How does San Francisco's drug overdose crisis compare with the rest of the U.S.?

[Pedestrian]

Yoohyun Jung
June 29, 2021
Updated: July 2, 2021 8:46 p.m.

The rate at which people are dying of accidental drug overdoses in San Francisco has soared in recent years. That increase is largely because of the rise of fentanyl, a synthetic opioid that is exponentially more powerful — and lethal — than heroin. Recently released data shows that overdose deaths in San Francisco have now surpassed the rates of many East Coast and Midwest communities that encountered the deadly fentanyl epidemic years before it came to San Francisco.

Accidental drug overdose deaths tend to be higher in places where fentanyl is more widespread in the community, said Dr. Phillip Coffin, director of substance abuse research for the San Francisco Department of Public Health. “We know solidly from data that fentanyl poses a several-fold higher risk of overdose and that in the event of overdose, it’s more likely to result in death compared to heroin.” The intake of just 2 milligrams of fentanyl can be lethal.

A Chronicle analysis of mortality data from the U.S. Centers for Disease Control Prevention and reports from state and local health departments shows that as fentanyl’s influence grew in San Francisco, especially in the late 2010s, overdose death rates rose above places like Philadelphia, which has been battling the same epidemic, but for longer. Philadelphia, which is both a city and a county, had the highest overdose rate in 2019 for an area with a population over 500,000. San Francisco surpassed it in 2020 with 81 deaths per 100,000 people, compared to Philadelphia’s 77 per 100,000.

Fentanyl’s role in driving the skyrocketing overdose death rates is evident in the numbers: In 2020, San Francisco medical examiner’s office data shows 516 out of 712 total overdose deaths, or 72%, involved fentanyl — in many cases, in combination with several other drugs. From January through May of this year, preliminary data showed the percentage was at about 73%. This is up from just 16% of overdose deaths in 2017.

In Philadelphia, 81% of overdoses involved fentanyl, according to its public health department. Just 34% of overdose deaths in 2020 were related to fentanyl in King County, where Seattle is located, according to the county’s overdose deaths dashboard. But fentanyl’s prevalence in the community appears to be rising. More than half of the 284 confirmed overdose deaths have been attributed to fentanyl-related causes . . . .

The deadly synthetic opioid used to be a mostly East Coast issue, Coffin and other experts said. A 2018 study in the Drug and Alcohol Dependence Journal found that the “28 states east of the Mississippi River accounted for 88% of synthetic opioid overdose deaths.”

In 2019, the most recent year for which comparable data for multiple cities and counties were available, San Francisco stood out as the lone Western community in the top 10 with the highest accidental overdose death rates. This data includes major cities and counties in large central metro areas as defined by the CDC and may exclude some smaller areas, such as Baltimore, with higher death rates.

However, data shows fentanyl is increasingly becoming a problem in the West, and not just in San Francisco. Overdose deaths from fentanyl are also rapidly increasing in Arizona, Los Angeles and Seattle, the Drug and Alcohol Dependence study said.

Still, San Francisco has the highest overdose death rate of all major California counties, and experts say, a higher concentration of fentanyl out in the community. “San Francisco is kind of the bellwether of the West in terms of the introduction of fentanyl,” Coffin said . . . .

. . . in most places across the country, fentanyl’s rise is the result of it being pushed by suppliers, not demanded by users. Suppliers prefer it because of its cheap costs and use it to boost the potency of other drugs or to make counterfeit opioid pills.

But San Francisco is one of the places where there is a specific demand for fentanyl, according to researchers at the UCSF.

https://www.sfchronicle.com/sf/artic...s-16283106.php




Last 2 images: https://www.sfchronicle.com/projects...overdoses-map/

[dktshb]

This probably correlates with the increase in homelessness too. I wonder the percentage of people addicted to Fentanyl laced heroin and meth become homeless?

[Yuri]

What is the main driver to those heavy drugs up there in the US? Recreation, poverty, depression, other mental disorders, what's happening?

[dktshb]

Originally Posted by Yuri

What is the main driver to those heavy drugs up there in the US? Recreation, poverty, depression, other mental disorders, what's happening?

I think it starts off as recreation but fentanyl apparently is extremely addictive, which starts the downward spiral into mental disorders, poverty and homelessness for many without a strong support group, I presume.

