Overdose Prevention Plan 2022

October 6, 2022

  1. Executive Summary 
    1. Preventing death and reducing both the disparities and the morbidity associated with drug use is a priority in San Francisco
    2. San Francisco’s four-part, comprehensive plan is evidence-based, equity-oriented, and will save lives
    3. Strategic Area 1: Increase availability and accessibility of the continuum of substance use services 
    4. Strategic Area 2: Strengthen community engagement and social support for people at high risk for overdose 
    5. Strategic Area 3: Implement a “whole city” approach to overdose prevention 
    6. Strategic Area 4: Track overdose trends and related drug use metrics to measure success and inform program development and change 
    7. The imperative of addressing the social determinants of health in overdose prevention 
  2. Preface
  3. Introduction
  4. Guiding principles
  5. Reducing racial disparities and advancing equity
  6. Overdose prevention plan strategic areas
  7. Overdose prevention plan goals
  8. Overdose prevention plan key metrics
  9. Overdose Plan Strategic Areas
  10. Strategic Area 1: Increase availability and accessibility of the continuum of  substance use services
    1. Gaps:
    2.  
    3. NEW AND ENHANCED INITIATIVES IN SUPPORT OF STRATEGIC AREA 1:
  11. Strategic Area 2:  Strengthen community engagement and social support for people at high risk for overdose
    1. Gaps: 
    2. NEW AND ENHANCED INITIATIVES IN SUPPORT OF STRATEGIC AREA 2:
  12. Strategic Area 3: Implement a “whole City” approach to overdose prevention
    1. Gaps: 
    2. NEW AND ENHANCED INITIATIVES IN SUPPORT OF STRATEGIC AREA 3: 
  13. Strategic Area 4: Track overdose trends and related drug use metrics to measure success and inform program development and change. 
    1. Gaps:
    2. NEW AND ENHANCED INITIATIVES IN SUPPORT OF STRATEGIC AREA 4: 
  14. The imperative of addressing the social determinants of health in overdose prevention
  15. Programs currently in place along the continuum of services
    1. The Addiction Care Team
    2. Project HOUDINI Link
    3. Treatment Access Program in the Behavioral Health Access Center
    4. Medications for Addiction Treatment (MAT), including low-barrier MAT and buprenorphine micro-dosing
    5. Contingency Management (CM)
    6. Residential treatment
    7. Residential step-down care to address needs of people who are unstably housed and unhoused
    8. Drug Sobering Center
    9. Outreach and training for city agencies, high-risk housing sites, community members, and individuals at risk of overdose to establish a culture of harm reduction
    10. Citywide overdose education and distribution of harm reduction supplies
  16. DPH is actively expanding its network of distribution of naloxone, the life-saving antidote to opioid overdoses. Naloxone is currently provided through the DPH Clearinghouse and at:
  17. Currently, fentanyl test strips are available at:
  18. How services along the continuum address racial disparities
    1. Expanding low-barrier treatment methods including medications for addiction treatment, contingency management, and assertive linkages and transitions to care
    2. EXPANDING OUD MEDICATION DELIVERY FOR AREAS WITH NO RETAIL PHARMACY ACCESS
    3. PROJECT HOUDINI LINK
    4. EXPANDING CA BRIDGE CLINIC
    5. EXPANDING BAART MARKET STREET CLINIC
    6. EXPANDING OFFICE- BASED BUPRENORPHINE INDUCTION CLINIC (OBIC)
    7. PROP 4 ALL EXPANSION
    8. Establish the Street Overdose Response Teams (SORT)
  19. Acknowledgement

