will take a federal response to be able to take down some of the barriers to help us be able to curb these overdose deaths.”


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