The inequitable conditions of living in the Bay Area are exemplified within the enterprising city of San Francisco where you can pass tall, gleaming buildings for corporations such as Uber or Salesforce and simultaneously see the large unhoused population sleeping on the streets or discarded needles from previous public drug use. For years San Francisco has dealt with issues pertaining to these larger inequalities including homelessness and housing crises, treating mental health services, and the opioid epidemic. Opioid use disorders (OUD) and overdoses are not unfamiliar public health issues the city has faced and tried to solve but as a global pandemic and a new highly lethal and addictive drug exacerbate the issue new solutions are needed. What policies and practices can San Francisco implement in order to treat this systemic disease?
Neurobiology of Opioid Use Disorders
Opioids are a classification of drugs including illegal substances, synthetic opioids like fentanyl, and legally prescribed pain relievers. They chemically interact with the three types of “opioid receptors” found in the brain and provide dopamine, a neurotransmitter that is involved in reward, motivation, memory, attention, and how we feel pleasure. By regularly using them the body becomes less sensitive to dopamine and the substance is less able to make someone feel “high” or be in a euphoric state.
This tolerance is harmful because opioids not only begin to control the body’s ability to feel pleasure from these drugs but from ordinary things that release dopamine as well like social interaction which can make overall less enjoyable and contributes to addiction. Over time, physical and emotional distress without the substances known as withdrawal occurs. Addiction is a vicious cycle, relief becomes purchased at increased distress when not using. The person no longer takes substances to “get high” but instead to avoid feeling low (Neurobiology of substance use, misuse, and addiction). This is how opioid use disorders form, and this national public health crisis is extremely prevalent in the San Francisco community.
“Substance use disorder is a medical disease. It’s treatable, it’s a brain disease. We have essentially criminalized a disease, which increases stigma. It’s the only medical diagnosis that is a crime.”Dr. Aimee Moulin, behavioral health director at UC Davis Emergency Department
The Current Issue
More people in SF died last year from overdoses than COVID 19
In 2020, 708 people in the city of San Francisco died of drug overdoses as compared to the 254 who died from COVID 19, making it the most deadly year in the city’s history by far (Lovett). Around 71% of these deaths were due to fentanyl, a synthetic opioid 50 times stronger than heroin that has recently been spreading throughout the city in recent years (Scheier). 2 milligrams of the substance can have deadly results, making accidental overdoses common. It was found that the main reason these overdose death rates weren’t even higher was due to an opioid reversal drug known as naxolone or Narcan which was found to have saved close to 3,000 lives that year (Overdose Deaths Far Outpace COVID-19 Deaths in San Francisco). Even so, there were 61 overdose deaths in January 2021 alone (as compared to the 38 fatal overdoses in January 2020) putting this year in trajectory to be even deadlier, and showing that a call to action is needed (Sabatini).
These overdoses have largely been in the Tenderloin and South of Market (SoMa) neighborhoods, which accounted for 40% of 2020 deaths (Thadani). The median income of this one-quarter square mile area is $31,000 per year, less than half of the average annual income of $78,000 (Bishari).
Due to COVID 19, treatment services have become more inaccessible, leaving many using more substances. Social isolation also plays a large role, as recovery is a lifelong process and many rely on group settings or support from others to stay sober or safe.
A Shift in Solutions
As a call for solutions is needed, there has been debate over how to address this heightened crisis. Recently, City Attorney Dennis Herrera created a legal restraining order blocking 28 known Bay Area drug dealers from entering the Tenderloin neighborhood. Many San Francisco community leaders opposed the plan, labeling it a reprocessed initiative that was punishment instead of treatment driven (Wolffe). Amidst a call for racial justice against police brutality with the Black Lives Matter movement and a call to defund police departments, many want limited law enforcement involvement in social issues as it may further harm minority populations. Upon creating solutions to this issue, social justice issues within the epidemic need to be considered as well as understanding who the epidemic can disproportionately affect.
Social Justice and the Epidemic
A social justice lens of the opioid epidemic shows that opioid use disorders have effects on a multitude of demographics nationally. According to a 2020 medical research paper on the American Opioid Epidemic’s effects on specific groups “[L]ittle research to date has been dedicated toward understanding the specific needs of these special populations, including building the evidence base for targeted approaches…Research has clearly shown that solutions for the opioid overdose epidemic are not one size fits all, and special attention should be paid to these populations that may be suffering unduly” (National Academy of Medicine). To me, this is a part of the issue. It’s crucial to understand the causes of substance abuse disorders stem from not only a healthcare system that incentivizes quick fixes to larger problems but also as a refuge from traumas, continued disadvantages, isolation, and hopelessness that different marginalized communities may uniquely understand.