Sections

  1. Executive Summary 
    1. Preventing death and reducing both the disparities and the morbidity associated with drug use is a priority in San Francisco
    2. San Francisco’s four-part, comprehensive plan is evidence-based, equity-oriented, and will save lives
    3. Strategic Area 1: Increase availability and accessibility of the continuum of substance use services 
    4. Strategic Area 2: Strengthen community engagement and social support for people at high risk for overdose 
    5. Strategic Area 3: Implement a “whole city” approach to overdose prevention 
    6. Strategic Area 4: Track overdose trends and related drug use metrics to measure success and inform program development and change 
    7. The imperative of addressing the social determinants of health in overdose prevention 
  2. Preface
  3. Introduction
  4. Guiding principles
  5. Reducing racial disparities and advancing equity
  6. Overdose prevention plan strategic areas
  7. Overdose prevention plan goals
  8. Overdose prevention plan key metrics
  9. Overdose Plan Strategic Areas
  10. Strategic Area 1: Increase availability and accessibility of the continuum of  substance use services
    1. Gaps:
    2.  
    3. NEW AND ENHANCED INITIATIVES IN SUPPORT OF STRATEGIC AREA 1:
  11. Strategic Area 2:  Strengthen community engagement and social support for people at high risk for overdose
    1. Gaps: 
    2. NEW AND ENHANCED INITIATIVES IN SUPPORT OF STRATEGIC AREA 2:
  12. Strategic Area 3: Implement a “whole City” approach to overdose prevention
    1. Gaps: 
    2. NEW AND ENHANCED INITIATIVES IN SUPPORT OF STRATEGIC AREA 3: 
  13. Strategic Area 4: Track overdose trends and related drug use metrics to measure success and inform program development and change. 
    1. Gaps:
    2. NEW AND ENHANCED INITIATIVES IN SUPPORT OF STRATEGIC AREA 4: 
  14. The imperative of addressing the social determinants of health in overdose prevention
  15. Programs currently in place along the continuum of services
    1. The Addiction Care Team
    2. Project HOUDINI Link
    3. Treatment Access Program in the Behavioral Health Access Center
    4. Medications for Addiction Treatment (MAT), including low-barrier MAT and buprenorphine micro-dosing
    5. Contingency Management (CM)
    6. Residential treatment
    7. Residential step-down care to address needs of people who are unstably housed and unhoused
    8. Drug Sobering Center
    9. Outreach and training for city agencies, high-risk housing sites, community members, and individuals at risk of overdose to establish a culture of harm reduction
    10. Citywide overdose education and distribution of harm reduction supplies
  16. DPH is actively expanding its network of distribution of naloxone, the life-saving antidote to opioid overdoses. Naloxone is currently provided through the DPH Clearinghouse and at:
  17. Currently, fentanyl test strips are available at:
  18. How services along the continuum address racial disparities
    1. Expanding low-barrier treatment methods including medications for addiction treatment, contingency management, and assertive linkages and transitions to care
    2. EXPANDING OUD MEDICATION DELIVERY FOR AREAS WITH NO RETAIL PHARMACY ACCESS
    3. PROJECT HOUDINI LINK
    4. EXPANDING CA BRIDGE CLINIC
    5. EXPANDING BAART MARKET STREET CLINIC
    6. EXPANDING OFFICE- BASED BUPRENORPHINE INDUCTION CLINIC (OBIC)
    7. PROP 4 ALL EXPANSION
    8. Establish the Street Overdose Response Teams (SORT)
  19. Acknowledgement
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Executive Summary 

Drug overdoses are a public health crisis in San Francisco, where 625 individuals died from overdoses involving opioids, cocaine, and methamphetamine in 2021. Thousands more experienced non-fatal overdoses. The majority of overdoses in the city involve fentanyl, a synthetic opioid that is 50-100 times stronger than morphine, which has driven San Francisco’s overdose death rate to be among the highest of large US cities. Furthermore, profound inequities exist: Black/African Americans in San Francisco are disproportionally affected, with an opioid overdose death rate that is more than five times higher than the citywide rate. Polysubstance use is common, with most overdoses involving more than one substance, including cocaine, methamphetamine, and other opioids. 

Preventing death and reducing both the disparities and the morbidity associated with drug use is a priority in San Francisco

In the past several years the City has implemented many key interventions under Mental Health San Francisco, showing that a collaborative, multifaceted approach can reduce people’s risk of overdose and expand the continuum of services. The many factors that contribute to overdose are longstanding and institutional, and include poverty, racism, lack of housing, and unaddressed trauma. Because of such complexity, the City’s work to address these issues is vital to the work of overdose prevention: while preventing overdose fatalities, changing the conditions that put people at risk is critical. Overdose prevention must be included in the actions of all City departments and partners, including engaging the most affected communities, because opportunities to intervene exist in all settings. 

