Emptying the Bathtub
Why Recovery Matters in San Francisco’s Addiction Crisis
San Francisco has been dealing with an addiction crisis for more than half a decade. Since the city started publishing data in 2020, 3,500 people have died of drug overdoses and more than 10,000 overdose related 911 calls have been made. In spite of numerous pushes to mitigate the crisis, the monthly overdose death rate has remained stubbornly persistent.
Much ink has been spilled over issues like the city's harm reduction strategy, where efforts were made to prevent overdoses deaths by handing out medications that can reverse overdoses like naloxone. In the past half decade, distributions of naloxone have seen a six-fold increase.
Critics of this policy contend that these distributions haven't moved the needle on overdose deaths and misses the point that overdoses will continue as long as the public has access to addictive drugs and what is really needed is a crackdown on drug dealing to keep substances like fentanyl, methamphetamine, and heroin off the streets.
Both of these approaches have merit, but there is another aspect to the San Francisco addiction situation that seems to be less prominently discussed.
One way to think about the addiction crisis is that you're trying to empty a bathtub. You naturally want to turn off the faucet so that the tub stops filling up, which one can analogize to the measures being taken to shut down the open-air drug markets, arrest dealers, and confiscate narcotics. All of these help stop people who aren't addicted from falling into the bathtub. But you also need to get the water to drain out of the bathtub.
However, it's important to think about how people are getting pulled out of the addicted population. If every person dealing with addiction died of an overdose tomorrow and no one subsequently became addicted, that would technically fix the issue of drug addiction, but no one would call that any sort of success.
Conversely, harm reduction strategies like naloxone distribution can have the perverse effect of making it seem like the addiction problem is getting worse because the number of people with addiction issues has grown, not because drugs are getting more addictive, but because many of the people you would have expected to die of an overdose survived due to timely medical interventions.
Instead the focus needs to be on recovery, so people leave the addicted population without becoming dead in the process. Luckily, there does seem to be an increase in the number of undergoing treatment for substance use disorders at city hospitals and clinics, but it’s been uneven and ought to be significantly higher considering the scale of the issue at hand.
The problem is that it's really hard to just stop being addicted to something. It's not a process that just naturally happens like healing a cut or regrowing hair. Smoking, a comparatively less debilitating habit than fentanyl or meth, can take an average of 6 attempts to quit, according to some surveys. Moreover, not all forms of treatment are created equal. While there is no Gold Standard approach to treating addiction that's proven to work 100% of the time, there may be a Silver Standard that is more effective than other studied approaches.
That approach is medication assisted treatment (MAT). While other therapies rely on non-pharmaceutical mechanisms like cognitive behavioral therapy to help people with addiction issues resist the urge to do drugs, MAT tries to manage withdrawal symptoms with medications. Drugs like methadone and buprenorphine taken in place of illicit opioids, while still using non-pharmaceutical interventions to help address the underlying causes of drug use.
The logic behind MAT makes sense. If drug addiction is a medical condition, then it makes sense to treat it with medication the way one would an infection, or perhaps more fittingly a mental illness like schizophrenia or depression.
But the more important question to ask is "does this treatment work?" While experimental data is hard to come by given the diversity of medical providers offering different forms of addiction treatment in the US, a research paper by Wakeman et. al. shows that patients given some form of medication assisted treatment were less likely to suffer a subsequent overdose than patients on non-medication based pathways. While not definitive, this is good evidence that MAT is a worthwhile way to treat addiction, at least for opioids.
So has San Francisco been using medication based approaches to try to tackle its addiction crisis? For a long time the answer was no. Between 2020 and the peak of the fentanyl crisis in 2023, the count of patients undergoing methadone or buprenorphine therapy was flat or down, even as 911 calls were spiking in mid-2023
Luckily, the tide seems to have turned in 2024 with a significant uptick of patients in buprenorphine, to a lesser extent methadone1, treatment.
This is a positive development, though one that has come far too late considering the number of lives lost during the three years of static MAT enrollment.
Hopefully, the efforts to tackle the distribution of illegal drugs, paired with a renewed emphasis on effective recovery treatments can help put an end to San Francisco's overdose crisis. If the city was able to significantly increase distribution of naloxone over the past several years, it ought to be able to create more capacity for medication assisted treatment to make sure that people don't just not die, but have a chance at a life without drugs.
The code used to generate the charts in this article can be found here. The data used to generate the charts in this article graciously provided by data.sfgov.org
January 2025 data shows methadone patients counts that indicate a massive increase in patients undergoing treatment if trends persist.
An interesting and insightful analysis of a very difficult problem. I wonder how city leaders would respond to questions about the importance of addiction treatment.