[iheartthed]

Originally Posted by dktshb

I think it starts off as recreation but fentanyl apparently is extremely addictive, which starts the downward spiral into mental disorders, poverty and homelessness for many without a strong support group, I presume.

Aren't people who OD on fentanyl actually heroin/opioid addicts? I thought the problem is that people were mostly attempting to get high on heroin/opioids, but end up dying because it is laced with fentanyl, which is far more potent and lethal.

[jd3189]

A good chunk of the people overdosing on fentanyl once had it prescribed to them as pain medication.

[JManc]

Much of the opioid addiction started in pain clinics in the 80's and 90's with physicians prescribing hardcore pain meds like fentanyl and oxycontin for just about anything.

[dktshb]

Originally Posted by iheartthed

Aren't people who OD on fentanyl actually heroin/opioid addicts? I thought the problem is that people were mostly attempting to get high on heroin/opioids, but end up dying because it is laced with fentanyl, which is far more potent and lethal.

That is true. The synthetic is in the heroin and the meth. As I understand it dealers want it in the drugs they sell because it is even more addictive than the heroin and meth without it. The drug addicts may not have initially knew or wanted it in their drugs but eventually seek it out because of how addictive it is. Some actually use test strips to make sure their drug choice contains it.

[Crawford]

SF appears to have not great, but not terrible rates. It has lower rates than Hamilton County, a mostly suburban Ohio county.

You would expect an urban city-county with concentrated homelessness and pathology to have higher rates than a standard middle-American suburban county, but it doesn't.

[Pedestrian]

Originally Posted by JManc

Much of the opioid addiction started in pain clinics in the 80's and 90's with physicians prescribing hardcore pain meds like fentanyl and oxycontin for just about anything.

From 1993 until 2005 I worked in 3 methadone clinics in San Francisco and one in Richmond CA. 2 of the SF ones were in the heart of the area shown on the map above as the concentration of fentanyl deaths--the Tenderloin.

I can't recall ever seeing a patient who had a significant history of getting oxycontin from a legitimate physician. There were a few well-known doctors who would prescribe opiates to anyone and some did seek those out but most bought their drugs on the street and always had. This was before fentanyl became a common street drug--the prevalent opiates were Mexican tar heroin and/or oxycontin.

I too have read about the phenomenon you describe about so many people being on heavy and addictive doses for oxycontin (and other prescription oral opiates of which there are a number) from physicians, a lot of which seemed to describe the situation in the midwest and Appalachia. But I just don't think it was ever that big a phenomenon in most areas of the West Coast (I'm betting maybe it was more common in the Central Valley than on the coast).

I'll also say that legitimate "pain clinics" operate contrary to this phenomenon. The purpose of a legitimate "pain specialist" is to help people find ways to manage chronic pain either non-pharmacologically (everything from acupuncture to dorsal column electronic stimulation) or with minimal doses of opiates. Most people practicing this specialty are trained anesthesiologists and they are very different from the people operating prescription mills.

Originally Posted by iheartthed

Aren't people who OD on fentanyl actually heroin/opioid addicts? I thought the problem is that people were mostly attempting to get high on heroin/opioids, but end up dying because it is laced with fentanyl, which is far more potent and lethal.

As the article I posted above specifically says, in the Bay Area people are intentionally seeking out fentanyl because it's a fantastic "high" if you can avoid ODing. As a substitute for Mexican tar heroin which it has largely replaced, it's also actually less injurious to your body, again as long as you can avoid ODing. The heroin users I used to see all had horrible scarring and infections from the dirty, impure heroin. The fentanyl, at least, is reasonably pure or, at least, has the advantage, I believe, of getting you a satisfactory high without injection. In SF, just walking down the street, much of what I see seems to be smoking it, but you can also snort it or take it orally.

[JManc]

Originally Posted by Pedestrian

From 1993 until 2005 I worked in 3 methadone clinics in San Francisco and one in Richmond CA. 2 of the SF ones were in the heart of the area shown on the map above as the concentration of fentanyl deaths--the Tenderloin.

I can't recall ever seeing a patient who had a significant history of getting oxycontin from a legitimate physician. There were a few well-known doctors who would prescribe opiates to anyone and some did seek those out but most bought their drugs on the street and always had. This was before fentanyl became a common street drug--the prevalent opiates were Mexican tar heroin and/or oxycontin.