San Francisco’s four-part, comprehensive plan is evidence-based, equity-oriented, and will save lives

Led by the San Francisco Department of Public Health, this plan aims to reduce fentanyl and other drug-related deaths, increase access to treatment for opioid use disorder (including addiction to fentanyl) and stimulant use disorder, increase social support for and reduce the stigma experienced by people at risk of overdose, and improve the community conditions in which drug use occurs. The plan builds upon decades of commitment and success by advocates, people who use drugs, and community organizations, whose partnership with the City is vital in this work. 

Strategic Area 1: Increase availability and accessibility of the continuum of substance use services 

Just as drug use exists on a spectrum from abstinence to problematic use and addiction, so too do the services available to people who use drugs. Treatment and harm reduction services – historically viewed as separate, mutually exclusive approaches – exist on a continuum. The services people seek can also vary over the course of their lifetime. The City aims to make services readily available to improve the wellbeing of people who use drugs and the communities in which drug use occurs. To achieve this, the City will: 

  • establish “Wellness Hubs” as a cornerstone of the City’s efforts, which will provide overdose prevention services and resources, services to improve health, and linkages to treatment, 
  • expand access and remove barriers to treatment for opioid use disorder, including fentanyl addiction, 
  • prevent overdoses from being fatal by supporting and broadening overdose prevention services (naloxone, fentanyl test strips, drug checking, and safe consumption), and 
  • improve post-overdose outcomes by enhancing targeted overdose response teams and connecting people to care. 

Strategic Area 2: Strengthen community engagement and social support for people at high risk for overdose 

Without increasing the social supports provided to people who use drugs, outreach and engagement will have limited success and the risk of overdose will remain high. This is particularly true in Black, brown and indigenous communities who have been deeply harmed by racist drug policies. To address these challenges, the City will establish or expand: 

  • communication to the public about drug use and the continuum of services available to people who use drugs, including through public messaging campaigns, 
  • public overdose response trainings and naloxone distribution using a citywide, data-driven approach, and 
  • collaboration with community organizations and development of partnerships to support populations most affected by overdose. 

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

Fatal and nonfatal overdoses occur throughout the city and people who are at risk of overdose interact with all City agencies. The health department is implementing innovative programs to reduce overdose risk, but it cannot do it alone. The magnitude of this crisis necessitates a “whole city” approach, in which overdose prevention initiatives exist in all departments, cover the city geographically, are tailored to meet the needs of diverse communities, and reduce disparities. The City will: 

  • establish protocols for first responders to refer and rapidly connect people who use drugs to health resources, overdose prevention services, and drug treatment, 
  • make overdose prevention training and naloxone available in all city-run housing facilities, 
  • embed overdose prevention resources in a range of settings that meet the needs of people who use drugs, such as in social services, health care, higher education, entertainment venues, and hubs that co-locate services, and 
  • promote low-barrier, street-based services and sufficient drop-in spaces throughout the city that are non-judgmental and welcoming to people who use drugs. 

Between 2015 and 2020, deaths involving fentanyl in San Francisco increased 4600%, illustrating the rapidity with which the drug supply and drug use can change. As today’s overdose crisis continues to evolve, it is essential that communities and public health organizations understand the trends in drug use, overdose, and the receipt of services along the continuum. Data must be used to inform and evaluate service delivery, policies, and resource allocation, as well as to address racial disparities. To achieve this, the City will: 

  • centralize data collection on drug-related metrics, including fatal and non-fatal overdose, 
  • use data to improve programs, 
  • develop materials for communicating data, including a publicly available dashboard for tracking important citywide metrics, and 
  • meet regularly with community members and frontline staff of service organizations to review data, discuss findings, and guide future planning 

The imperative of addressing the social determinants of health in overdose prevention 

A great amount of life-saving work is already underway in San Francisco and implementing the strategies in this plan will save more lives. At the same time, it is essential that efforts also continue to be made to improve the overall health and wellbeing of people who use drugs, which means addressing systemic issues and the social determinants of health. By making a concerted effort to engage people who use drugs, organizations focusing on these determinants – particularly housing – will not only improve health outcomes, but also be supporting overdose prevention. This collective work must be done with an unfailing commitment to reduce the disparities in overdose deaths seen among Black/African American San Franciscans and people experiencing homelessness, and advance equity in the City and County of San Francisco. 

