Guiding principles

While overdose prevention is complex, key principles provide guideposts for organizing and driving such work. San Francisco’s Overdose Prevention Plan:

• builds upon the decades of successes by advocates, people who use drugs, and community organizations, whose partnership with the City is vital in this work,
• expands the continuum of services available to people who use drugs, from low-barrier services to residential care,
• improve the health and wellness of people who use drugs and communities impacted by drug use and overdose, and
• is driven by evidence-based approaches, yet recognizes that flexibility is needed as conditions change.

Reducing racial disparities and advancing equity

In addition to the principles above, the plan is centered around equity, acknowledging the disparities that exist in drug-related outcomes and the unequal and often unjust ways that different populations experience drug-related harms. Black, brown and indigenous communities nationwide have long been impacted by – and continue to be impacted by – the racism and criminalization that have been the hallmark of federal US drug policy for the past several decades.

San Francisco’s profoundly high opioid overdose death rates among Black/African American residents illustrates the urgency of a tailored and focused approach, one that is informed by the community and supported with sufficient resources to make meaningful change. The opioid overdose death rate among Hispanic/Latinx populations has also been rising in past years and exceeds the citywide rate. Reducing disparities in overdoses requires addressing cultural and linguistic needs in drug-related education, outreach, engagement, and treatment.

This plan reaffirms the City’s commitment to learning from and working with partners across the city to advance equity and improve the health of all city residents.

Overdose prevention plan strategic areas

1. Increase availability and accessibility of the continuum of substance use services
2. Strengthen community engagement and social support for people at high risk for overdose
3. Implement a “whole city” approach to overdose prevention
4. Track overdose trends and related drug use metrics to measure success and inform program development and change.

Overdose prevention plan goals

• Reduce fatal overdoses by 15% citywide by 2025
• Reduce racial disparities in fatal overdoses among Black/African Americans by 30% by 2025
• Increase number of people receiving medications for addiction treatment (MAT) by 30% by 2025

Overdose prevention plan key metrics

Within 1-2 years:

• Establish at least 2 Wellness Hubs that co-locate needed services and improve the health of people who use drugs
• Open 70 additional residential step-down beds
• Open 40 new beds for dual diagnosis transitional care for women in the Bayview
• Increase the number of people receiving MAT by 20%
• Increase the number of programs offering contingency management from three to five
• Establish drop-in space with low-barrier therapy for people experiencing homelessness
• Increase citywide naloxone distribution from 47,000 kits to 75,000 kits annually
• Have naloxone available in 50% of supportive housing facilities

Within 3-4 years:

• Establish additional Wellness Hubs across San Francisco in priority neighborhoods
• Increase the number of people receiving MAT by 30%
• Increase the number of people participating in contingency management by 25%
• Increase citywide naloxone distribution to 100,000 kits annually
• Have naloxone available in 100% of supportive housing facilities
• Train 250 people in overdose recognition and naloxone use in educational settings and entertainment venues annually

Overdose Plan Strategic Areas

With input from agency stakeholders, advocates, and community members, San Francisco’s four-point plan is evidence-based, community-responsive, and equity-driven. The plan recognizes the importance of addressing today’s overdose crisis using a person-centered approach.

There are many paths to addiction and just as many paths to recovery. The City has established a rich continuum of services to meet the needs of all individuals who use drugs. For those seeking treatment for opioid use disorder, the continuum is centered around treatment involving methadone and buprenorphine. These two FDA-approved medications have been shown to reduce mortality by up to 50% . There are few, if any, medications that confer this lifesaving potential. By comparison, treatment without medication has not been shown to have the same mortality benefit. Similarly, detoxification (withdrawal management) is not treatment; it can support individuals in the earliest stages of refraining from drug use, but it is essential that following withdrawal management they be transitioned to long-term treatment, ideally one that includes medications if they have an opioid use disorder.^_vi   Similar to the care of a person who has experienced a heart attack, after the acute treatment and hospitalization, patients are transitioned to long- term management of their heart disease. And just as treatment for heart disease must be timely, so must treatment for substance use disorders.

Residential treatment and care is also an important component of the continuum, as are residential step- down programs that address the needs of people who are experiencing homelessness or who are unstably housed and transitioning out of residential care programs.

