For years, San Francisco has made harm reduction its standard drug policy. Keeping drug users alive, not punishing or shaming them, has been the overarching goal.
But in the past year or so, unable to stem record overdose deaths driven by fentanyl, along with open drug use and sales in some neighborhoods, the city’s stance has started to change. It’s not just a Daniel Lurie thing. Mayor London Breed said more than a year ago that “harm reduction, from my perspective, is not reducing the harm.”
One month later, SF voters passed Breed-backed measures to give police more power and require drug screenings for welfare recipients. In November, 63 percent of SF voters backed California Prop 36, which increased punishments for repeat offenses of drug use and theft.
Last fall, Lurie beat Breed with an emphasis on public safety. His first major bill, which sailed through the Board of Supervisors, declared a “fentanyl state of emergency,” giving Lurie more power to issue contracts on a broad range of services, from drug treatment facilities to police hires. Lurie also ordered last month that city workers cannot hand out clean needles or foil in public spaces.
On the board, Sup. Matt Dorsey has promoted what he and others see as less permissive policies around drug use and treatment. They stress the need for – and public funding for – recovery and sobriety, which are not main harm-reduction goals.
A former SFPD spokesperson, Dorsey is also a recovering addict who says he’s not trying to eliminate harm reduction. He supports supervised drug-consumption sites, for example. But many harm reduction advocates are skeptical, even furious, about his push.
The debate – sober (or “abstinence-based”) recovery versus harm reduction – was on full display last month. Dorsey held a hearing for his “Recovery First” bill to change the city charter and make recovery SF’s primary drug-policy goal.
“People die from conventional abstinence-based treatments because they are left out or kicked out if they don’t comply,” Patt Denning, a harm reduction pioneer and founder of SF’s Harm Reduction Therapy Center, said at the hearing. “No one dies from harm reduction.”
Some harm reduction elements, like access to overdose reversal drug Narcan, indisputably save lives. But Denning’s claim seemed to ignore that nearly 3,000 people have died of overdoses in SF this decade, and it underscored the polarization of the issue.
The response to Dorsey’s bill did force changes. At first, the bill sought to “establish the cessation of illicit drug use and attainment of long-term recovery” as the “primary objective” of city policy. But the final version substituted “long term remission” for “cessation,” and “goal” for “objective,” among other tweaks. The San Francisco Marin Medical Society and the National Harm Reduction Coalition eventually gave it their blessing. SF supervisors approved it unanimously this week.
The charter amendment is a symbolic act, which Dorsey himself acknowledges. It could have little or no impact. (SF amended its charter more than 50 years ago to declare itself a “transit first” city.)
But the debate won’t fade anytime soon, which makes it all the more important to understand what people mean by harm reduction.
‘Meet people where they’re at’
Harm reduction is a concept, a philosophy, and ultimately a set of practices. San Francisco was ground zero for its origins, which began during the AIDS epidemic in the 1980s. The Frisc asked several organizations for their key components of harm reduction practice.
An SF Department of Public Health spokesperson referred to the federal Substance Use and Mental Health Services Administration’s (SAMHSA) harm reduction framework. Others, including the National Harm Reduction Coalition (NHRC) and the San Francisco AIDS Foundation, have their own definitions. They share many elements, sometimes with different emphasis. NHRC, for example, has eight “principles” that guide implementation of harm reduction practices.
(Note: SAMHSA is part of the US Department of Health and Human Services. The framework comes from the Biden administration and remains on the site. The Trump administration’s drug policy priorities, published April 1, do not mention harm reduction but support some elements, such as overdose reversal drugs.)
Here are several common harm reduction practices.
* Drug-use supplies and spaces: These include clean needles, needle exchange programs, and clean foil and pipes to encourage fentanyl users to smoke instead of inject. Harm-reduction proponents also call for supervised consumption sites. (They often use the phrase “safe consumption.” New York City operates two sites and calls them “overdose prevention centers.”)
The intent behind such sites is to “meet people where they’re at,” as NHRC puts it, to underscore that “licit and illicit drug use is part of our world,” and that harmful effects should be minimized, not condemned.