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Preface

This plan builds upon successful work underway in San Francisco and incorporates the best available evidence to reduce overdose deaths and drug-related harms as of September 2022. The City also recognizes the ever-changing nature of drug use and drug overdoses, and how our collective response will also need to evolve. This plan will be revised annually as new strategies are identified and lessons are learned, with ongoing input from stakeholders and community members across the city.

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Introduction

Overdose death is a crisis in San Francisco, where more people died of overdose than COVID-19 in 2020. San Francisco has the highest overdose death rate among large California counties, a rate that is similar to other major cities across the United Statesi. And while every demographic group has been affected, profound disparities also exist: the opioid overdose death rate among Black/African American San Franciscans is more than five times the citywide rateii.Thousands of San Franciscans have died from drug overdoses and every one of these deaths is a tragedy. Every individual is someone’s relative, friend, neighbor, or colleague. The City mourns the loss of these members of our community and remains committed to aggressively approaching drug overdoses as a public health crisis. Addiction is not a moral failing. Lives can be saved by increasing access to treatment and implementing evidence-based harm reduction interventions.

San Francisco has been a national leader in promoting the health and recovery of people who use drugs and/or with substance use disorders and has a strong track record of innovation iii,ivThe new challenges presented by fentanyl, an extremely potent synthetic opioid, and methamphetamine can be met with expanded, coordinated, and data-driven responses.

San Francisco’s four-point plan to reduce fatal overdoses is comprehensive, compassionate, and respects the needs of people who use drugs. It provides a roadmap for taking a “whole city” approach to expanding access to the continuum of drug-related services, increasing community engagement and social support for people who use drugs, and measuring outcomes with robust data collection and analysis.

This document describes the continuum of services currently in place in San Francisco. These services, led by community organizations and health care systems, are saving lives. Yet despite the plateau in monthly overdose deaths since February 2021, approximately 50 people still die each month from overdoses.

These deaths are preventable. More work and innovation must occur if we are to reach the many people – especially Black/African Americans, Hispanic/Latinx populations, people experiencing homelessness, and people with co-occurring serious mental health conditions – who have historically and systematically been excluded from many efforts. As such, the plan also identifies gaps in today’s landscape and the additional initiatives that will help fill these gaps.

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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.
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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.

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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.
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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
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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
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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.

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Strategic Area 1: Increase availability and accessibility of the continuum of  substance use services

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 changeix, 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 usexii,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.

stages of change

 

 

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.

 

NEW AND ENHANCED INITIATIVES IN SUPPORT OF STRATEGIC AREA 1:

  • 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.
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Strategic Area 2:  Strengthen community engagement and social support for people at high risk for overdose

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

Gaps: 

  • 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.
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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.

 
The City is taking a comprehensive approach by:

 

  • 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.

Gaps: 

  • 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.

NEW AND ENHANCED INITIATIVES IN SUPPORT OF STRATEGIC AREA 3: 

  • 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. 
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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.

Gaps:

  • Although preliminary mortality data are available monthly, the level of detail is limited. In-depth mortality surveillance data are only available annually.
  • Surveillance of entrants and retention in buprenorphine treatment is limited to California’s prescription monitoring program.
  • There is no surveillance system in place that currently enables early detection of concerning increases in overdoses. This limits the City’s and its partners’ ability to respond rapidly and in a targeted, coordinated manner.xix

NEW AND ENHANCED INITIATIVES IN SUPPORT OF STRATEGIC AREA 4: 

  • Increase the City’s ability to understand trends in drug use through analysis of existing data as well as primary data collection, including community surveys and focus groups. Participants will include a variety of stakeholders, such as populations disproportionately impacted by overdose, family and loved ones of individuals who have experienced an overdose, community leaders, treatment and health care providers, and business owners.
  • Develop public health surveillance systems to promote the routine receipt and analysis of drug-related data, such as emergency department visits, 911/EMS calls, and mortality data. 
  • Ensure all new and existing data are consistently analyzed through a lens of racial equity to reduce disparities in both receipt of services and in outcomes. 
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The imperative of addressing the social determinants of health in overdose prevention

Overdose prevention activities include measures that directly reduce the likelihood that an overdose occurs (treatment with methadone or buprenorphine, fentanyl test strips) and those that reduce the risk that an overdose is fatal (naloxone, safe consumption). Strengthening these measures is a priority in City’s efforts to save lives.