Syringe access and overdose prevention programs, additional components of the continuum of services, are evidence-based public health interventions that have also been shown to save lives, reduce the risks of bloodborne infections such as HIV and hepatitis C, and increase receipt of drug treatment.^{vii, viii}

Over the past two years, the City has greatly expanded the treatment and harm reduction services available in San Francisco. There is no one-size-fits-all solution. Treatment must be made available to people who seek it, whereas other services, including harm reduction resources and supplies, should be accessible to individuals not seeking treatment. Treatment and harm reduction are not in opposition but exist along a continuum to meet the breadth of needs of people who use drugs and who are at risk of an overdose, wherever they are in their stages of change^{ix, x, xi}. In fact, studies have shown that syringe access and overdose prevention programs serve as important entry points into drug treatment when people are ready to reduce and stop their use^xii,xiii. Much of this success is due to syringe access and overdose prevention programs – often licensed as treatment providers as well as harm reduction service providers – being safe and trusted places for people who use drugs.

San Francisco’s continuum of substance use services includes (see Appendix A for more information)

• Medications for Addiction Treatment (MAT), which is available in many of San Francisco’s clinics and hospitals, including low-barrier MAT and buprenorphine micro-dosing.
• The Addiction Care Team (ACT) at Zuckerberg San Francisco General Hospital (ZSFG), which starts MAT for hospitalized patients with opioid use disorder (OUD) and links patients to care.
• Project HOUDINI LINK, which provides 6-months of peer navigation, contingency management, and linkage to community-based OUD treatment, primary care, and mental health care.
• Behavioral Health Services (BHS) Pharmacy, which delivers buprenorphine to many high-risk housing locations and in areas without retail pharmacy access.
• BAART Market Street Clinic, which offers expanded hours for treatment with methadone and buprenorphine, seven days a week.
• The Office-based Buprenorphine Induction Clinic (OBIC), which has expanded by adding evening and weekend hours to match with the BHS Pharmacy and adding a substance use navigator.
• SoMa RISE, a 24/7 drug sobering center, which provides a safe and supportive place for individuals who have recently used drugs and may still be feeling the effects of them, to rest, be connected to services, and avoid the threats they may face on city streets.
• The Treatment Access Team in the Behavioral Health Access Center (BHAC), which is an assessment team that matches people seeking care with treatment providers.
• 500 residential and residential step-down beds for the treatment of substance use disorders, to which seventy additional step-down beds will soon be added to the City’s inventory.
• The Street Overdose Response Team (SORT), an immediate, street-based response for people experiencing homelessness with a recent non-fatal overdose. A multi-disciplinary team engages with the individual immediately after the overdose and then on the day after the overdose, continuing to offer engagement, care coordination, and low barrier treatment, including MAT.
• Several syringe access sites, which offer low-threshold medical care, contingency management, and/or drug checking services regularly.
• Overdose education and distribution of harm reduction supplies that are increasing across San Francisco, tailored to setting and taking a citywide approach. This distribution includes naloxone and fentanyl test strips, and occurs at ZSFG, primary care clinics, and behavioral health treatment sites.

Strengthening and enhancing the continuum of services in a person-centered and equitable way is a priority in San Francisco, and DPH and partners have identified a number of gaps that can and will be filled by new and enhanced initiatives:

Gaps:

• While buprenorphine is increasingly available across San Francisco, there continue to be opportunities to expand treatment in additional primary care sites, mental health facilities, emergency departments, and other sites.
• Methadone is only available in highly regulated programs, and more flexible delivery of this highly effective medication should be encouraged.
• Contingency management, an effective treatment approach particularly for stimulant use disorder, has been funded through Prop C investments and is available through Project HOUDINI LINK, the Citywide Substance Treatment Outpatient Program, and Prop 4 All. However, this treatment approach will likely be insufficiently utilized without further training and incentives.
• SORT’s current funding scope is assertive follow-up for persons experiencing homelessness; follow up for housed persons is supported solely by grant funding. Recognizing that many overdoses occur among housed persons, stable funding for program expansion should be considered.
• All syringe access sites should provide low-threshold medical and treatment services, including contingency management, as well as drug-checking; however, these are not available at all sites due to a lack of funding and resources.
• Scientific information increasingly points to the effectiveness of opioid agonist medications besides buprenorphine and methadone. San Francisco should explore these options.

• Building upon the successful elements of the Tenderloin Center, the City is pursuing a strategy of several smaller “Wellness Hubs” that co-locate services along the continuum in a drop-in setting and provide overdose prevention services and linkage to treatment, housing and benefits. All of these can improve health and reduce a person’s risk of overdose. These hubs form a new cornerstone of the city’s multi-prong overdose prevention strategy.
• Make starting buprenorphine, distribution of naloxone and other risk reduction supplies, and implementation of best practices for treatment linkages standard in all hospital inpatient units, emergency departments, and safety-net primary care sites in San Francisco. Priority populations are persons presenting for medical/surgical care with untreated opioid use disorders (OUD), persons presenting in withdrawal, and those presenting following non-fatal overdose.
• Establish/routinize contingency management (CM) across all funded substance use disorder treatment programs and other prioritized programs that serve people who use stimulants. Providers should be financially supported in offering incentives needed to implement contingency management, assuming funding will not be available through Medi-Cal.
• Continue to pursue other innovative substance use services, such as the use of short-acting opioids for replacement treatment, that have shown promise in other parts of the country and world.