Evidence: According to the Centers for Disease Control and Prevention and the National Institute on Drug Abuse, nearly 30 years of research shows that needle exchange programs, which sometimes include vaccination and testing services, prevent sickness and death. However, a 2022 study in the Journal of Public Economics presented new evidence in light of the opioid epidemic that exchange programs increase rates of opioid-related deaths, especially in rural programs and in ones that opened after the influx of fentanyl.
A 2022 American Family Physician study cited substantial evidence showing supervised injection sites reduce overdose deaths. A temporary site in SF, open for nearly a year in the Tenderloin, saved 333 lives, according to the CEO of the nonprofit running it.
* Medical interventions: The big one here is the OD reversal drug naloxone, often known by the brand name Narcan. It’s applied as a nasal spray, and first responders carry it. It’s also available in some housing. Harm reduction can also include drug-test strips for users to make sure they know what they are taking, and wound-care products for infections and ulcers that users can develop. Xylazine, for example, started appearing in the fentanyl supply last year, and is linked to skin rot.
Evidence: Narcan has been used for more than 50 years to prevent overdose deaths. Medical professionals and harm reductionists are calling for its availability over the counter, in bars, and in other social spaces. Fentanyl’s potency is only adding to the demand — in a study of 125 adults U.S. residents who administered Narcan, multiple doses were needed to reverse an overdose, with more than 90 percent of participants worried one box of Narcan would not be enough.
* Housing and other social spaces: A key tenet of homelessness work is Housing First – get people into housing with as few barriers as possible. Sobriety should not be a requirement. Homes such as San Francisco’s permanent supportive housing, as well as “day centers” and other social spaces, should offer harm-reduction products (Narcan, clean needles, foil, etc.). SF’s policy has been a flashpoint for Dorsey and others who say residents who want drug-free environments need more options.
Evidence: A 2021 National Institutes of Health study and others found a significantly higher risk of opioid overdose for people who were homeless, demonstrating the importance of policies like Housing First in indirectly preventing overdose. However, in 2024, more than three-quarters of SF overdose deaths happened indoors, at a fixed address.
* Easy access to medically-assisted treatment: Methadone is a decades-old prescription treatment for people trying to kick opioids. A newer version is buprenorphine. Harm reduction advocates call for access through quick or telehealth referral and mobile delivery or take-home services.
We as doctors understand the importance of harm reduction, and we also support the aspirational goal of Recovery First.
John Maa, former president of the San Francisco Marin Medical Society
Evidence: There is substantial evidence showing medically-assisted treatment reduces opioid use and overdose. However, a 2021 study found that instead of reducing withdrawal symptoms, buprenorphine was associated with severe withdrawal symptoms after recent fentanyl use. Methadone had better outcomes reducing withdrawal.
* Stable workforce and infrastructure: Harm reduction works best when the organizations offering services reflect the population being served, according to SAMHSA and NHRC. This includes hiring people who use drugs and offering them fair pay and leadership positions, according to the SAMHSA framework.
Grim record
The April 24 hearing on Dorsey’s charter amendment led to compromises. It also highlighted a split in the harm-reduction camp, as one advocate sees it. The practice and philosophy “grew up in the 1980s” with a public health lens to reduce the risk of HIV and AIDS, says Stanford University professor and addiction researcher Keith Humphreys. But recent years have produced a “rights and liberties strategy,” which seeks to maximize drug users’ autonomy and support their choices, says Humphreys.
He adds that evidence supporting harm reduction isn’t being properly applied to the current situation. “Today we can treat those infectious diseases, drug law enforcement is way down, and continued drug use is much more dangerous. Instead there has been an unfortunate tendency to try to deny this.”
One set of numbers is indisputable: Overdose deaths in San Francisco remain shockingly high. The grim record, 799, came in 2023. Last year saw a drop to 644, and now the pace has picked up again, with nearly 200 the first three months of 2025. More people in SF are asking what else the city can do to adjust to the frustrating reality.
“We as doctors understand the importance of harm reduction and we also support the aspirational goal here of recovery first,” said John Maa, former president of the San Francisco Marin Medical Society, speaking at the April hearing in support of Dorsey’s charter amendment. “I think through unity and a multi-pronged strategy, we can be successful.”
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