However, improving the health, safety, and socioeconomic status of people who use drugs, particularly people who are also experiencing homelessness, should also be considered overdose prevention and should be considered the responsibility of all City departments and agencies. Addressing the social determinants of health can change the environment and conditions in which drug use may occur, leading to improved overall health and a reduced risk of adverse effects from drug use.

Efforts are particularly needed to provide housing for people experiencing homelessness and who use drugs, whose risk of overdose is especially high. San Francisco’s 2022 point-in-time count estimated that over half of the ~7,750 people experiencing homelessness in San Francisco have a substance use disorder While not all of these individuals may use fentanyl, and while housing alone will not prevent all overdoses, the risk of adverse effects from drug use in these individuals remains very high. This is borne out by DPH’s systematic death review of people experiencing homelessness.

Appendix A

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Programs currently in place along the continuum of services

The Addiction Care Team

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 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.

Medications for Addiction Treatment (MAT), including low-barrier MAT and buprenorphine micro-dosing

MAT is currently available in multiple DPH-funded settings. Seven Opioid Treatment Programs (OTPs) offer methadone and buprenorphine. Four Federally Qualified Health Centers (FQHCs) participate in office-based methadone treatment, and all San Francisco Health Network FQHCs have physicians who can prescribe buprenorphine. The Family Health Center FQHC campus houses the CA Bridge Clinic, which provides referrals from hospital and primary care to substance use disorder (SUD) specialty care. The system also has a mobile OTP site. Approximately 80% of residential treatment programs offer MAT when needed, and all of our residential programs accept patients on MAT and continue during residential treatment. Jail Health continues both methadone and buprenorphine in coordination with treatment programs. ZSFG Emergency Department (ED) and inpatient services can begin MAT and provide linkage support upon discharge. MAT is also available in Behavioral Health Services-Office-based Buprenorphine Induction Clinic (BHS-OBIC) for people being released from the county jails and through DPH’s Whole Person Integrate Care (Street Medicine, Shelter Health, Urgent Care, Respite and Sobering Center, Permanent Supportive Housing Nursing). For people who do not have primary care, BHS Pharmacy supports buprenorphine access by medication delivery or prescription-filling and individualized counseling.

Contingency Management (CM)

Contingency management (CM) is an effective treatment approach for people with stimulant use disorders. In CM, patients receive tangible incentives to reinforce positive behaviors such as abstinence. Currently, contingency management for stimulant use disorder is available through the San Francisco AIDS Foundation and at Citywide Substance Treatment Outpatient Program (STOP). Contingency management to enhance retention and linkage from acute settings is offered through Project HOUDINI LINK.

Residential treatment

Residential treatment offers a more intensive level of care for some individuals with substance use disorders to support treatment and recovery, particularly for people experiencing homelessness. In San Francisco, residential treatment programs offer medication treatment as well as counseling and other behavioral treatments.

Residential step-down care to address needs of people who are unstably housed and unhoused

Residential step-down beds are a type of behavioral health bed in the City’s system. These beds provide a safe and stable place for people to live as they continue outpatient treatment for substance use disorders. Residential step-down care may be an effective strategy to support retention in care of unstably housed and unhoused people. Under Mental Health SF, 70 additional residential step-down beds will be newly added to the City’s inventory.

Drug Sobering Center

Drug sobering centers offer a low-threshold, trauma informed, safe place to be while intoxicated. Services provided at drug sobering centers can include medical care and observation, linkages to services or to housing, referrals to providers, individual and group counseling, and the provision of safe supplies. DPH is committed to drug sobering centers as recommended by the Methamphetamine Task Force in 2019 and as legislated by Mental Health SF, and opened SoMa RISE in June 2022. Beginning September 2022, the center operates 24/7.

Outreach and training for city agencies, high-risk housing sites, community members, and individuals at risk of overdose to establish a culture of harm reduction

During the COVID-19 pandemic, City agencies came together to protect the health of San Franciscans; one effort included implementing harm reduction policies in Shelter-in-Place (SIP) hotels. Continuing this work, the Department of Public Health (DPH), the Department of Homelessness and Supportive Housing (HSH), the Human Services Agency (HSA), and Department of Emergency Management (DEM) have begun the process of implementing overdose prevention policies across their departments.

These overdose prevention policies formalize procedures for suspected overdoses on site, as well as require the development and distribution of harm reduction training and substance use treatment resources for City staff.