I too have read about the phenomenon you describe about so many people being on heavy and addictive doses for oxycontin (and other prescription oral opiates of which there are a number) from physicians, a lot of which seemed to describe the situation in the midwest and Appalachia. But I just don't think it was ever that big a phenomenon in most areas of the West Coast (I'm betting maybe it was more common in the Central Valley than on the coast).

I'll also say that legitimate "pain clinics" operate contrary to this phenomenon. The purpose of a legitimate "pain specialist" is to help people find ways to manage chronic pain either non-pharmacologically (everything from acupuncture to dorsal column electronic stimulation) or with minimal doses of opiates. Most people practicing this specialty are trained anesthesiologists and they are very different from the people operating prescription mills.

SF doesn't strike me as a place Rx companies would set up shop and exploit the local community. It's an affluent cosmopolitan major city (regardless of the homeless population) where most people sit at a desk compared to lower income blue collar towns who work with their hands and are prone to aliments and/or less than stellar lifestyles which make them an easy mark to be taken advantage of.

[austlar1]

Originally Posted by Crawford

SF appears to have not great, but not terrible rates. It has lower rates than Hamilton County, a mostly suburban Ohio county.

You would expect an urban city-county with concentrated homelessness and pathology to have higher rates than a standard middle-American suburban county, but it doesn't.

Cincinnati is located in Hamilton County, and I would imagine most of the Hamilton County drug overdose deaths are located in that city, but it would seem the entire region is being hit hard with opioid related deaths. https://www.wcpo.com/news/local-news...rdose-hot-spot

[Pedestrian]

Originally Posted by JManc

SF doesn't strike me as a place Rx companies would set up shop and exploit the local community. It's an affluent cosmopolitan major city (regardless of the homeless population) where most people sit at a desk compared to lower income blue collar towns who work with their hands and are prone to aliments and/or less than stellar lifestyles which make them an easy mark to be taken advantage of.

I think it's wrong to blame "drug companies". From what I've seen, it was ONE drug company, Purdue Pharma, the maker of Oxycontin, doing most of the damage. The evidence of this, aside from all the inside politics known mostly to doctors (I'll explain in a minute), is that there are lots of orally effective opiates from morphine itself to Dilaudid to Percodan to many others that never became street drugs the way Oxycontin did and some of them are more potent than Oxycontin.

But the main reason I particularly fault Purdue was their very effective lobbying campaign all over the country to convince legislators with no medical training that American doctors were near-universally under-treating pain because they were chary of the addictive potential of opiates. The narrative according to Purdue, that was accepted by certain prominent doctors on the Purdue payroll and transmitted to state legislators all over the country, was that opiates weren't addictive when used to manage real pain and only when abused by addicts without pain and so they could be prescribed widely and in massive amounts to genuine pain victims (or almost anybody claiming to be).

The solution proposed by Purdue was "re-educating" doctors to believe this by forcing them to accumulate "continuing education" credits annually in pain management classes that pushed the Purdue line. California adopted this policy but so did other states.

Here's how one author puts the story:

From 1996 to 2001, Purdue conducted more than 40 national pain-management and speaker-training conferences at resorts in Florida, Arizona, and California. More than 5000 physicians, pharmacists, and nurses attended these all-expenses-paid symposia, where they were recruited and trained for Purdue's national speaker bureau. It is well documented that this type of pharmaceutical company symposium influences physicians’ prescribing, even though the physicians who attend such symposia believe that such enticements do not alter their prescribing patterns.

One of the cornerstones of Purdue's marketing plan was the use of sophisticated marketing data to influence physicians’ prescribing. Drug companies compile prescriber profiles on individual physicians—detailing the prescribing patterns of physicians nationwide—in an effort to influence doctors’ prescribing habits. Through these profiles, a drug company can identify the highest and lowest prescribers of particular drugs in a single zip code, county, state, or the entire country. One of the critical foundations of Purdue's marketing plan for OxyContin was to target the physicians who were the highest prescribers for opioids across the country. The resulting database would help identify physicians with large numbers of chronic-pain patients. Unfortunately, this same database would also identify which physicians were simply the most frequent prescribers of opioids and, in some cases, the least discriminate prescribers.

A lucrative bonus system encouraged sales representatives to increase sales of OxyContin in their territories, resulting in a large number of visits to physicians with high rates of opioid prescriptions, as well as a multifaceted information campaign aimed at them. In 2001, in addition to the average sales representative's annual salary of $55 000, annual bonuses averaged $71 500, with a range of $15 000 to nearly $240 000. Purdue paid $40 million in sales incentive bonuses to its sales representatives that year.

