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Fentanyl related overdoses have become a crisis in San Francisco, CA

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Fentanyl related overdoses have become a crisis in San Francisco, CA

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Accidental opioid overdose deaths (AOOD) in San Francisco have increased significantly doubling each year since 2016. Fatal overdoses involving fentanyl surpassed heroin and other opioids. Fentanyl contributed between 3%-12% of deaths per year from 2009 to 2015 and between 20% and 73% from 2016 to 2019. Several factors contribute to this trend including increased availability of fentanyl in the illicit drug market, drugs containing fentanyl and fentanyl is cheaper in bulk. Fentanyl is also the preferred choice for drug users because fentanyl has a more potent euphoric effect than heroin and the restrictions of opioid prescriptions.

(ScienceDirect, Fentanyl epidemic hits the U.S. West Coast: Opioid-related deaths in San Francisco from 2009–2019, August 2021)

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Deaths

-52,404 deaths in the U.S. in 2015, 33,091 (63%) involving an opioid. Overdose rates by fentanyl increased by 72% from 2014 to 2015.

Hospitalization rates

-Increased overdose hospitalization rates through out the years.

Access or availability of Naloxone/Narcan

-Naloxone kits are provided to trained individuals by several organizations (DOPE project).

Accessibility of safe sites to prevent overdose

-DOPE Project sites, etc.

Rowe, C., Wheeler, E., Stephen Jones, T., Yeh, C., & Coffin, P. O. (2019). Community-Based Response to Fentanyl Overdose Outbreak, San Francisco, 2015. Journal of urban health : bulletin of the New York Academy of Medicine, 96(1), 6–11. https://doi.org/10.1007/s11524-018-0250-x

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Several Individual Factors Contribute to Fentanyl Overdose

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Several Individual Factors Contribute to Fentanyl Overdose

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Individual risks for overdose for fentanyl in homeless population in San Francisco:

Lack of awareness Fentanyl contamination in other drugs as just "white powder"

Lack of knowledge of available resources for harm reduction such as opioid reversal Naloxone

Underestimate potency of Fentanyl

https://rdcu.be/dHgQ4

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Homeless Population are Vulnerable to Drug Overdose 

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Homeless Population are Vulnerable to Drug Overdose 

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In the first year of the COVID-19 pandemic in San Francisco, there were 331 deaths among people experiencing homelessness. This number was more than double any number in previous years.

Eighty one percent who died were male.

Acute drug toxicity was the most common cause of death in each year, followed by traumatic injury.

The proportion of deaths involving fentanyl increased each year (present in 52% of toxicology reports in 2019 and 68% during the pandemic).

Cawley, C., Kanzaria, H. K., Zevin, B., Doran, K. M., Kushel, M., & Raven, M. C. (2022). Mortality Among People Experiencing Homelessness in San Francisco During the COVID-19 Pandemic. JAMA network open, 5(3), e221870. https://doi.org/10.1001/jamanetworkopen.2022.1870

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Substance users Tenderloin, SOMA area codes

Homeless populations living in Tenderloin, SOMA

SRO Single Room Occupancy residents

Fentanyl, and synthetic users who pay less

Men between the ages of 35 and 64

Latinx and Black populations

Non-supervised substance users

Homeless with limited access to Narcan due to outreach center closures

The number of overdoses increased every year since COVID. 200 homeless people expired within 3 months. Homeless living on the streets of Tenderloin, SOMA are drug-plagued by substance dealers, putting many at risk. Most deaths detected fentanyl and synthetic substances mixed with fentanyl. The closure of an outreach center caused high overdose incidence rates. The outreach center provided housing referrals, health care, and daytime shelter, space to use outside and be supervised. Narcan access reversed 330 overdoses. 810 accidental drug overdose deaths in 2023. In 2020-2021 there were 23% deaths in Tenderloin district, and 18% in SOMA. 70% were due to fentanyl overdoses in 2020.

McCormick E & Reed B April 28, 2023, Overdose deaths in San Francisco hit 200 in three months: ‘A crying shame. The Guardian

Jung Y & Kopf D March 12, 2024, 61 people died in March in San Francisco from accidental overdoses. San Francisco Chronicle

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Shortage of housing

Lack of shelter space

Limited social infrastructure

No family support

High housing costs

Redlining

Systemic inequalities

Substance use epidemic

During the 1930s-1960s people of color lack home ownership. Many were at risk of being homeless due to high rent costs, then became homeless. Due to economic factors and not meeting basic needs to survive. The cost of living is too high and many are below median income. Chronic homeless are seeking remedies to forget the loss of assets by using substances to escape reality. There are 35% of shelters available but needs are higher and waitlists are 1,000 plus people trying to get housing. Lack of sufficient care is often not available to the homeless and puts them back on the streets when they need more support beyond housing.