People who use drugs experience profound stigma and face barriers to receiving services.^xiv Increasing community engagement and social support are essential to overcoming barriers, saving lives, reducing stigma, and improving outcomes for people who use drugs.

Punitive policies have not been shown to be effective at reducing overdose deaths, while incarceration is known to significantly increase risk of dying of drug overdose. Studies have shown a 37- to 129-fold increased risk of fatal overdose among people leaving incarceration in the first two weeks of release compared to the non-incarcerated population.^{xv, xvi} This illustrates the need to offer support and connection to care to individuals immediately after release.

Such efforts must be citywide, yet also be focused on Black/African American and Latinx communities that have been disproportionally harmed by racist drug policies. Programs and policies should be tailored racially, culturally and linguistically to support these populations who experience elevated rates of fatal overdoses in San Francisco and who have not been reached by previous efforts (see Appendix B for how programs aim to reduce racial disparities).

The City is investing in this strategy by:

• Investing in drug sobering centers, such as SoMa RISE, that offer low-threshold, trauma informed, safe places to be while intoxicated. Services can include medical care and observation, linkages to benefits or housing, referrals to providers, individual and group counseling, and the provision of safe supplies.
• Conducting outreach and training for City agencies, high-risk housing sites, community members, and individuals at risk of overdose to reduce stigma and establish a culture of overdose prevention.
• Making naloxone and fentanyl test strips available at important points of contact for people who use drugs, including syringe access sites, BHS pharmacy, pre-release at SF County Jail, Shelter-in- Place (SIP) hotels, Shelter Health, and through street outreach.

The City has also identified gaps in this Strategic Area and intends to fill them through several new and enhanced initiatives

• More high-impact locations are needed for the systematic distribution of naloxone and fentanyl test strips, including but not limited to harm reductions sites, medical settings, behavioral health settings, social service settings, and in community settings. 
• There is misinformation about drug use in San Francisco, as well as a lack of public messaging about the continuum of services available to people who use drugs and how the public can help. This lack of understanding perpetuates the discrimination towards and experienced by people who use drugs, which can reduce their likelihood of seeking services. 
• Peer education is limited to a small number of community-based organizations.

NEW AND ENHANCED INITIATIVES IN SUPPORT OF STRATEGIC AREA 2:

• Establish multiple Wellness Hubs throughout the city, which co-locate needed services and improve the health of people who use drugs.

• Scale up public overdose response education, trainings, and naloxone distribution using a citywide, data-driven approach in settings with people at highest risk of overdose. These venues include substance use disorder (SUD) treatment programs, mental health clinics, Single Room Occupancy buildings (SRO), higher education, entertainment venues, and through community settings like churches and food distribution sites.

• Develop communication to the public about drug use and the continuum of services available to people who use drugs. Public messaging campaigns will educate people who use drugs, their family and loved ones, and the general public on how to prevent overdose deaths and obtain help. The campaigns will also aim to decrease stigma.

• Develop and implement a peer-led, racially-congruent outreach, education, and support program to reduce overdose and health disparities among people who use drugs. The program will be tailored to need and consonant with different communities’ values.

• Create drop-in harm reduction spaces to engage and create supports and linkage to ongoing care and treatment. Drop-in spaces will offer social support for people who use drugs, decrease public drug use, and offer a range of desired social services.

• Expand the availability of care coordination services offered to individuals released from the San Francisco Jail.Support overdose champions at priority sites to promote culture change within organizations, and to manage overdose education and the distribution of naloxone.

• Expand drug checking in multiple settings that reach people who use drugs. Drug checking not only allows for detection of novel drugs, but also empowers people to know what is in their drugs and the measures they can take to reduce adverse reactions, including overdose.

Strategic Area 3: Implement a “whole City” approach to overdose prevention

Drug use is a complex public health and social issue. Individuals who use drugs are often made vulnerable due to poverty, structural racism, unaddressed trauma, and profound inequities in the social determinants of health, especially a lack of housing. ^xvii DPH is implementing evidence-based and innovative programs to reduce overdoses, but the breadth and magnitude of today’s overdose crisis requires a “whole city” approach. All departments serve people who use drugs and must be part of the response to an epidemic that affects all demographics and every corner of the city.