From 1996 to 2000, Purdue increased its internal sales force from 318 sales representatives to 671, and its total physician call list from approximately 33 400 to 44 500 to approximately 70 500 to 94 000 physicians. Through the sales representatives, Purdue used a patient starter coupon program for OxyContin that provided patients with a free limited-time prescription for a 7- to 30-day supply. By 2001, when the program was ended, approximately 34 000 coupons had been redeemed nationally.

The distribution to health care professionals of branded promotional items such as OxyContin fishing hats, stuffed plush toys, and music compact discs (“Get in the Swing With OxyContin”) was unprecedented for a schedule II opioid, according to the Drug Enforcement Administration.

Purdue promoted among primary care physicians a more liberal use of opioids, particularly sustained-release opioids. Primary care physicians began to use more of the increasingly popular OxyContin; by 2003, nearly half of all physicians prescribing OxyContin were primary care physicians. Some experts were concerned that primary care physicians were not sufficiently trained in pain management or addiction issues. Primary care physicians, particularly in a managed care environment of time constraints, also had the least amount of time for evaluation and follow-up of patients with complicated chronic pain.

Purdue “aggressively” promoted the use of opioids for use in the “non-malignant pain market.” A much larger market than that for cancer-related pain, the non–cancer-related pain market constituted 86% of the total opioid market in 1999. Purdue's promotion of OxyContin for the treatment of non–cancer-related pain contributed to a nearly tenfold increase in OxyContin prescriptions for this type of pain, from about 670 000 in 1997 to about 6.2 million in 2002, whereas prescriptions for cancer-related pain increased about fourfold during that same period. Although the science and consensus for the use of opioids in the treatment of acute pain or pain associated with cancer are robust, there is still much controversy in medicine about the use of opioids for chronic non–cancer-related pain, where their risks and benefits are much less clear. Prospective, randomized, controlled trials lasting at least 4 weeks that evaluated the use of opioids for chronic, non–cancer-related pain showed statistically significant but small to modest improvement in pain relief, with no consistent improvement in physical functioning. A recent review of the use of opioids in chronic back pain concluded that opioids may be efficacious for short-term pain relief, but longer-term efficacy ( > 16 weeks) is unclear.

In the long-term use of opioids for chronic non–cancer-related pain, the proven analgesic efficacy must be weighed against the following potential problems and risks: well-known opioid side effects, including respiratory depression, sedation, constipation, and nausea; inconsistent improvement in functioning; opioid-induced hyperalgesia; adverse hormonal and immune effects of long-term opioid treatment; a high incidence of prescription opioid abuse behaviors; and an ill-defined and unclarified risk of iatrogenic addiction.

A consistent feature in the promotion and marketing of OxyContin was a systematic effort to minimize the risk of addiction in the use of opioids for the treatment of chronic non–cancer-related pain. One of the most critical issues regarding the use of opioids in the treatment of chronic non–cancer-related pain is the potential of iatrogenic [doctor-caused] addiction. The lifetime prevalence of addictive disorders has been estimated at 3% to 16% of the general population. However, we lack any large, methodically rigorous prospective study addressing the issue of iatrogenic addiction during long-term opioid use for chronic nonmalignant pain.42

In much of its promotional campaign—in literature and audiotapes for physicians, brochures and videotapes for patients, and its “Partners Against Pain” Web site—Purdue claimed that the risk of addiction from OxyContin was extremely small.

Purdue trained its sales representatives to carry the message that the risk of addiction was “less than one percent.” The company cited studies by Porter and Jick, who found iatrogenic addiction in only 4 of 11,882 patients using opioids and by Perry and Heidrich, who found no addiction among 10,000 burn patients treated with opioids. Both of these studies, although shedding some light on the risk of addiction for acute pain, do not help establish the risk of iatrogenic addiction when opioids are used daily for a prolonged time in treating chronic pain. There are a number of studies, however, that demonstrate that in the treatment of chronic non–cancer-related pain with opioids, there is a high incidence of prescription drug abuse. Prescription drug abuse in a substantial minority of chronic-pain patients has been demonstrated in studies by Fishbain et al. (3%–18% of patients), Hoffman et al. (23%), Kouyanou et al. (12%),55 Chabal et al. (34%), Katz et al. (43%), Reid et al. (24%–31%), and Michna et al. (45%). A recent literature review showed that the prevalence of addiction in patients with long-term opioid treatment for chronic non–cancer-related pain varied from 0% to 50%, depending on the criteria used and the subpopulation studied . . . .