Krivkovich A, Schiff R. The ongoing crisis of homelessness in the Bay Area: What’s working, what’s not. March 23, 2023. McKinsey & Company

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Although opioid use nationwide is higher for whites than they are for Blacks, but rates of increase in opioid deaths have been rising more sharply among Blacks (43%) than whites (22%) over the decades. Generational inequity and mistreatments of black people in the criminal justice system, health care, economic opportunity and media attention mostly on white people's overdose are the reasons for this trend.

James, K., & Jordan, A. (2018). The Opioid Crisis in Black Communities. The Journal of Law, Medicine & Ethics, 46(2), 404–421. https://doi.org/10.1177/1073110518782949

In San Francisco County, opioid related deaths among African American significantly increased since 2011, the number is 426.2 per 100,000 while the nationally it is 51.8. Moreover, African Americans disproportionately affected compared to other races. For example, it is 4 times higher than second highest race which is Hispanics.

Drug overdose death rates for every US county (sfchronicle.com)

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Black Opioid Fentanyl Overdose Death Disparity Linked to Systemic Racism  #DoctorMicahJohnson

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In 2016, 22 people in San Francisco died of fentanyl overdose, double the number in 2015.

Fentanyl overdose deaths rose to 36 in 2017, then to 89 in 2018 and 239 in 2019.

The Department of Public Health predicts that Mental Health SF with reforms approved in December 2019, will play an essential role in preventing overdose and providing accessible substance use therapy. Mental Health SF heavily relies on the passage of a business tax proposal in the November 2020 election.

DPH funds expanded naloxone distribution and training through the Drug Overdose Prevention and Education (DOPE) Project. In 2019, the program furnished more than 47,000 doses of injectable naloxone and more than 5,000 nasal naloxone kits in San Francisco. The DOPE Project has trained more than 15,000 San Franciscans in how to identify and respond to overdose.

Lane, J. (2020, August 31). Fentanyl drove steep increase in overdose deaths in San ... San Francisco Department of Public Health. https://www.sfdph.org/dph/alerts/files/PR-2020-Substance-Use-Trends-2019-Annual-Report.pdf

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Since April 2022, the California DOJ has seized approximately 9,348,852 fentanyl pills and 1,213 pounds of powder, and made over 200 arrests.

Enforcement | State of California - Department of Justice - Office of the Attorney General

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State of California - Department of Justice - Office of the Attorney General

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Fentanyl Enforcement

California DOJ through its Division of Law Enforcement's Bureau of Investigation works with law enforcement partners to take fentanyl out of communities and hold fentanyl traffickers accountable.

Since April 2022, the California DOJ has seized approximately 11,920,097 fentanyl pills and 3,518 pounds of powder, and made 303 arrests.

DOJ's Fentanyl Enforcement Program

In April 2021, Attorney General Bonta established the statewide Fentanyl Enforcement Program that is designed to detect,disrupt, and dismantle fentanyl criminal enterprises and prevent fentanyl from reaching California neighborhoods and communities.

DOJ works with allied task forces, including local and federal law enforcement partners throughout California. The Fentanyl Enforcement Program works with local and federal law enforcement partners throughout the state to address the fentanyl crisis and get these dangerous drugs off California's streets. The program is comprised of Bureau of Investigation regional investigative teams placed in San Diego, Los Angeles, Dublin and Sacramento.

Through the 2023 Budget Act, DOJ secured $7.9 million for the creation of the program within DOJ under coordination of the Bureau of Investigation to expand this important work, with an allocation of $6.7 million in ongoing funding.

Fentanyl Abatement and Suppression Team (FAST)

FAST is a multiagency taskforce first established in August 2022, focused on the disruption and dismantlement of criminal organizations who smuggle and distribute fentanyl within San Diego County. FAST targets fentanyl smuggling and distribution networks to counter the rising overdose rate and decrease the availability and accessibility of fentanyl. With its close proximity to the U.S.-Mexico border, San Diego County has experienced a 700% increase in fentanyl overdose deaths since 2016, linked to the illegal trafficking of fentanyl - both pressed into counterfeit pills and in powder form -from Mexico into the United States. FAST uses traditional as well as advanced investigative techniques to target the individuals and criminal organizations involved in fentanyl smuggling and distribution. California DOJ joins Homeland Security Investigations (HSI) San Diego, with full time partnership from U.S. Customs and Border Protection Office of Field Operations (CBP OFO) Enforcement and Removal Operations, the United States Marshals Service, the Drug Enforcement Administration, the Federal Bureau of Investigation, Naval Criminal Investigative Service, the Internal Revenue Service, and the San Diego United States Attorney's Office in this work.

Bureau of Forensic Services

DOJ's offers support through its Bureau of Forensic Services, which, among other things, helps law enforcement across the state by identifying fentanyl in drug offense-related samples and quantifying fentanyl in cases involving driving under the influence of a controlled substance submitted to DOJ.

