How San Francisco's Harm Reduction Strategies Are Changing Under Mayor Lurie

Dimitri Clark is everywhere in his South of Market apartment building. Greeting residents in the lobby, checking in on floormates and keeping a door open for others to come by the tiny studio he shares with two affectionate terriers, Porcupine and Panda.

He’s doing it all to promote safer drug use and reduce overdoses as part of a broader public health program that the city is now expanding within permanent supportive housing buildings. But it comes as San Francisco is scaling back other harm reduction programs, and as high overdose rates in the city persist.

Nearly 460 people died of overdose from January to August 2025, according to the most recently available public data, putting the city on pace to exceed last year’s total.

“There are people who use drugs—that’s just part of human nature—and a lot of people want to isolate themselves, and that’s often when they’ll experience an overdose,” said Clark, who has been in recovery for about a year. “We talk to people about it, take the shame away.”

The city’s Public Health Department recently gave the peer responder program Clark is part of a boost: $600,000 over the next five years to expand its work in San Francisco.

As a peer responder, Clark guides neighbors through safer drug use practices and ways to prevent an overdose. For a couple of hours each week, he posts up in his building lobby to talk about overdose prevention and hands out safety supplies like oxygen masks, sanitizing wipes and information on how to get help for anyone ready—or even just curious—about quitting. He also frequently gives out drug test kits and the opioid overdose-reversal medicine naloxone.

The program started in 2021 with five people, including Clark, at his former South of Market residence, the Minna Lee. Overdoses were soaring during the pandemic, so the building’s service provider, a nonprofit called Delivering Innovation in Supportive Housing (DISH SF), decided to train residents with experience using drugs on life-saving strategies to help their neighbors.

Suddenly, overdoses at the Minna Lee began dropping.

“We had multiple years of zero fatal overdoses at the Minna Lee, specifically due to, I would argue, that intervention,” said Mattie Loyce, senior manager of community development at DISH SF.

DISH SF has been training more peer responders ever since. This spring, 25 peer responders graduated from the program that is now operating in seven permanent supportive housing buildings.

To help incentivize residents to join, the program offers peer responders a $600 stipend. It’s hardly enough to cover a single month’s rent, but several members said the 14-week training program provided tools to change their own relationship to substances, help others and build confidence in other areas of their lives.

During the three-month training program, participants take classes on everything from how to respond to an overdose to where to direct people for treatment, as well as different substances’ potencies and effects on the mind and body.

“I actually didn’t know before I started this program how many overdoses were happening in our buildings,” said Nicole Flores, another peer responder in the program, who said she is still navigating her own relationship with drugs. “A lot of these resources I didn’t know were available, not just harm reduction supplies, but also wound care and other programs for our community.”

Peer responders have crafted overdose prevention safety plans with dozens of residents already. Harm reduction, a method backed by scientific research to reduce overdose risk and other negative consequences of drug use, is just one element of the city’s approach. San Francisco also sends medical professionals into supportive housing buildings to deliver drug treatment options like buprenorphine, a medication that can reduce opioid cravings and withdrawal.

“I would like for people to start looking at this community and seeing an asset, instead of seeing a problem, because there’s a lot of potential,” said Katie O’Bryant, manager of the peer responder program. “There’s lot of transferable skills that people learn in this lifestyle that can be replicated for all kinds of good in other instances.”

Mayor Daniel Lurie made reducing overdoses, and particularly the most visible street-level drug use and dealing, a central part of his campaign. As part of the mayor’s “Breaking the Cycle” initiative, the city has opened a stabilization center at 822 Geary St., reorganized street response teams and increased policing of outdoor drug use and dealing.

Last spring, Lurie controversially ended public health programs that handed out clean smoking supplies to drug users on the street, and the city now requires people to participate in counseling in order to obtain any safer drug use supplies, like clean needles, from city-funded public health providers.

Critics of the city’s approach to harm reduction applauded the shift, including Stanford professor Keith Humphreys, who told KQED it previously had not done enough to connect people to treatment.