Opioid prescribing has had significant geographical variations. In some areas, such as Maine, West Virginia, eastern Kentucky, southwestern Virginia, and Alabama, from 1998 through 2000, hydrocodone and (non-OxyContin) oxycodone were being prescribed 2.5 to 5.0 times more than the national average. By 2000, these same areas had become high OxyContin-prescribing areas—up to 5 to 6 times higher than the national average in some counties . . . .

The increasing OxyContin abuse problem was an integral part of the escalating national prescription opioid abuse problem. Liberalization of the use of opioids, particularly for the treatment of chronic non–cancer-related pain, increased the availability of all opioids as well as their abuse. Nationwide, from 1997 to 2002, there was a 226%, 73%, and 402% increase in fentanyl, morphine, and oxycodone prescribing, respectively (in grams per 100 000 population). During that same period, the Drug Abuse Warning Network reported that hospital emergency department mentions for fentanyl, morphine, and oxycodone increased 641%, 113%, and 346%, respectively. Among new initiates to illicit drug use in 2005, a total of 2.1 million reported prescription opioids as the first drug they had tried, more than for marijuana and almost equal to the number of new cigarette smokers (2.3 million). Most abusers of prescription opioids get their diverted drugs directly from a doctor's prescription or from the prescriptions of friends and family . . . .

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2622774/

You will note that this extensive review of what happened mentions one and only ONE drug company: Purdue Pharma. And I believe that's correct. I never encountered the kind of misinformation from other companies I did from Purdue nor have I heard stories of other companies lobbying or similar efforts to use the ignorance of bureaucrats to further their greed.

If you Google "CME Pain" (that's Continuing Medical Education) you will still find page after page of courses designed to meet state "pain management" requirements except now that the Purdue-inspired fallacy that we were under-treating pain and needed to be educated to prescribe MORE opiates has been shown to be utterly false, these courses must now undo the damage by trying to educate doctors on the appropriate and inappropriate use of opiates, something that, for the most part, they were doing before Purdue started marketing Oxycontin.

[Buckeye Native 001]

Originally Posted by austlar1

Cincinnati is located in Hamilton County, and I would imagine most of the Hamilton County drug overdose deaths are located in that city, but it would seem the entire region is being hit hard with opioid related deaths. https://www.wcpo.com/news/local-news...rdose-hot-spot

Yup. My cousins all live there and have friends who died from ODs. I was in Ohio, Kentucky and West Virginia a few weeks ago and there's no shortage of horror stories of people losing loved ones to opioids. There's also a shit-ton of billboards advertising opioid addiction assistance throughout the region.

I'm in social services/law enforcement in Northern Arizona. We've had opioid issues, but not nearly to the same extent as Appalachia. For whatever reason, meth is still the drug of choice around these parts.

[LA21st]

Originally Posted by JManc

Much of the opioid addiction started in pain clinics in the 80's and 90's with physicians prescribing hardcore pain meds like fentanyl and oxycontin for just about anything.

Had oxy after a shoulder surgery in 2008. It was incredibly addictive. Scary shit. If that's the feeling of heroin, I totally get why some people do it.

[Pedestrian]

Originally Posted by MF DOOM

To what is this new persona by one of the older participants around here (and I could guess which ones) referring. Each post has a citation.

Attention mods! Multiple registration suspected!

[Pedestrian]

Originally Posted by LA21st

Had oxy after a shoulder surgery in 2008. It was incredibly addictive. Scary shit. If that's the feeling of heroin, I totally get why some people do it.

In the 1990s I had a slipped disk in my back. It was extremely painful--I couldn't do much more than lie flat on my back. I saw a neurosurgeon who prescribed me enough Percocet for a month (and said if I was still in that much pain after a month he would operate). For anyone who doesn't know, Percocet is also oxycodone with acetaminophen (Tylenol) added whereas Oxycontin is an extended-release form of pure oxycodone. Anyway, I knew what taking that stuff for a month would do--addict me for sure. So I never took the first one. Gritted my teeth and endured along with Naprosyn (a non-addictive, non-steroidal pain drug) for the month, then had the surgery which worked very well.

