It’s 9am in San Francisco’s Tenderloin district and sleeping our bodies line the sidewalks as Felanie Castro units out on her route in Glide Memorial church’s hurt discount van.

Alongside Ellis Road, hungry folks queue up for the church’s each day breakfast of buns, hard-boiled eggs and plastic-wrapped muffins. Down the block, a fireplace division truck, a part of a metropolis response crew, awaits the day’s first drug overdose name.

This neighborhood and the adjoining South of Market (SoMa) district have change into floor zero in an opioid overdose disaster that’s killing 1000’s of California residents, together with many experiencing homelessness. Up to now two years, greater than 1,300 folks have died of overdoses in San Francisco, an increase pushed by the emergence of fentanyl, a super-potent artificial opioid that’s 50 instances stronger than heroin. Practically half of these deaths have occurred in these two hard-hit neighborhoods alone.

Castro and Glide’s hurt discount crew are combating one entrance within the battle to maintain folks alive.

Glide, an almost century-old church, has been advocating for the rights of the poor and disenfranchised communities for the reason that Nineteen Sixties. At the moment the church runs dozens of applications, together with assist for these combating homelessness and habit. Armed with provides resembling clear syringes, glass pipes, alcohol wipes and bottles of water, their crew goals to provide folks the well being instruments to make drug use as protected as attainable, whereas working to construct the belief that drug customers could have to finally search assist.

Among the many strongest instruments of their arsenal are nasal spray bottles of Narcan, every containing 4mg of the life-saving opioid-reversal drug naloxone. Castro says she has already reversed 50 overdoses utilizing Narcan, within the Tenderloin and across the metropolis.

However she will be able to’t save everybody alone. As a part of a broader hurt discount technique, suppliers are providing Narcan at clinics, meal applications and homeless drop-in facilities and distributing it straight into the palms of drug customers and anybody residing round them, growing the possibilities somebody can act.

“The thought is to have Narcan out there in all places,” stated Laura Guzman, a senior director on the Nationwide Hurt Discount Coalition. .

Because the Glide outreach van pulls as much as a group of tarps and tents beneath the shadows of a freeway overpass that morning, Castro and her accomplice, Rizzy Spoer, name out to the occupants, who seem like sleeping inside.

“Hello, sorry to hassle you. We’re from Glide. We now have hurt discount provides and primary wants stuff. Do you want something?”

A bearded younger man in a baseball cap comes out and asks if he can have some “longs” and a few “shorts”, referring to 2 completely different sizes of syringes.

Castro hundreds a paper bag with the provides and provides some water. Then she calls to the soft-spoken younger man as he turns to return to the tent: “And likewise, do you might have any Narcan in there?” The person gratefully takes a single-dose Narcan dispenser wrapped in foil packaging.

A historic neighborhood faces new crises

The Tenderloin, a historic neighborhood within the coronary heart of San Francisco’s downtown, includes roughly 50 sq. blocks, most constructed simply after the 1906 earthquake. Throughout the twentieth century its gently sloping streets and residential accommodations developed a popularity as the town’s seedy underbelly, identified for drug dealing, intercourse work and vice.

At the moment the Tenderloin is grappling with the interlocking crises of homelessness, poverty and habit. It’s residence to tons of of individuals attempting to outlive with out housing, many residing simply steps from glitzy high-rise residences, luxurious model retailers, and the headquarters of tech corporations resembling Twitter and Uber.

Town supervisor Matt Haney, who represents and lives within the district, describes it as a spot of final resort for individuals who have fallen by means of the social security internet.

“The Tenderloin is a spot the place individuals who have been pushed out, stepped on and who’re struggling can discover a residence and refuge,” he stated. “That’s a robust and exquisite factor. It additionally brings with it lots of want.”

In recent times, new forces have intensified these challenges. One is the rise of fentanyl, now the substance of alternative for a lot of illicit drug customers in San Francisco. One other is hovering rents and a statewide housing disaster that consultants say has pushed much more folks on to the streets.

Resolving the scenario has change into one of many metropolis’s most divisive points. Going through mounting strain to behave, San Francisco’s mayor, London Breed, declared a “state of emergency” within the Tenderloin in December 2021 – promising a crackdown on drug sellers, extra interventions for customers and cleaner streets.

The declaration reignited a debate on the coronary heart of drug habit remedy: ought to customers be given “powerful love” and urged to abstain from drug use? Or ought to the town make drug use safer and assist folks rebuild their lives at their very own tempo?

