man nurse bandage corner
This man received a Covid vaccine as well as a fresh round of bandages. Nurses said he had edema from long-term drug use, and his pant legs were chafing, causing the wounds to bleed. He could only walk with extreme difficulty. Photo by Griffin Jones. July 8, 2023.

Half a dozen public health and addiction experts interviewed by Mission Local said that Mayor London Breed’s recent comments denigrating harm reduction went against best practices in their field. 

Breed’s stance against harm reduction, which is a staple of her administration’s own Overdose Prevention Plan and one of the seven pillars of the White House’s National Drug Control Strategy, was a 180-degree turn from her positions as supervisor and while running for mayor. 

“She’s wrong,” said Dr. Daniel Ciccarone, an addiction expert at the University of California, San Francisco, who has authored several studies on fentanyl and overdose crises. “Harm reduction engages the population better than anything else that we have … the problem is, it’s having its heyday in the middle of the worst overdose crisis the United States has ever seen, and fentanyl is a historic foe.”

In 2017, Breed helped create the city’s safe injection task force and, as mayor, supported the creation of safe-consumption sites, even as they defied federal law. In the years since, she has still favored harm reduction, a grouping of strategies like needle exchanges and safe-consumption sites that seek to keep people using drugs safer, often in a bid to connect them to treatment, instead of demanding abstinence before treatment. 

But this week, she did an about-face in the run-up to a tough re-election campaign in November. She is facing well-funded fellow moderates, like Mark Farrell and Daniel Lurie, and an electorate in revolt. She has responded by tacking to the right, supporting measures to loosen police oversight and seize welfare recipients’ benefits if they use drugs.

And now Breed is attacking harm reduction, which, she said at a Monday rally, is “not reducing the harm … it is making things far worse.”

Breed’s comments, public health experts said, showed understandable frustration with record overdose deaths in a city grappling with a historically deadly drug, fentanyl. San Francisco saw an unprecedented 813 overdose deaths last year, and another 66 in January 2024. The vast majority, about 80 percent, involved fentanyl.

But harm reduction is not to blame, experts said. Breed’s views go against the science of addiction and the best practices in the field, which conclude that programs like needle exchanges and safe-consumption sites can lead to fewer deaths and help connect users to treatment. Without harm reduction, experts said, the city’s fentanyl crisis might well be far deadlier.

“Harm reduction is based on decades of evidence that it improves health outcomes in people who use drugs,” added Dr. Leslie Suen, a primary care and addiction doctor at UCSF, who said she was “disappointed” to read Breed’s statements.

Suen has patients who would otherwise not go to the hospital for a “raging infection,” for instance, fearing they would be forced to go into withdrawal while being treated. But at Zuckerberg San Francisco General Hospital, which has a unit dedicated to working with drug users who are hospitalized, they get treated and have a chance to enroll in drug treatment.

“By using harm reduction, people are less likely to delay future episodes of care,” she said.

Every tool in the toolbox

The Department of Public Health did not respond to Breed’s comments when asked about them. The mayor’s own public health experts created the city’s overdose plan that lists harm reduction as a centerpiece, but she has not always followed their lead: Last year, she called Supervisor Dean Preston a “white savior” for asking if she would follow her own department’s recommendations.

The Mayor’s Office did not say which policies Breed opposed and what harms she meant. A spokesperson said Breed likely meant that combating the drug crisis “takes every tool and resource to tackle our drug crisis — it’s not just one or the other. We have to use everything available to us to save lives.”

Public health experts have no issue with that.

“Harm reduction is a piece of the answer, but it is by no means the only solution,” said Dr. William Andereck, a physician and medical ethics expert at California Pacific Medical Center. 

He said harm reduction “has its limits,” and that “even the people on the streets doing the harm reduction, keeping people off the floor” say that “these people need more.” 

“There’s a lot of different harms associated with substance use, and any particular harm-reduction intervention is going to address some harms, but not others,” added Harold Pollack, a professor of public health at the University of Chicago. 