Citywide overdose education and distribution of harm reduction supplies

DPH currently funds naloxone distribution in San Francisco through the DPH Clearinghouse and the Drug Overdose Prevention and Education (DOPE) Project of the Harm Reduction Coalition. The following lists DOPE current distribution sites in 2022:

  • San Francisco AIDS Foundation Syringe Access Services

  • Glide Harm Reduction Services

  • Homeless Youth Alliance/San Francisco Needle Exchange

  • St. James Infirmary

  • Harm Reduction Therapy Center

  • San Francisco Community Health Center

  • At the Crossroads

  • San Francisco Homeless Outreach Team (SF HOT)

  • Shanti HIV Services

  • Road to Resilience (R2R) Team – Epiphany Center

  • Lost Souls Courier Collective

  • Bay Bridge Solidarity Mutual Aid Network Hospitality House, 6th Street

  • Hospitality House, Tenderloin Self Help Center

  • The Gubbio Project

  • HopeSF/Urban Services YMCA

  • SF Community Clinic Consortium - Street Outreach Services (SFCCC-SOS)

  • Raising Sparks Interfaith Ministry

  • Tom Waddell Urban Health Clinic

  • HOMEY

  • TAY Navigation Center – 3rd Street Youth Center and Clinic

  • LavaMae2

  • Huckleberry Youth Center

  • UCSF Street Nursing

 

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DPH is actively expanding its network of distribution of naloxone, the life-saving antidote to opioid overdoses. Naloxone is currently provided through the DPH Clearinghouse and at:

 

  • harm reduction sites, including all syringe access sites
  • medical settings, including several safety- net primary care clinics in San Francisco and hospital emergency departments
  • behavioral health settings, including several substance use disorder (SUD) treatment settings and the Behavioral Health Services (BHS) Pharmacy
  • social service settings, including some Single Room Occupancy buildings (SRO) and Shelter-in-Place (SIP) hotels
  • community and outreach settings, including street fairs, sex clubs, and bookstores; street outreach to people experiencing homelessness; and distribution of naloxone by SF Paramedics through project FRIEND
  • pre-release at the San Francisco County Jail
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Currently, fentanyl test strips are available at:

  • harm reduction sites, including syringe access sites
  • behavioral health settings, including the Harm Reduction Therapy Center (HRTC)
  • community and outreach settings through Street Medicine

Appendix B

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How services along the continuum address racial disparities

 

Expanding low-barrier treatment methods including medications for addiction treatment, contingency management, and assertive linkages and transitions to care

EXPANDING OUD MEDICATION DELIVERY FOR AREAS WITH NO RETAIL PHARMACY ACCESS

BHS Pharmacy has expanded its buprenorphine delivery to people residing in Shelter-in-Place hotels to additional sites in San Francisco. The service expansion is guided by data on overdose deaths, including location and race/ethnicity, to

identify specific high-need areas and engage key stakeholders. Developing this expanded service involved identifying potential locations where

the delivery service would best support the most vulnerable populations in the city, including those in supportive housing units in which live

a disproportionate number of Black/African American San Franciscans.

 

Project HOUDINI LINK’s diverse clinical team includes physicians and patient navigators.

The team facilitates starting medications for addiction treatment (MAT) while the patient is in the Emergency Department or during an inpatient admission. The team also provides follow-up for six months after enrollment, facilitating ongoing

treatment in both outpatient and residential settings. HOUDINI LINK also offers financial incentives and case management services to help link patients to housing, primary care, mental health care, and other needs. The program also follows patients who stop MAT to facilitate re- engagement. In HOUDINI LINK’s first three years, 150 individuals were served, including 36% Black/ African Americans. Nearly two-thirds (63%) of Black, Indigenous, and People of Color (BIPOC) patients link successfully to community-based treatment within 30 days after discharge, much higher than Zuckerberg San Francisco General (ZSFG) patients not enrolled in HOUDINI LINK (40%).

EXPANDING CA BRIDGE CLINIC

CA Bridge Clinic is an addiction clinic at Family Health Center (FHC) led by addiction medicine specialists. At FHC Bridge Clinic, approximately one-fifth of patients identify as Black/African American; due to well documented disparities in access to buprenorphine, FHC Bridge Clinic clinicians focus on ensuring that all Black/African American patients at Zuckerberg San Francisco General Hospital (ZSFG) with opioid use disorder (OUD) are offered buprenorphine. Current efforts at FHC Bridge Clinic also include the distribution of naloxone kits, and soon, fentanyl test strips.

