Overdose deaths in San Francisco continue to rise: the Office of the Chief Medical Examiner reported 647 confirmed overdoses in 2022. In the first six months of 2023, OCME reported 406 overdose deaths, putting us on track for a 25% increase over last year. Efforts aimed at decreasing overdose death (increased public awareness campaigns, improved access to free naloxone, a new city department and two programs dedicated towards responding to and preventing overdoses, for example) have been paired with state-sponsored policing campaigns and decreased funding for harm reduction programming all while we lose more and more people to overdose death. What is happening in San Francisco?

Overdose deaths are increasing here mostly because we are not doing the things we know work to prevent overdose:

• providing safe/safer drug use supplies and education,
• ensuring easy access to treatment where people are greeted by kindness not judgment,
• access to safe housing and stable income,
• access to safe consumption sites,
• decriminalizing drug use and removing policing from what people choose to put into their bodies,
• turning our focus and funding efforts instead to providing robust care options for people who use drugs who may, or may not, want to change their drug use,
• and actively welcoming all members of our community by providing spaces of radical inclusion.

HRTC provides compassionate, collaborative, people-focused, integrative mental health and substance use treatment in San Francisco despite current local, and national, challenges. We know that welcoming people IN—regardless of how they come to us—prevents overdose because it builds connection and community. We share our love of this work with all our community partners. We are grateful to be part of the solution.

Patt Denning, PhD & Jeannie Little, LCSW

Co-founders of HRTC

BACKGROUND

After almost a decade of horrific human rights violations in the Philippines that featured the extra-judicial killings of thousands of people who sell and use drugs, harm reduction is finally being promoted under the auspices of the United Nations Joint Programme on Human Rights in the Philippines. Long-advocated for by our dear colleague and fierce harm reduction warrior Inez Feria of NoBox Philippines and increasingly hoped-for by a core group of workers and leaders in the health and legal fields, harm reduction therapy is being piloted for the next year in seven local government regions.

In addition to thousands of murders, the previous presidential administration created a national “list” of people who use drugs. Anyone, absolutely anyone, can put your name on the list by filling out a half-page form accusing you of being a person who uses drugs, a form that includes no request for evidence of the claim. Some people on the list are arrested and charged with a crime. Some are referred for involuntary assessment. Most are forced into 6 months of drug treatment in programs often staffed by at least 50% law enforcement. If clients leave treatment early, they can be jailed. State-sponsored terrorism in the form of surveillance, forced treatment, and punishment are the foundations of treatment in the Philippines. Until now.

After years of waiting with Inez for this to happen, Patt and Jeannie traveled to Manila in May for a week of training. The training was titled Compassionate Pragmatism so that controversies about harm reduction could be avoided. It wasn’t hard to fit all our work under that umbrella. After all, Alan Marlatt characterized harm reduction as compassionate pragmatism back in the 1980’s to combat fierce resistance to it in the US. It’s simple, he said – harm reduction’s attitude is humane, caring and its strategies work. Why would we not embrace it?

Jeannie, Inez & Patt just off the plane

Having the United Nations sponsor this training gave it an international “gold star.” In 2022, the United Nations issued a call for the end to the drug war, and the beginning of health and compassion-related policies and programs. Housing the creation of a new treatment model under the human rights umbrella sends a powerful message that noncoercive and effective treatment is a human rights as well as a health issue.

THE WORKSHOP



The week began with commitments from the Philippine government (with the notable exception of the Dangerous Drugs Board, the equivalent of our DEA) and encouragement from the international community, especially those from Southeast Asia where harm reduction is national health policy. We were surprised and encouraged at the level of enthusiasm and support.

The 60 or so treatment and legal staff in attendance were diverse in their attitudes, with some already well-versed in public health harm reduction interventions and practicing harm reduction underground. Other participants were struggling with old ideas about abstinence-only and forced treatment, having been steeped in 100 years of Drug War prohibition (as are most of us in the United States, where we exported the drug war to the Philippines in the first place!). It was hard for them to imagine trusting people to change without the threat of punishment hanging over their heads.

Small group facilitators prepping for next session

The training group expressing goodwill

The group worked hard to understand and embrace harm reduction. They were particularly impacted by the following concepts:

• Developing a relationship before any change agenda,
• Understanding that being present for treatment does not necessarily indicate readiness,
• Accepting that change is incredibly slow, and needs to be at the right pace for each individual.