He gave the analogy of harm-reduction programs meant to deter drunk driving. Designated driver programs, for instance, tremendously reduced roadside deaths, but did nothing to reduce violence related to alcohol use. 

Similarly, a needle-exchange program would reduce blood-borne disease rates, but not overdose deaths; a safe-consumption site might reduce overdose deaths, but not help recovery for those who need to be away from visible drug use — nor, sometimes, help the surrounding community.

“When I go to St. Anthony’s in the Tenderloin, I think there is a lot of damage to the families trying to raise kids in that neighborhood,” said Keith Humphreys, a professor at the Stanford School of Medicine focused on addiction. “Everyone’s well-being matters — yes, people who are using drugs matter, but so do those families.”

“You have to look at each harm-reduction intervention in terms of the specific harm it’s intended to reduce,” added Pollack.

Still, “the mayor should be more respectful of the need for harm reduction,” Pollack said, pointing out that overdose deaths “dwarf gun homicides, roadside accidents, everything” across the city and country, and harm-reduction strategies are “a key set of tools to address that.”

Too often, experts said, harm reduction is pitted against other programs — as Breed did in her speech. Abstinence-only or recovery programs, which stress the need to be sober before receiving services like a treatment bed, are on the rise in San Francisco. 

In 2021, Breed and Supervisor Ahsha Safaí launched the city’s first “abstinence-based” program for those in jail hoping to get clean. Salesforce donated $1 million last year to a Salvation Army residential treatment center in the Mission that would require patients to be sober before receiving a bed. At Monday’s rally, Breed stood alongside the executive director of the Salvation Army, who has stressed abstinence-only and said, “we are drawing a line in the sand.”

“There’s a battle in the field,” said Andereck. The conflict between service providers, he said, is “bullshit, absolute bullshit,” because different programs were needed for different situations.

“It’s the way they’re funded,” he added. “They’re each funded as individual actors to compete with one another.”

“It has baffled me, over the last two years, how people take issue with health professionals saying we should be expanding the options available to folks, versus we should be narrowing these options,” added Gary McCoy, the policy head of HealthRight360 which, among other programs, ran the de facto safe consumption in the Tenderloin site for 11 months until it was discontinued in December 2022.

McCoy said eliminating or reducing harm reduction and focusing only on programs such as abstinence-only recovery is shortsighted. There would be fewer avenues to help those who enter recovery and then relapse, for instance — something McCoy has seen time and time again.

“From January 2020 till December 2023, I counted 21 people that I knew who practiced a program of recovery, abstinence-based, and had a return to use and died,” he said. “This is why it’s important to have harm reduction … There’s something that works for everyone in whatever stage they’re in.”

Correlation, causation, frustration

Harm reduction presents an easy target: It’s a relatively new concept in the United States to engage drug users without either jailing them or compelling treatment. But it has gained ascendance over the last decade, following wider use in Europe and Canada, and is now an accepted policy from local governments to the White House.

But in the last 10 years, fentanyl has swept across the country. More than 100,000 Americans have died every year since 2021 due to overdose, up from some 50,000 in 2015, when fentanyl deaths began rapidly ascending.

“When you have these two things line up, you see the rise of harm reduction, policies changing, money going to naloxone [Narcan to reverse overdoses] and you say, ‘Wow this has been a very robust harm-reduction response, but deaths keep going up,’” said Ciccarone, the UCSF addiction expert. 

Is “tough love” a good political strategy? I have no idea, I’m a public health attorney and drug policy researcher, not a political strategist. I can tell you that it’s not good for public health.

Corey Davis, network for public health law

He said that conflation was a mistake: Breed and others criticizing harm reduction “don’t have any evidence to support” its alleged role in facilitating drug use. “The problem is, correlation is not causation … overdoses are leading to a harm-reduction response, but our harm-reduction response is not leading to overdoses.”

Given the historic death rates, experts said Breed’s response was likely an emotional and political one, but not one grounded in science.

“Everyone is upset, deservedly upset,” said Humphreys from Stanford. “Lots of people are dying, and that emotional environment often polarizes discussion and pushes people to maximalist policy positions … the passion outruns the evidence — on both sides.”