EXPANDING BAART MARKET STREET CLINIC

BAART Market Street offers opioid use disorder (OUD) treatment, hepatitis C screening and treatment, mental health, and primary care services in one location. The medication for addiction treatment (MAT) program for opioid addiction offers methadone and buprenorphine maintenance as well as withdrawal management options. BAART Market Street also provides other programs including the Family Addiction Center for Education and Treatment which offers services specific to pregnant and post-partum parents who have opioid use disorder. BAART Market Street accepts a wide range of insurance programs ranging from Medicare to Medi-Cal to most commercial providers.

BAART Market Street has engaged with BIPOC community-based organizations in the last several years to increase access to treatment. This includes partnering with:

  • MA’AT, a case management program that specifically works with Black/African American San Franciscans,
  • The Latino Commission, which offers a range of substance use disorder services, and
  • The Friendship House, which serves Native Americans struggling with alcohol and with whom DPH continues to engage.

BAART Market Street staff has also engaged in a learning collaborative provided by UCLA that covered the “Racist War on Drugs as Fundamental Cause of Health Inequality”. Content covered in the two-hour seminar included defining racism, structural racism and its fundamental causes, as well as a breakdown of racial disparities.

EXPANDING OFFICE- BASED BUPRENORPHINE INDUCTION CLINIC (OBIC)

Prop C funding has recently enabled the addition of evening and weekend hours to match the hours of the BHS pharmacy. Funds have also been added for a substance use navigator to support patients to remain in care.

The aim of the OBIC expansion is to increase access to treatment of opioid use disorder and stimulant use disorders, both of which are the primary drivers of overdose deaths in San Francisco and which disproportionately impact BIPOC communities. OBIC will collect self- reported race and ethnicity information from all participating individuals in order to assess who the program serves, identify disparities in outcomes, and create a plan for addressing those disparities. The peer navigator will focus on high-risk populations, including people leaving incarcerated settings which are disproportionally comprised of BIPOC populations. The peer navigator will be an individual with lived experience.

PROP 4 ALL EXPANSION

Prop 4 All provides ‘one stop’ access to four levels of care at mobile syringe access sites and prioritizes engaging BIPOC. The program offers supplies and naloxone, drop-in drug counseling with incentivized counseling sessions for people who use fentanyl, buprenorphine access and a 12-week program of contingency management for stimulant use and buprenorphine stabilization. This is followed by 6 months of peer support and full substance use disorder treatment for those who decide to continue in care. The program specifically focuses on Single Room Occupancy buildings (SRO), where overdoses have been occurring at high rates among people of color.

Establish the Street Overdose Response Teams (SORT)

Prop C investments fund two response units, providing real-time response to individuals who have experienced a recent non-fatal overdose and who are identified to have opioid use disorder, and three follow-up units to engage clients within 24 to 72 hours of the initial contact.

The Street Overdose Response Team (SORT) focuses on people experiencing homelessness and populations in permanent supportive housing. Following the initial response, the Post Overdose Engagement Team (POET) provides follow-up and outreach citywide and does not exclude any neighborhood. Additionally, in collaboration with organizations that work with BIPOC and people who use drugs, all SORT staff receive training to improve health care system trust. Training includes methods to reduce stigma and misinformation related to medications for addiction treatment that are prevalent in BIPOC communities.

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Acknowledgement

Thank you to the many individuals from across the city and state who contributed their time, energy, and expertise to the development of this plan. Overdose deaths are preventable. As we collectively strive to save lives and reduce disparities in overdoses, we share your vision of and commitment to a city free of overdoses and overdose deaths and we thank you for your work, dedication, and partnership.