• Implementing the Departmental Overdose Prevention Policy legislation of 2021, which requires DPH, the Department of Homelessness and Supportive Housing (HSH), the Human Services Agency (HSA), and the Department of Emergency Management (DEM) to have established their own overdose prevention policies and to have all staff who regularly work with people who use drugs trained in overdose recognition and response. These City agencies are working together to review lessons learned in policy implementation and track progress toward shared goals.
• Opening SoMa RISE, a drug sobering center, to which the teams of all City agencies can refer.
• Expanding low-threshold buprenorphine and contingency management to high-risk housing sites including HOPE SF, Shelter-in-Place (SIP) Hotels, Single Room Occupancy buildings (SRO), and Permanent Supportive Housing (PSH).

The City intends to close identified gaps in Strategic Area 3 by establishing a culture of overdose prevention across all departments.

• Housing and benefits assistance are frequently physically separate from other services along the continuum of care. This requires people who use drugs and are experiencing homelessness to often navigate complex systems and potentially travel to receive assistance. 
• Using alone indoors is a major risk factor for overdose. Despite this, not all City-supported housing facilities have adequate access to naloxone. 
• Stigma towards people who use drugs persists in throughout City agencies.

• Implementation of several Wellness Hubs across the city will help improve the health of people who use drugs by directly connecting them to the continuum of services, including treatment, housing, and benefits assistance. 
• Overdose response trainings and naloxone will be made increasingly available in all types of City-supported housing. 
• The City aims to create a culture of overdose prevention through the development of online trainings, including one on reducing stigma, that are available to all City staff and partners. 

Overdose deaths involving fentanyl increased 4600% in San Francisco between 2015 and 2020, and the drug is now involved in 75% of overdose deaths in the city, mirroring national trends.^xviii As the drug supply and drug use patterns change, it is critical to understand the trends and how successful programs can be adapted to meet evolving patterns of drug use and their consequences. Data should be used for surveillance (e.g. to identify new drugs), to respond to increases in overdoses, as well as to develop and evaluate new and existing programs.

The City recognizes the importance of data collection in monitoring the overdose crisis and informing overdose prevention efforts. To this end, the City is:

• Conducting a community assessment of drug use and drug overdoses, with a focus on drug overdoses among Black/African American San Franciscans.
• Working to measure the unmet need for treatment among people who use drugs.
   
• Meeting regularly with community partners and stakeholders to review existing data and findings.

There is a wealth of information on drug use and overdose in San Francisco, but it is decentralized. Improving coordination of the data will maximize their utility.

The Addiction Care Team (ACT) initiates medication for addiction treatment (MAT) for hospitalized patients with opioid use disorder (OUD) and links patients to ongoing care. ACT provides person-centered care to people with unhealthy substance use at Zuckerberg San Francisco General Hospital (ZSFG). ACT is composed of interprofessional members who meet patients where they are and use motivational interviewing to move patients towards healthier behaviors. ACT offers harm reduction, evidence- based treatment (medication and psychosocial), and linkage to care for patients. At the same time, ACT is focused on systems improvements to expand the capacity of addiction medicine knowledge and skills among frontline staff and providers.

Project HOUDINI Link

Project HOUDINI LINK provides enrolled patients six months of targeted (1) patient navigation, (2) contingency management, and (3) linkage to community-based OUD treatment, primary care, and mental health care for patients starting on one of three FDA-approved medications for OUD while hospitalized at ZSFG. In conjunction with the treating providers, patients are started on buprenorphine, methadone, or extended-release naltrexone. Enrolled patients are assigned a personal navigator who helps patients choose a community-based treatment provider, makes all necessary referrals, enrolls in insurance, and helps overcome barriers to attending intake appointments. The navigator meets with the patient at least twenty times over the course of 6 months, either in-person, via telephone, or using video-conference technology (e.g., Zoom). Under the supervision of licensed practitioners, patients are screened for psychiatric symptoms and offered appropriate referrals when needed. Patients are also offered financial incentives using gift cards or a reloadable debit card for attending appointments, ongoing adherence to MAT, and urine drug screens free of stimulants and opioids. The program has increased linkage rates by 460% when compared to 2017-2018 (the year prior to HOUDINI LINK) and led to sustained engagement with MAT treatment.

Treatment Access Program in the Behavioral Health Access Center

The Treatment Access Program in the Behavioral Health Access Center assesses and matches people seeking care with treatment providers. TAP assesses clients who self-refer or are referred by various providers throughout the city. In addition, TAP staff provide support via telehealth to Zuckerberg San Francisco General Hospital social workers and facilitate placement for discharged patients from triage and inpatient settings into community-based programs.