“It strikes me that she’s very frustrated,” added Andereck. “To her credit, she’s trying … [but] don’t throw the baby out with the bathwater, just because people are falling down through the cracks does not mean it’s not effective.”

That frustration leads to retrograde policies, several experts said, like the increased arrests of drug users or Proposition F, a Breed-backed measure on the ballot Tuesday that would compel some welfare recipients to undergo drug screening. Anyone found to be using would be mandated to enter treatment or potentially lose cash benefits or even housing — a strategy experts called foolhardy.

Prop. F has attracted outsized funding from wealthy donors presumably seeking to bolster the mayor’s standing in an election year when the vast majority of the city disapproves of her performance and she is facing well-heeled opponents. 

The measure has more than $650,000 in support, largely from a small coterie of donors who fund big money networks in San Francisco: They include Ripple chairman Chris Larsen, San Francisco heiress Diane “Dede” Wilsey and Yelp CEO Jeremy Stoppelman. The campaign against it has raised just shy of $25,000.

“The policies that don’t work are shutting down harm reduction, arresting people who use and charging them with crimes,” said Ciccarone from UCSF. “The ones that don’t work are taking away their benefits, as if that will help them … People in this sector are so dehumanized, there is nothing further you can do to dehumanize them.”

Corey Davis, the director of the harm-reduction project at the Network for Public Health Law, said it was “absurd” to think that “the idea of ‘compassion is killing people’” and “arresting, prosecuting and jailing people” would lower overdose deaths. That approach has been tried in this country before, he said, and failed. As a result, he said, “we have both one of the highest arrest rates and one of the highest overdose rates.”

“Is ‘tough love’ a good political strategy? I have no idea, I’m a public health attorney and drug policy researcher, not a political strategist,” he added. “I can tell you that it’s not good for public health.”

‘A wonderful orchestra with no conductor’

Most experts agreed on one thing: San Francisco’s overdose policy is disjointed, involving dozens of nonprofits without an overarching goal. Is the goal to reduce overdose deaths? To get more people into successful drug treatment? To get drug users off the streets?  

“There’s no one saying, ‘Look, the goal of all our policies is to produce this outcome,’” said Humphreys from Stanford. He said the city has “an extraordinary number of nonprofits” that do not form a “coherent response” to the overdose crisis. Breed might be frustrated, he said, but she is in charge, after all: “The person who picks the heads of agencies and signs the checks.”

“Tell all of us, ‘This is the goal, and for that, this agency needs more money, this nonprofit needs more money; that’s what leadership is about,’” he said. “I don’t see that. I see an incredibly byzantine system where we just do what we did last year.”

“Nobody is stepping up to the plate, here,” added Andereck, who said he sees the same individuals cycle through his hospital time and time again, and called San Francisco’s drug approach “a wonderful orchestra with no conductor.”

“We’re playing ping pong with a lot of patients right now,” he added.

A more effective approach, experts said, would not mean focusing on one tactic over another, but coordinating efforts and eliminating a turf-like mentality that pits programs against each other. Such an approach would not prioritize harm reduction over abstinence, but ensure that different interventions at different moments are aimed at a common goal.

Attacks on harm reduction, they said, would only maintain the status quo.

“I’m afraid it’s not going to work, and we’re going to be in the same position six months from now, a year from now,” said Ciccarone from UCSF. “These types of policies go through fashion: We like fat ties, we like skinny ties. The fact that we’re going back to criminal-justice approaches just means we’re cultural animals. It doesn’t make it right; it just means it’s fashionable now to be tough on crime.”

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Joe was born in Sweden, where half of his family received asylum after fleeing Pinochet, and spent his early childhood in Chile; he moved to Oakland when he was eight. He attended Stanford University for political science and worked at Mission Local as a reporter after graduating. He then spent time in advocacy as a partner for the strategic communications firm The Worker Agency. He rejoined Mission Local as an editor in 2023.

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  1. This is a great article on a very complicated subject.