One group of anonymous residents is suing the city over its harm reduction practices, saying they have led to litter and concentration of dangerous drug activity in neighborhoods like the Tenderloin.

Other addiction experts like Tyler TerMeer, who leads the San Francisco Aids Foundation, raised concern over the change, however. He warned it could strip medically vulnerable people of connections to health workers and push drug users toward tainted supplies, increasing chances of disease spread, riskier use, like injection, or overdose.

Fatal overdoses have slightly decreased in recent months, after several months of increasing, according to city data. It’s good news, yet addiction treatment providers are raising concerns about other changes they’re noticing after the city cut back on outdoor harm reduction efforts.

“Our clients are letting us know that when it’s harder to get smoking supplies, they feel a pressure to inject or share equipment. It’s not large numbers, but we have been hearing that,” said Anna Berg, director of the Harm Reduction Therapy Center. She said the center is also handing out far less naloxone now that they distribute at fewer street-based sites following the policy change.

The residential peer responder program happens mostly indoors and is one area where San Francisco is investing more in harm reduction.

Berg has clients in treatment who are also participants in the city’s peer responder program, who tell her it works.

“They really take it seriously,” Berg said. “These are the kinds of interventions that really work; you need community and to lead with care and support in as many places as possible.”

For Flores, who has been in and out of rehabilitation programs, strict abstinence-based requirements made it harder to work through already difficult relapse periods. Having access to housing allowed her to stabilize, something she said was positively life-changing, but it didn’t wipe away her challenges with drug use.

“Abstinence-based programs don’t make it easy for people to reach out,” during a relapse, Flores said. “And I think that this peer responder program does make it feel very safe to reach out in those circumstances, to just come hang out in the same room so that somebody’s there if they overdose.”

Rob Hoffman of the city’s Office of Overdose Prevention said the goal of growing the peer responder program is “to leverage the community to connect with other people and break down isolation.”

That’s already beginning to happen, and people like Flores and Clark are saving lives.

“I know of two of our clients who have successfully reversed overdoses as part of that program,” Berg said.

Flores met one of her floormates after stepping into the role. She’s helped treat his wounds and said she’ll sometimes go over to his room while he is using drugs to offer support if something goes awry.

“He has vision problems and other health problems, and just the knowledge that I’ve gained from helping him has been helpful in other areas of my life, too,” Flores said. “It means a lot to me that people trust me enough to come in. I would consider him one of my best friends now.”

Clark has occasionally given out clean needles when someone needs them. But due to legal and political challenges, the peer responder program does not fund the distribution of safe-use supplies like needles and does not describe its work as drug-use supervision. Peers themselves entirely lead those efforts..

“This program focuses specifically on overdose prevention, and the supplies we give out are CPR masks, naloxone and linkage to care. But the safer-use supplies, that is, the direct advocacy of peers themselves,” said Loyce, with DISH SF. “We don’t give that out, but you know we also support their inclination toward whatever types of resources they want to carry for themselves.”

Lurie’s changes this year aren’t the first time the city has pulled back on harm reduction, an approach pioneered in San Francisco during the AIDS crisis. In 2021, the city pulled the plug on a safe consumption site following legal concerns and complaints from neighbors and local businesses over long lines outside the facility, which was located in United Nations Plaza.

Thousands of people visited the site for support. More than 300 overdoses were reversed at the facility, and no one died of an overdose on site during the program’s nearly 10-month run.

Berg said the disparity between what peer responders are allowed to do with the program and what neighbors come to them needing reveals a gap in the continuum of care.

“We have safe consumption sites all over the place, they’re just not necessarily sanctioned. It is things like neighbors looking out for each other. That is not a new concept. And the reason it sticks around is that it works,” Berg said. “What would it be like to allow people to do things that work? How many people are we losing every month in San Francisco? How many of those folks, if they had somebody there, could have a different outcome?”

For Clark, a simple tool is being around when someone needs him.

“What’s so nice about this is it’s not forceful,” Clark said. “It’s the isolation, you know, and fundamentally we have to overcome that.”