Endnotes

  1. Centers for Disease Control and Prevention, National Center for Health Statistics. National Vital Statistics System, Mortality 1999-2020 on CDC WONDER Online Database, released in 2021. Data are from the Multiple Cause of Death Files, 1999-2020, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Accessed at http://wonder.cdc.gov/ucd-icd10.html on Sep 21, 2022.
  2. Coffin PO, McMahan V, Haq N. Substance Use Trends in San Francisco through 2020. Department of Public Health, City and County of San Francisco. 2021 December 20.
  3. San Francisco Department of Public Health. 2017 Final Report, San Francisco Safe Injection Services Task Force. 2017 September. Available at https://www.sfdph.org/dph/files/SIStaskforce/SIS-Task-Force-Final-Report-2017.pdf San Francisco Department of Public Health. 2019 Final Report, San Francisco Methamphetamine Task Force. 2019 October. Available at https://www.sfdph.org/dph/files/MethTaskForce/Meth%20Task%20Force%20Final%20Report_FULL.pdf
  4. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Sciences Policy; Committee on Medication- Assisted Treatment for Opioid Use Disorder; Mancher M, Leshner AI, editors. Washington (DC): National Academies Press (US); 2019 Mar 30.
  5. US Department of Health and Human Services (HHS), Office of the Surgeon General, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC: HHS, 2016 November.
  6. US Department of Health and Human Services (HHS), Office of the Surgeon General, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC: HHS, 2016 November.
  7. National Institute on Drug Abuse. Syringe Services Programs. n.d. Available at: https://nida.nih.gov/research-topics/syringe-services-programs#what- are-syringe
  8. Kral AH, Davidson PJ. Addressing the Nation’s Opioid Epidemic: Lessons from an Unsanctioned Supervised Injection Site in the U.S. Am J Prev Med 2017;53(6):919–922
  9. Center for Substance Abuse Treatment. Brief Interventions and Brief Therapies for Substance Abuse. Treatment Improvement Protocol (TIP) Series, No. 34. Rockville, MD: Substance Abuse and Mental Health Services Administration (US), 1999.
  10. Krawczyk N, Allen ST, Schneider KE, et al. Intersecting substance use treatment and harm reduction services: exploring the characteristics and service needs of a community-based sample of people who use drugs. Harm Reduct J 19, 95 (2022).
  11. Andraka-Christou B, Randall-Kosich O, Totaram R. Designing an “Ideal” Substance Use Disorder Treatment Center: Perspectives of People Who Have Utilized Medications for Opioid Use Disorder. Qualitative Health Research. 2021;31(3):512-522.
  12. Centers for Disease Control and Prevention. Summary of Information on The Safety and Effectiveness of Syringe Services Programs (SSPs), n.d.Available at: https://www.cdc.gov/ssp/syringe-services-programs-summary.html
  13. DeBeck K, Kerr T, Bird L, et al. Injection drug use cessation and use of North America’s first medically supervised safer injecting facility. Drug Alcohol Depend. 2011 Jan 15;113(2-3):172-6.
  14. Tsai AC, Kiang MV, Barnett ML, et al. Stigma as a fundamental hindrance to the United States opioid overdose crisis response. PLoS Med. 2019;16(11): e1002969.
  15. Pizzicato L, Drake R, Domer-Shank R, et al. Beyond the walls: Risk factors for overdose mortality following release from the Philadelphia Department of Prisons. Drug Alcohol Depend. 2018 Aug 1;189:108-115.
  16. Binswanger IA, Stern MF, Deyo RA, et al. Release from prison – a high risk of death for former inmates. N Engl J Med. 2007 Jan 11;356(2):157-65.
  17. Dasgupta N, Beletsky L, Ciccarone D. Opioid Crisis: No Easy Fix to Its Social and Economic Determinants. Am J Public Health. 2018 February; 108(2): 182–186.
  18. Mattson CL, Kumar S, Tanz LJ, et al. Drug Overdose Deaths in 28 States and the District of Columbia: 2020 data from the State Unintentional Drug Overdose Reporting System (SUDORS). SUDORS Data Brief, No 1. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; 2022.
  19. Lasher L, Hallowell BD, Chambers LC, et al. Using Timely Overdose Data to Address a Spike in Nonfatal Overdoses and Inform a Coordinated Community-Level Response in Rhode Island, 2019. Public Health Reports. 2021;136(1_suppl):24S-30S.
  20. San Francisco Department of Homelessness and Supportive Housing, “San Francisco Homeless Count and Survey, 2022 Comprehensive Report”, 2022. Available at https://hsh.sfgov.org/wp-content/uploads/2022/08/2022-PIT-Count-Report-San-Francisco-Updated-8.19.22.pdf
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