    San Francisco’s overdose policy is indeed “disjointed, involving dozens of nonprofits without an overarching goal.” Why?

    For some it pays.

    I have been homeless (and tentless!) in the city twice for extended periods.

    I didn’t drink or take drugs. For general assistance money (a pittance) I once “volunteered” for a harm-reduction non-profit. I mostly believe in harm reduction practices.

    I definitely believe so-called “tough love” policies are a pretense that involve very little love, but provide generously to the wounded egos of the well-heeled who want to atone for the damage their greed and desire for influence inflict on all of us.

    On the streets we ridiculed the labyrinthine public assistance at which San Francisco supposedly excels: the filthy and smelly lines and waiting rooms, the scowling and contemptuous bureaucrats, the jabberwocky rules enforced to break one.

    Beyond the bloated and Kafkaesque government, we called most of the non-profits “poverty pimps.”

    They might trot us out for their lavish fund-raising parties as examples of how effective they were.

    It is all very sad because most of their tough, poorly-paid non-profit front-line workers were themselves but a step away from destitution: their bosses and boards tight-lipped and hard-nosed, always aspiring, but forever locked out of the real accomplishments their professions had prepared them for.

    And don’t get me started about the way these poverty pimps partner with idealistic suburban weekenders who come to San Francisco to get a lesson in “giving”, or the tech wiz-kids who tithe time and gimmicky anti-poverty solutions to look good to their bosses, or rather to make their bosses look good.

    Be it all as it may, there are really no villains, only an antiquated system that puts profits for a minority ahead of providing for the needs of the majority in our world.

    Off the streets today, my life today is no heaven. But I observe how this system is increasingly failing us, and how society’s problems are interconnected.

    We give “billions to war, but all we get is a lousy t-shirt!”

    For those who are sick and on the street I have this practical advice: get into the program, any program.

    The people you expect to help you will lie to you and make things impossible for you. It is as if they want you to drop out and just go away.

    Don’t allow it. When the program fails, and it will, go back and tell them you did everything they asked of you and ask them “what do I do next?”

    The ball will be in their court and they will resent you, but after so long of this they will give up and actually help you. Just to get rid of you!

    They can then pat themselves on the back, while you may possibly have your own door to close and lock, or find a small space where you can be more free to live your life on your own terms.

    If nothing more, you will have an education unlike any other.

    You may start to ask real questions about why we tolerate so much sickness and death in our streets. How did it get this way? Who does it serve?

    Why do so many clamor for “accountability” from those who can least afford it, but none from those who can?

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  2. I think the fundamental question here is do we, as a society, have an obligation moral or otherwise to help drug addicts.

    The data suggests that rehabilitation with the current harm reduction approach is highly, highly unlikely, so what we are solving for is keeping them alive. I would argue that it is not success to merely keep someone on the streets alive, and allow them ready access to drugs.

    In most expensive rehab clinics, it is a form of tough love – you are forced to live in a drug free environment; why do we not to do that with the folks here? In other words, you get clean shelter, but you cannot bring any of your belongings, pets, or drugs with you – at this moment, you cannot care for yourself and so the main priority is to get you into a clean environment where you are forced to sober up. Also, the negative externality of screwing up public spaces for law abiding citizens is quite frankly ridiculous – a poor, drug free person pays tax to fund a drug addict’s treatment already, is it fair to say they shouldn’t bear the burden of also walking over their comatose, feces covered body on the street? I think so.

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    1. I am SO tired of societal problems being bandied around like tennis balls favoring one team or another. This either/or mentality is and will continue to kill people. Literally. Often very slowly and with billions of dollars pouring through the chasm between proposed resolutions. It isn’t the actual tangible efforts that are the problem. It’s the gaps between the efforts and the politically motivated policies that none of you are either driven or willing to try to bridge. It’s ridiculous, sickening, and utterly infuriating. Cooperation would solve a lot more problems than this incessant pandering to the ignorance of the masses.

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  3. ML and health professionals are good at science, but they are not good at paying for it, figuratively and literally

    It’s very easy for ideologues and scientists to advocate for their ideas and goals, but they do so in a vacuum, waving their collective hand at consequences of those ideas and goals, much in the vein of, “those side-effect problems aren’t our problems to solve.”

