ADVOCACY MEMO – Understanding Overdoses and Harm Reduction in San Francisco.

At its core, drug use is a coping mechanism. It is often a symptom of trauma, alienation, and pain, whether physical, emotional, psychological, or all of the above.

The Covid-19 pandemic has disrupted San Francisco’s fragmented system of social services, but impressively, thanks to community and City-wide mobilization, Covid-19 infections and deaths amongst people experiencing homelessness have been curtailed, if not prevented entirely. Instead, the pandemic has amplified a preexisting public health crisis that is taking ever-greater numbers of people from our community.

In 2019, 441 individuals in San Francisco died of a drug overdose. That is more than one person a day. This is a 70 percent increase from 2018, and experts and advocates expect that we have already surpassed that number in 2020 given the disruption of the pandemic, the closure and limitation of social services, and the economic crisis leading to greater insecurity, isolation, and poverty.

Especially given the increasing focus on California’s and the nation’s opioid epidemic, we feel it is essential for us to learn about and understand what drives drug use and what harm reduction really is, contrary to much of the misinformation and distortion circulating around people who use drugs.

Why Are Overdose Deaths Increasing?

In short, conditions for overdose are going up:

  • Root causes and factors of overdose are being amplified by the pandemic, inequality, and by the drug supply in the community:
    • Poverty
    • Displacement
    • Trauma
    • Homelessness
    • Untreated mental health disorders
  • The drug supply, especially of cheap but incredibly powerful synthetic drugs like Fetanyl, has grown.
  • Moreover, given the demands of physical and social distancing in order to avoid the spread of Covid, more drug users are using alone, creating a dangerous circumstance where they are more susceptible to overdosing in the absence of a partner to reverse their overdose.

At its core, drug use is a coping mechanism. It is often a symptom of trauma, alienation, and pain, whether physical, emotional, psychological, or all of the above. Moreover, drug use is intersectional, encompassing a diverse mix of identities and people, often those marginalized by systems of violence and inequality.

  • Overdose crises are not new. It is only recently that we’ve seen our nationwide overdoses skyrocket accompanied by calls for compassionate, public-health responses, mostly because of who’s dying.
  • Drug use is not specific to one community but has always been about what drugs people are using, who those people are and their social status, what resources and networks they have externally, and if the drug they are using is criminalized. Criminalization also parallels socioeconomic inequality.

To say this is a citywide (and national) tragedy and failure does not adequately capture the suffering, pain, and loss of life. These deaths were not inevitable, but are instead the consequences of systems that do not value human life and that cause and perpetuate violence and trauma in the lives of the vulnerable, marginalized, and oppressed.

The lives lost reflect a failure of political, social, economic, and public health systems that value the lives and circumstances of some more than others, that deem some worthy of compassion and others undeserving of humanity and dignity. We know how to not only prevent these deaths but how to humanize, to dignify, and to compassionately help people.

Criminalization and Substance Use

Criminalization is the process through which actions become illegal and people become labeled “criminal”. Essential to this is the fact that crime is constructed: what is considered a crime depends on time, place, and politics.

Actions become crimes only after they have been legally and culturally defined as such. Many “crimes” are acts of survival that poor and oppressed communities rely on. Criminalization is built upon systems of dehumanization, violence, and inequality that target, create, and perpetuate the inequalities for black, brown, and indigenous communities, people experiencing homelessness, the LGBTQ+ community, and lower-income communities.

As harm reduction advocates say, we have legalized certain drugs such as caffeine (a stimulant) or alcohol (a depressant), regulated them, and provided “safe consumption sites” to use them, i.e. cafes or bars (or a form of shelter if one has one). Why some drugs are legal and some illegal is embedded in false beliefs and political, economic, and social power. These perceptions, the vulnerability of those using drugs, influence how we respond.

In fact, this is one of the key differences between drug use we see outside and that which we cannot see. One takes place among people who are in a state of extreme vulnerability, the other takes place behind four walls that can offer some form of protection from the gazes of other people.

Decriminalization is the process of removing or reducing the operation of criminalization, or the penalties and classification of being made “criminal” for actions people do to survive. This goes beyond simple legalization as this challenges the shame, stigma, and judgment associated with the activity or behavior and addresses inequitable conditions and punishment due to corresponding historical criminalization and oppression.

Harm Reduction

Harm reduction is a problem-solving approach aimed at intentionally reducing negative consequences associated with harmful, criminalized, stigmatized, or “risky” activity (substance use, sex work, abusive relationships, living on the street, etc.). Harm reduction is one tool we can use in problem solving, addressing harm or potential harm, and cultivating community well-being and accountability.

  • It engages people where they are without judgment, while taking small, straightforward steps to lessen negative consequences as much as possible.
  • It is rooted in a deep respect for the rights, agency, and dignity of all people, and centers compassion, care, and support.
  • It actively challenges narratives that dehumanize, shame, or punish people who engage in risky behaviors, and gives people access to tools that reduce potential harm.
  • It is about approaching people with dignity and love, especially because many people who use drugs have often been denied compassion and loving recognition.

Harm reduction, as an alternative to criminalization, enables communities to not have to rely on policing, jailing, and punishment. It can prevent stigmatization and the placement of people in cages and instead provide non-violent responses to people in need of support. Making people criminals only allows the police to lock them up and cover up the social inequality rather than addressing it from a place of compassion and care.

There are a number of interventions that would both save lives and help people access treatment that advocates in the world of harm reduction have been pushing for:

  • Lower barrier access to vacant units / beds;
  • Re-opening and adding more low barrier, harm reduction-based drop-in centers that allow people to have places to be during the day;
  • Increased low barrier access to buprenorphine/suboxone and other medication-assisted therapies;
  • Expansion of drug checking services;
  • Supervised consumption services / overdose prevention / safe injection sites
    • These are basically a decriminalized bubble for people who use drugs.
    • These safe spaces for people who use drugs allow them to be themselves in their full humanity and protect them from the potential harms of use, such as overdose or contracting a disease, as well as from criminalization harms and violence that come particularly for people who are unhoused and using drugs on the street.
    • Although there are more than 165 supervised consumption services operating worldwide, they are prohibited by U.S. federal law and remain controversial outside the harm reduction community.

To learn more about and demystify the often stigmatizing myths surrounding supervised consumption sites that have been roundly disproved by a voluminous collection of scientific literature, you can read more here.

Another life-saving tool has been the introduction and expansion of Narcan, an overdose reversal medication that has now saved hundreds of thousands of lives.

The San Francisco-based Drug Overdose Prevention and Education (DOPE) Project of the Harm Reduction Coalition Project has counted at least:

  • 2,610 successful community overdose reversals in 2019.
  • 1,629 successful community overdose reversals between January – June 2020.
  • 13,000 successful overdose reversals since 2001.

In 2019, people who use drugs, people experiencing homelessness and their loved ones were responsible for reversing the most overdoses in San Francisco compared to any other group of first responders. People who use drugs in San Francisco prove what’s possible when they have access to the resources they need to keep themselves and each other safe. By ensuring low-barrier access to Narcan and other harm-reduction services, people are prepared to respond to an emergency themselves.

In 2019, the DOPE Project provided over 47,000 doses of injectable naloxone to 19 community partners in the Bay Area, who distributed it onward, as well as over 5,000 nasal naloxone kits to organizations to have on hand in the event of an overdose. Approximately 500 overdose reversals were reported by San Francisco service providers while at work, nearby, or on their commute in 2019.