Opinions vary, with some in favor of the abstinence-based strategy, a philosophy typically related to America’s “warfare on medication” period, and a few who need the town to make use of a firmer hand to clear the Tenderloin of seen drug use and encampments.

In distinction, hurt discount advocates say broadly accepted scientific proof reveals this technique is ineffective at decreasing habit in the long run. Along with inserting folks in supportive housing, they imagine the town ought to open supervised areas for folks to make use of medication, to allow them to obtain immediate medical consideration within the case of an overdose. Slowly constructing relationships, they are saying, helps folks get into remedy and in the end heal.

“Hurt discount is type of the flip aspect of criminalizing drug use,” stated Glide Memorial church’s CEO, Karen Hanrahan. “We observe hurt discount to save lots of lives and to scale back illness, but additionally as a result of it builds relationships with individuals who we will then wrap our arms round and assist them by means of a continuum of different providers that they want.”

Hurt discount began as an underground motion distributing clear needles to drug customers in the course of the Aids epidemic of the Nineteen Eighties, stated Dr Daniel Ciccarone, a professor specializing in habit medication on the College of California, San Francisco. The mantra, at a time “when injection drug customers and males who had intercourse with males weren’t solely ignored, however have been vilified”, says Ciccarone, “was assembly folks the place they’re at – not judging them, not disciplining them, not telling them what they wanted to do.”

These rules now type a lot of what we consider as drug remedy, he stated, from the usage of medicines like methadone and buprenorphine to assist wean folks from opioids, to the counseling that helps folks rebuild their sense of dignity. And for the primary time, hurt discount grew to become a part of federal coverage when the Biden administration included it as a pillar of its plan to stem nationwide overdose deaths.

“It began scrappy; it began low-budget and it began underground,” stated Ciccarone, who labored with road activists within the Nineteen Eighties attempting to cease the unfold of Aids. “It has grown to change into legit, accepted, funded and politically accepted.”

‘I’m scared to dying of fentanyl’

Proponents of hurt discount are placing their strategies up towards one of many best exams but as fentanyl floods the US drug market.

In California, the variety of fatalities attributed to fentanyl jumped by greater than 2,100% in 5 years. In San Francisco, overdose deaths hit a brand new excessive of 711 in the course of the first yr of the pandemic, with these experiencing homelessness going through among the highest mortality charges.

Based on Alex Kral, who has been interviewing opioid customers for many years as a part of his work with the non-profit analysis institute RTI Worldwide, many heroin customers have converted to fentanyl – which is being each injected and smoked – as a result of it’s a less expensive and faster excessive. However the drug’s excessive efficiency implies that even longtime opioid customers can shortly go right into a breath-stopping overdose.

That’s made distributing Narcan much more pressing. Whereas there’s no silver bullet for the disaster, consultants say many extra can be dying with out it.

For instance, in 2021, after climbing precipitously for 3 years, the variety of overdose deaths within the metropolis decreased barely to 650, a interval that coincided with Narcan resuscitations ramping up considerably – from 4,300 in 2020 to eight,200 in 2021.

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A number of months in the past, Laurie Rudner, a former Tenderloin resident, noticed for herself simply how briskly fentanyl can take somebody out.

A buddy was sitting in entrance of her in a wheelchair when he took a success of the drug. Virtually immediately, she noticed the drink he was holding drop out of his hand. Happily, Rudner had been given some Narcan. She pulled it out of her bag, and he or she and one other buddy rushed to their fallen companion and squirted the Narcan up his nostril.

An ambulance arrived shortly and administered a number of extra doses of the antidote and, fairly quickly, Rudner’s buddy was respiration once more and on his method to the hospital.

“The principle downside proper now’s fentanyl,” stated Rudner. “There have been like two deaths a day.”

Whereas the drug is killing everybody from Hollywood celebrities to highschool youngsters, it has posed a specific risk to folks experiencing homelessness, driving a doubling of deaths amongst this group in the course of the first yr of the Covid-19 pandemic, based on a UCSF research.

One massive distinction between the late Nineteen Nineties and now, stated Kral, is that again then solely about 30% of all injection drug customers surveyed thought of themselves homeless. At the moment, the determine is 75% to 80%.

He believes the distinction is that a lot of a budget, marginal housing – like $20-a-night accommodations, warehouse areas and deserted buildings – has disappeared and been changed by high-rise condominium buildings fetching prime greenback from tech business workers.

“Folks not have locations to be,” he stated.