Recent Fentanyl Enforcement Actions:

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Fentanyl Enforcement California DOJ through its Division of Law Enforcement's Bureau of Investigation works with law enforcement partners to take fentanyl out of communities and hold fentanyl traffickers accountable. Since April 2022, the California DOJ has seized approximately 11,920,097 fentanyl pills and 3,518 pounds of powder, and made 303 arrests.

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1. Decrease in the number of deaths of the homeless community due to Fentanyl overdose in the SOMA and Tenderloin neighborhood in San Francisco in 2.5 years.

2. Decrease in the number overdose cases in homeless community due to Fentanyl overdose in the SOMA and Tenderloin neighborhood in San Francisco in 2.5 years.

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1. Increase the number of residents stigma and fear to empathy and proactive engagement when it comes to an overdose in the SOMA and Tenderloin neighborhoods in San Francisco in 1 year. (behavior)

2. Increase the number of residents ability to recognize the signs of potential accidental Fentanyl overdose in the SOMA and Tenderloin neighborhood in San Francisco within 1 year. (skill)

3. Increase in the number of people who are experiencing homelessness and suffering from drug addiction in the SOMA and Tenderloin neighborhoods of San Francisco to test for fentanyl in order to safely use substances by 1 year. (skill)

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1. Increase the number of residents experiencing homelessness access to Naloxone to avoid overdoses in the SOMA and Tenderloin districts of San Francisco by 6 months. (circumstance)

2. Increase the number of residents experiencing homelessness living in the SOMA and Tenderloin districts education on Naloxone by 3 months. (Knowledge)

3. Increase the number of homeless residents in the SOMA and Tenderloin districts of San Francisco with the belief it's necessary to administer Naloxone for overdose by 3 months. (attitude)

4. Increase the number of people experiencing homelessness who are suffering from drug addiction in the SOMA and Tenderloin districts of San Francisco who know that potential Fentanyl overdoses are from contaminated drugs by 3 months. (knowledge)

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New Life

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Individuals who are experiencing substance use disorder and homelessness in the Tenderloin and SOMA districts in San Francisco.

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Program Activities Phase 1: Program Development (mos. 1-3)

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Program Activities Phase 1: Program Development (mos. 1-3)

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Hire New Life Staff

Identify a space in the Tenderloin/SOMA to rent for program activities.

Purchase materials.

Develop a curriculum to train volunteers for overdose intervention and prevention.

Develop a curriculum to train individuals experiencing homelessness in overdose intervention and prevention.

Recruit 10 individuals who have recovered from substance use disorder and have experienced homelessness to be mentors.

Connect to other programs, government agencies, hospitals, and churches.

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Program Activities Phase 2: Program Implementation (mos. 4-21)

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Program Activities Phase 2: Program Implementation (mos. 4-21)

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Train individuals to become mentors (New Life Mentors)

10 New Life Mentors will meet 2 hours a day for 2 days a week for 6 weeks for training and to create prevention strategies and safe dosing materials.

Mentors (peer-to-peer program) will meet once a week on the field (more meetings by request if appropriate).

Red flag clients (suicidal ideation, mental health distress, physically unwell, etc.) will be sent to HSA for resources from social workers, case workers, and therapists (outside resources).

New Life staff conduct education

New Life Mentors distribute flyers and conduct street outreach to individuals experiencing homelessness and drug addiction in the Tenderloin/SOMA to recruit them to attend prevention training (curriculum).

New Life Staff to conduct a two-hour prevention strategy training twice a month, every month for 2 years (with incentives: food, hygiene packs, etc.).

Training Approach

Observation of situations that carry risk.

Demonstration of steps to prevent overdose risk.

Conduct part of the training on the street sidewalks for participants to practice.

Peers demonstrate preventative skills and knowledge.

Training Topics

Identify situations that carry higher risks of future overdoses.

Steps to control these situations as much as possible.

Overdosing prevention skills

New Life Safe Zone Site

Provide drug testing kits, reversal kits, and educational resources.

CPR certification, offer AED services if needed.

Access to healthcare professionals (medical assistants, EMTs, nurses, clinicians, etc.)

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Program Activities Phase 3: Closing (mos 22-24)

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Program Activities Phase 3: Closing (mos 22-24)

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Hold Tenderloin/SOMA community "New Life" block party to highlight overdose injury & death in the Tenderloin, SOMA

Partnership with the city of SF/HSA to hold graduation ceremony for the New Life mentors and give certificates

Conduct evaluation activities

Develop final report about New Life program

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10 New Life Mentors

1 curriculum to train the New Life Mentors

12 New Life Mentors training completed

180 New Life Mentor participants complete program

Naloxone/Naloxone vending machine

Testing kits

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Copy of G5- GANNT Chart - SP24  Update 5 12

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Project Director (part-time)

Project Coordinator (part-time)

Physican Assistant

10 New Life Mentors