The feeling from opiates is pretty much the same regardless of which one but what addicts are often seeking is the "rush" one gets from using it in a form that sends it into the blood stream in a quick bolus: Either injection or, to a slightly less extent, snorting or smoking it. You don't get that sudden hit so much with pills which is why addicts usually graduate to the other methods. Even if pills is all they can get, they dissolve and inject them.

By the way, I recently had an outpatient procedure for which I was given Fentanyl. I'll testify that's a pretty nice high too (but let your anesthesiologist control the dose).

[edale]

Originally Posted by Crawford

SF appears to have not great, but not terrible rates. It has lower rates than Hamilton County, a mostly suburban Ohio county.

You would expect an urban city-county with concentrated homelessness and pathology to have higher rates than a standard middle-American suburban county, but it doesn't.

That's not really an accurate assessment. Hamilton County is not a mostly suburban county-- it's where Cincinnati is located. There is a lot of poverty both in the city of Cincinnati and in many of its inner suburbs, and Ohio has been the epicenter of the opioids crisis for a while now. Overdoses have been a huge problem there for many years.

All this is to say, Hamilton County, OH is not good company for SF in this metric. In fact, it should be troubling that an insanely wealthy city on the West Coast is just barely better than Hamilton County. And this isn't an issue of numbers distorting reality-- SF and Hamilton County have nearly identical populations (874k for SF, 830k for HamCo). I think this underscores just how huge the homeless problem is in SF. The home of the modern gold rush should not have an opioid overdose crisis akin to a rust belt city on the edge of Appalachia.

[Pedestrian]

Originally Posted by edale

That's not really an accurate assessment. Hamilton County is not a mostly suburban county-- it's where Cincinnati is located. There is a lot of poverty both in the city of Cincinnati and in many of its inner suburbs, and Ohio has been the epicenter of the opioids crisis for a while now. Overdoes have been a huge problem there for many years.

All this is to say, Hamilton County, OH is not good company for SF in this metric. In fact, it should be troubling that an insanely wealthy city on the West Coast is just barely better than Hamilton County. And this isn't an issue of numbers distorting reality-- SF and Hamilton County have nearly identical populations (874k for SF, 830k for HamCo). I think this underscores just how huge the homeless problem is in SF. The home of the modern gold rush should not have an opioid overdose crisis akin to a rust belt city on the edge of Appalachia.

The "insanely wealthy" city of which you speak in part has the problem it has because it pays what some consider insanely good benefits and provides insanely expensive services to the homeless and other poor within its borders. One of the things it offers is walk-in opiate detox. Does Cincinnati? Even single adult males can get a basic "general assistance" monthly check at the highest rate in CA (the rate is determined by counties), but many of the homeless are either vets and eligible for veterans benefits or mentally ill and eligible for SSI or other benefits also. The problem is they may need help knowing what they can get and SF provides that as well with roving outreach workers and regular benefit "fairs" to explain it all and help with applications.

But none of this--totalling over $600 million per year, seems to work. Even offering housing doesn't work because the housing necessarily comes with minimal rules of decorum and behavior that many don't want to abide by. They are so addicted they'd rather lay around on the sidewalk in a tent and "nod" on opiates.

[mrnyc]

Originally Posted by Pedestrian

The "insanely wealthy" city of which you speak in part has the problem it has because it pays what some consider insanely good benefits and provides insanely expensive services to the homeless and other poor within its borders. One of the things it offers is walk-in opiate detox. Does Cincinnati? Even single adult males can get a basic "general assistance" monthly check at the highest rate in CA (the rate is determined by counties), but many of the homeless are either vets and eligible for veterans benefits or mentally ill and eligible for SSI or other benefits also. The problem is they may need help knowing what they can get and SF provides that as well with roving outreach workers and regular benefit "fairs" to explain it all and help with applications.

But none of this--totalling over $600 million per year, seems to work. Even offering housing doesn't work because the housing necessarily comes with minimal rules of decorum and behavior that many don't want to abide by. They are so addicted they'd rather lay around on the sidewalk in a tent and "nod" on opiates.

well by the map above its clear that by far most of the sf opioid od problem is in the notorious tenderloin where the poors are kept and where you would expect it. i would bet its more spread out around hamilton county and that would be tougher to deal with.