Reginald Dillard Sr, 65, says what he sees taking place on the streets now terrifies him. Born in San Francisco, he has lived within the Bay Space his entire life. After his household misplaced their West Oakland residence within the 2008 housing crash, Dillard stated, “I did just a few too many medication and I ended up on the sidewalk.”

Dillard spent years residing on the streets within the Tenderloin earlier than he acquired assist from a metropolis caseworker and, 4 years in the past, moved right into a backed one-room condominium in an previous Tenderloin resort. Now he surveys the road scene round Glide from a distance, trying sharp in a white and blue windbreaker, denims and a baseball cap.

“I’m scared to dying of fentanyl,” he stated. “It don’t take however a match head’s value of that stuff to place you out for good.”

Twenty-nine-year-old Eletise Niumata has skilled these risks first hand. Sitting in a wheelchair just a few blocks from Glide church, she locations pink fentanyl powder on a sq. of tin foil and holds a lighter beneath, inhaling the rising fumes by means of a straw-like tube.

Between puffs, Niumata explains that her title means “electrical energy” in her ancestral homeland of Samoa, a spot she visited twice whereas rising up in San Francisco. In recent times, each she and her youthful sister have confronted homelessness. She’s been attempting to get into housing, however hasn’t managed to but.

Niumata says she’s overdosed and been revived by naloxone two or thrice. With Narcan, “all people can assist out. Should you want some, most likely any individual has it.”

Hurt discount on the frontlines

Not too long ago, the town opened a “linkage heart” within the Tenderloin, offering a spot for these with out housing to get respite and hook up with providers resembling remedy and housing referrals. The middle provides scorching meals, restrooms and showers – and individuals are allowed to make use of medication in a fenced outside space, a choice that not everybody agrees with.

For the reason that linkage heart opened in January, 35 drug overdoses have been caught and reversed with Narcan, based on a press release from the town’s well being division.

Discovering housing for individuals who go to the middle has been a a lot slower course of. Town’s web site reveals that as of 10 April, the linkage heart has acquired 28,984 visits and supplied 1,220 referrals to providers, but the town’s housing knowledge for the mission present solely 99 folks have gotten housing, with one other 71 positioned on a precedence checklist. The linkage heart made a further 366 placements into momentary shelter beds.

In Glide Memorial’s outreach van, Felanie Castro is attempting to make a distinction one go to a time.

The van comes geared up to supply testing for Covid-19, HIV, hepatitis C and quite a lot of sexually transmitted ailments. The crew additionally passes out a lot of bottled water, female provides, snacks, and self-heating meal kits, in varieties like “rotini and kielbasa sausage in a spicy sauce”.

Smoking provides, together with tin foil, straws and glass pipes, are more and more in demand. Distributing the supplies has raised controversy on the federal stage – after conservatives erroneously charged that federal cash was going for use to cross out “crack pipes”.

However no federal funding goes to glass pipes, and Castro dismisses criticism that her work encourages drug use. “We’re not simply right here to provide out stuff,” she stated. “Every little thing we do out right here is public well being. We wish to decrease the obstacles to getting assist. That’s my job: reducing the obstacles to bodily well being or psychological well being.”

As soon as every week, a physician from the town of San Francisco’s road medication crew rides alongside within the hurt discount van and provides medical providers to anybody who needs them. The cellular medical doctors are even capable of begin folks on drug-assisted remedy, a technique favored by hurt discount specialists, that may assist them get off opioids with out the excruciating withdrawal signs.

Frank Vaccari, who now lives in a residence resort within the Tenderloin, credit the earliest type of medication-assisted remedy out there in the US, methadone, with getting him off heroin and off the streets greater than twenty years in the past.

“I couldn’t get off chilly turkey,” he stated “Once I tried, it was horrible. You couldn’t eat. You couldn’t sleep. You’re throwing up. Your eyes are able to come out of your cranium. The bodily results go on for weeks. Then there’s the psychological results.”

Vaccari, 63, goes to the methadone clinic three days every week to choose up his remedy, which comes within the type of a pink syrup, which he stated “tastes nasty, however works actual good” to stave off withdrawals.

Many different folks he is aware of have died of overdoses. In January, Vaccari discovered his youthful brother lifeless of a fentanyl overdose in his personal condominium.

As Vaccari steps out on to the Tenderloin’s Eddy Road in his purple pajama pants to provide his chihuahua, Cleo, a fast stroll, he credit the hurt discount philosophy for retaining him alive.

“Methadone saved my life,” Vaccari stated. “I might have been lifeless years in the past.”