    But more to the point, we’ve been trying ‘enlightened’ approaches for well over 20 years in SF, and, while some addicts and other street people have benefited from those approaches, most people have paid the price for it in money spent and general city disorder that they’ve had to put up with.

    It’s time for another city to be a petri dish for social experiments. San Francisco needs to be done with all of it now.

    That means that some traditional elements of tough love have to return to the equation. Measure F is a good start.

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    1. No, bchill, “we” haven’t been trying “enlightened approaches” for any amount of time in SF. That would require everyone having stable housing and health care, and access to drug treatment.

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    2. …This comment is shortsighted and nonsensical.

      Why are ML and health professionals paying for a government problem? Breed should be leading and funding solutions that are effective.

      Then there’s the comment about ideologues, about people who literally research and field test solutions, alongside cost factors from status quo. And here’s someone mocking health professionals without basis that they are increasing the problem.

      “Enlightened” approach for well over 20 years? We aren’t “enlightened”, harm reduction came from the aftermath of the HIV/AIDS crisis, because of blood borne diseases spreading that cost municipalities a lot more than prevention by magnitudes. It’s a core principle for public health response since at least the 80s nationwide because it saves government money.

      This is why your rhetoric is dumb, because it’s reactionary and so ill informed, that you ignore a entire article of health professionals simply explaining their work.

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  4. “needle exchange”
    Mentioned 3 times.
    This is the kind of miss-reporting that casts a shadow on this whole opinion piece.
    We don’t have a “needle exchange” program.
    We have a needle and drug use equipment distribution system.
    In 2019 the Department of Public Health distributed 4.45 million needles.
    Who knows what it is today.
    You can walk in and get all sorts of stuff to keep your addiction to insanely dangerous and debilitating drugs “safe”.
    Cookers, cotton (small and large), alcohol wipes, sani hands, sterile water, saline, tourniquets (both latex and non-latex), and, to keep your vitality up, vitamin C.
    And aluminum foil, pipe covers and brillo, wound care and medical supplies like gauze, medical tape, hot hands (instant hot compress), Band-Aids, saline, and triple antibiotic ointment for those gangrenous wounds.
    Don’t forget, you can now get needles in 6, count them six! – convenient sizes.
    I recommend 30 gauge 1/2 inch for the fastest trip to the morgue.

    Perhaps I’m ignorant but it sure sounds like San Francisco is in the enabling business almost to the point of encouragement that being a junkie is just a lifestyle choice and we’ll help you consume all you want to the point of death.

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    1. The point of needle reduction is to reduce the chance of further disease and infection when they take the drugs, because it costs more to treat HIV/AIDS etc than giving out needles they’ll use with drugs anyways.

      You’d know that if you READ the article.

      Harm reduction is a BIG umbrella doing many different things to tackle the big problems.

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    2. Add insult to injury – all conveniently sorted into plastic bags that your taqueria on the block would get fined for by the City if they where caught going back to using them again.
      When they switched away from needle exchanges, the AIDS foundation *swore* we wouldn’t end up where we are today. It is high time we find better advice than what we’ve been offered in the past.

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  5. The problem with quoting “Experts” is you can find an expert that agrees with whatever point you want to make. People who have experienced long term recovery from addiction and alcoholism through 12 step programs are experts, and they do not believe harm reduction is the best approach. Confronting addiction head on and then finding a path to total abstinence has worked for hundreds of thousands if not millions of people for many decades.

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    1. And you know, just ignore all the dead people who didn’t get proper treatment for what they have.

      It’s called survivorship bias.

      You hear from the 12 steppers who survive, not the ones who relapse.

      It’s like food allergies, idiots forcefed their children something they were allergic to in the “good old days”, until we found out that the consequences are quite real.

      Similar to how Manic depression was really a mental illness called Bipolar disorder.

      They didn’t survive the 12 step, and you have to be dumb if you think LESS treatment options would be better than MORE.

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