For us, highlights of the training included:

• Meeting the person who’s been doing underground needle exchange since 2014,
• The surprising number of people who said that decriminalizing drugs and removing punishment from the equation is the only way to have an effective treatment system,
• Hearing the deputy director of health promise that staff safety when they practice harm reduction is her highest priority (currently, anyone who is accused of assisting people who use drugs can also be charged and jailed),
• Listening to a retired judge share her distress about the number of people she has sentenced to life in prison for their involvement in the drug trade, and her wish to make amends.

UN delegation with the Executive Secretary at the Presidential Palace

On our last day we presented summaries of our model to staff of the department of health and had a very encouraging discussion. Then we were transported to the presidential palace for a series of strategy discussions with the Executive Secretary to the President of the Philippines. The discussions were led by the Regional Director of the UN Office on Drugs and Crime, and the goal of our delegation was to get harm reduction policies that might be supported submitted to the president.

To us workers in the trenches of treatment, the process was painfully tentative, intimidating, and exhausting. And ultimately disappointing - decriminalization was definitely off the table for near future discussions. (There was a hint in a preliminary meeting that the Philippines is waiting until the U.S. is willing to sign onto ending the drug war.) We were excited to take part in this historic shift to compassionate care for people who use drugs and hope to continue to assist the providers by providing monthly clinical consultation.

Join us Friday, October 13th, from 4-9pm at HRTC’s fixed site, 21 Merlin Street, as we strengthen and support each other in our Harm Reduction efforts in San Francisco. Community prevents overdose—and burn-out!—and we’d love to have you join us for an evening of connection and reconnection in hopes of filling our cups a bit. We’ll have refreshments, community drumming, games, prizes and look forward to great conversations with you there!

Maurice Byrd, LMFT

Director of Training & Business Operations

In May 2020 Jason Brown and myself knew we had a unique opportunity when HRTC was asked to provide mental health services at site F (or Pier 94 as we adoringly call it). Only 5.4% of San Francisco’s population is Black and many Black residents call Bayview-Hunters Point (or HP as I called it growing up in San Francisco) home. Pier 94 is situated in the southeast corner of the Bayview-Hunters Point between the train tracks and the ocean. A set of about 200 trailers was set up here by the City of San Francisco as a response to the pandemic and the ensuing lockdown. It was a shelter-in-place location that was unique in a few key ways: it was not a hotel and it was in one of San Francisco’s only historically Black neighborhoods serving primarily Black folx. 

Jason and I offered a unique and non-typical situation as well. We are two Black male therapists that would be setting out to offer mental health services to a mostly Black population. So, feeling deeply honored, we took up the challenge with a sense of purpose. We were immediately, and rightfully so, met with pushback mainly from the staff that was managing the site. This was because we came in offering harm reduction therapy and harm reduction has historically been met with suspicion and/or outright hostility in the Black community. (As Imani Woods wrote in a now-famous article, “You are asking me to rearrange my furniture while the house is burning down.”) We had to assuage any concerns that we were there to give people drugs or encourage drug use. We thought of this as a healthy suspicion of any model that strays from the norm, anyone who may want to come in and “save” the Black community. The historical impacts of things like the Tuskegee experiment have made it necessary for Black folx to be suspicious regardless of who was bringing in harm reduction. We attended to these fears by being honest, direct, and consistent.

Camper-trailers at Pier 94

Maurice and Jason together at a game

Black folx have culturally rejected therapy services for many reasons of self-preservation. Historically, Black folx that have been seen as “crazy” have been punished or even murdered, and the institution of psychology has been outright hostile to Black folx, even creating a mental health disorder called Drapetomania. So we showed up every Friday with our smiling faces, radical hospitality, and our low threshold model. We utilized some of the principles of harm reduction that help to develop quality therapeutic alliances. We treated everyone with dignity and respect, understood that people are not problem people but people with problems, and practiced radical acceptance. The turning point for us was when our clients started to refer to us as “My Therapist.” We understood this to mean that they had accepted us as therapists and were engaged in therapy; an additional honor we continue to experience with the people, and site, of Pier 94.

Thank you so much to everyone who participated in our BOGO sale with Unite to Light. With your help, we received an additional 12 solar chargers and 8 solar lights to give to our clients.

On our wishlist: Clif bars, coloring books, socks, hats, blankets & hygiene kits