The effects of OUDs on homeless and low-income populations
When considering who opioid use disorders are affecting most, I found a connection between another large and long-standing issue in San Francisco: the decade-long housing shortage and affordability crisis. As of recently, the Bay Area was deemed as having the highest rates of income inequality in the entire state of California with the top 90% earning around $384,000 annually while the bottom 10% earned only $32,000 (Hellerstein). This expensive cost of living has left 8,000 people living on the streets of San Francisco as of 2019 and is a main cause of California homelessness statewide (Brinklow). Substance abuse disorders are both a cause and effect of homelessness, and overdose risk is much greater in the unhoused community. Additionally, co-occurring substance abuse disorders and mental health disorders are common, as someone may use strong drugs such as opioids to suppress mental health issues they’re experiencing. These layers of stigma make accessible care difficult, especially since someone experiencing homelessness with these disorders may face a lot of societal blame for their conditions. For San Francisco to solve one of these issues they need to create better programs toward solving all three.
For Now Solutions
Harm Reduction is a social justice movement and a public health tenet that focuses on respecting the rights of people using drugs. It works to implement strategies meant to reduce negative stigmas and consequences surrounding drug use.
The 8 Principles of Harm Reduction
- Acceptance that the usage of both legally and illegally obtained drugs is a part of America, and use this knowledge to minimize the harmful effects these substances can have on individuals and communities instead of ignoring the issue.
- Acknowledgment that drug use involves a spectrum of behaviors, from complete abstinence to severe usage, and that some ways of drug usage are safer than others.
- Views successful intervention as bettering the quality of an individual or community’s livelihood, as opposed to stopping the drug use.
- Uses a non-coercive approach to sharing services and resources.
- Prioritizes the voices of those with a history or current experience with drug use when creating programs meant to serve these groups.
- Places people who use drugs at the forefront of reducing the harm of their drug usage, and empowers them to support others in strategies to better the conditions of their use.
- Recognizes the intersectionality between class, racism, social isolation, past trauma, sexism, and other inequalities and social determinants that affect the causes and effects of substance use disorders as well as the capacity to deal with drug-related harm
- Does not ignore the existent mental and physical dangers of illegal drug use.
(Principles adapted from the National Harm Reduction Coalition. More information on Harm Reduction here)
Preventative Care: Expanding Narcan and Overdose Training
Preventative overdose reversal drugs such as nasal naloxone have the potential to stop fatal overdoses and save lives. Naxolone (also referred to as Narcan) has the capacity to reverse overdoses from a range of opioids such as prescription pills, heroin, and even fentanyl. It’s an opioid antagonist, meaning it binds to the nervous system’s opioid receptors and blocks the effects of opioids in the system while quickly working to restore slowed or stopped breathing. However, high dosage opioids are still being prescribed 70 times more often than Narcan is (Overdose Prevention).
To increase this preventative care for emergent situations, there needs to be a stronger consideration for giving people prescribed opioids from hospitals or pharmacies Narcan as well as for family and loved ones of someone experiencing an opioid use disorder. Overdose prevention training can help as well for groups who come in contact or work with people who use opioids and are at high risk for overdose.
Safe Injection Sites
Factors that contribute to overdoses include unsafe injection in isolated locations. These sites offer a secure environment with no criminal prosecution where clinicians are prepared in the case of an overdose and there is access to a guided process in withdrawal management if wanted. They also include sterile injection tools which diminish the risk of transmitting viruses such as HIV (Safe Injection Sites: What Are They & How Do They Work?).
As of August 2020, a bill pushing for San Francisco to establish safe injection sites failed to win approval due to COVID shortening legislative sessions. As of now, the soonest the bill could possibly pass is January 2022. The San Francisco mayor has been pushing for these sites and made them an integral part of her campaign promises, and many believe areas for safe injection could be a bolder solution to rising overdoses yearly (Sabatini).
What Can You Do?
Language Matters: Break the Stigmas
In the comments below:
- Reflect on the National Institute on Drug Abuse “Terms to use and avoid when talking about addiction” above. What language have you maybe used in the past that reflected stigmatizing language? Why do you think using better terminology is important?
- Share information you found about the epidemic in your local level community. How has COVID 19 affected the issue?
- How does your state (or province/region if you live outside the U.S.!) currently implement or not implement harm reduction strategies?
- Let me know any additional thoughts or questions you have!