As San Francisco’s addiction crisis continues to claim lives, destroy families and communities, and decimate the city’s reputation as a business and tourism destination, the Department of Public Health (SFDPH) has a goal. For 2025, it aims to make 149,171 doses of naloxone available to the city’s population of drug users. That equates to 408 doses per day.
It appears, though, that SFDPH will exceed its target long before the end of the year.
From the three-month period of January to March, the department distributed 55,904 doses of naloxone, pushing the daily average up to 621. At that rate, the medication alone will cost $7,452 every day of the year.*
Did any of the people who overdosed and were administered naloxone quit their habit on their own? What percentage received medical care, entered a recovery program, or left the city? How many overdosed again the next day, week, or month, or died later?
When asked, SFDPH responded that they do not, in fact, track overdose reversals. Who these people are and what happens to them after they receive naloxone is anyone’s guess.
The high cost of free naloxone
Naloxone is used to save a person who has ingested too much of an opioid, such as heroin and its far stronger synthetic cousin, fentanyl, from death. When a person overdoses, the body stops functioning normally, as their respiratory and central nervous systems shut down. Naloxone blocks the effects of opiates on the brain and restores breathing.
Per a study published in Harm Reduction Journal, the vast majority of fentanyl overdoses require two doses at a time.
Where is the money coming from to pay for the overdose medication? The state of California, mainly. Which means taxpayers.
In 2024, Gov. Gavin Newsom announced that the state would purchase CalRex-branded naloxone from New Jersey-based Amneal Pharmaceuticals Inc.
Amneal Pharmaceuticals had recently secured FDA approval for its over-the-counter nasal spray product. For the next 10 years, California will be buying the medication at the wholesale price of $24 per two-pack dose. Walgreens is currently selling the same boxed product for $34.99, so the state receives a slight discount of about $11 for buying in bulk.
Yet the company didn’t grant the special price to California for altruistic reasons. It was forced to discount its product after a lawsuit was filed against it for its role in contributing to the country’s opioid epidemic. Amneal Pharmaceuticals was part of a $273 million multistate settlement for the manufacturer’s alleged failure to report suspicious opioid orders.
San Francisco’s addicts served by pro-drug programs
Certainly there is no shortage of naloxone customers in San Francisco. Over the past five years, the city has become an epicenter of the fentanyl crisis as dealers and users have flooded such areas as the Tenderloin, Civic Center, South of Market, and the Mission District to participate in the trade.
The death toll is staggering. 3,462 people lost their lives to accidental drug overdose in San Francisco between 2020 and 2024, primarily from illegal fentanyl. From January to July 2025, an estimated 358 people have already died, sometimes on the streets but most often, at 74 percent, in their fixed address.
That’s just the fatalities. Far more people are extremely ill and on the precipice of death. As reported by the San Francisco Chronicle, data accumulated by U.C. San Francisco and SFDPH found approximately 37,500 San Franciscans to be currently at risk of overdose due to drug addiction.
Ostensibly as an effort to save people suffering from opioid addiction, the city distributes naloxone to city departments and community-based programs, which in turn supply substance users with the medication. Drug Overdose Prevention and Education (DOPE), run by the National Harm Reduction Coalition, is chief among them.
SFDPH collaborates with and provides funding to DOPE, which claims to be the largest single-city naloxone distribution program in the country. However, DOPE’s business is to teach people how to use drugs and to disburse naloxone, not advance recovery. They are responsible for the “Know Overdose” public awareness campaign, which received widespread condemnation for its posters of happy people on the street using drugs with friends.
SFDPH does not track overdose reversals. Who these people are and what happens to them after they receive naloxone is anyone’s guess.
Another local program that receives and distributes naloxone is the San Francisco AIDS Foundation. Up until recently, they were behind the controversial mobile harm reduction program. Their staff drove vans stocked with a wide spectrum of supplies to ingest such substances as fentanyl and methamphetamine to various locations throughout the city. In lieu of promoting recovery and offering health care, they distributed boxes of naloxone. In the event the person stops breathing, the hope is that a nearby person will notice and take action to administer a life-saving dose.
The embedded profits of the short-term solution
Although naloxone can reverse an overdose, it does nothing for the person’s lasting physical and psychological health. Unlike medically assisted medications such as buprenorphine and methadone, it is not meant to help people overcome addiction but to keep a person alive for that moment. Therefore, it is not uncommon for San Francisco’s drug users who do not receive the proper care to overdose repeatedly. They will then not just need several doses of naloxone at the time of overdose, but constantly over the course of months or years.
Thus, the profitability of naloxone manufacturers and distributors. The more people who continue to use opioids, the more naloxone is needed when they eventually ingest too much. And the more naloxone is required, the more financially secure harm reduction organizations that provide it can become.
As for Amneal Pharmaceuticals, it has a diverse portfolio of products, but has seen significant success in its naloxone business, particularly through the CalRx Naloxone Access Initiative in California. The company has projected a 2025 capacity to produce up to 10 million two-packs of their naloxone nasal spray, indicating a strong demand and potential for substantial future revenue.
The missing steps: treatment and recovery
Frequently missing from the discussion about naloxone is how repeated doses can affect a person’s brain and body. Long-term reactions include increased neuronal damage in asphyxia, altered pain responsiveness, and seizures. For those given high doses, it can also increase sympathetic nervous system activity, resulting in dysrhythmias, hypertension, and pulmonary edema.
Bringing people back from the brink of death is a first step, but by no means the end of the journey, stresses Gina McDonald, cofounder of Mothers Against Addiction and Drug Deaths.
“Naloxone is a critical tool for saving lives in the moment, but it’s not a path to recovery,” says McDonald. “We are pouring millions into keeping people alive without investing enough in the steps – accessible treatment, counseling, and recovery programs. If we stop at naloxone, we’re failing those who need real pathways to healing.”
Real medical care is needed. In 2025, the Centers for Disease Control reported that emergency departments are critical to preventing fentanyl-involved overdoses. In addition to health care professionals introducing prevention strategies, they can link patients to buprenorphine and other medications to offset withdrawal symptoms, then quickly connect the patients to ongoing treatment, with the ultimate goal of recovery.
Battle against radical harm reduction is intensifying
Although giving out reams of free foil for fentanyl use along with endless boxes of naloxone has been standard practice in the city for years, harm reduction programs are now facing increased social backlash and political pressure.
In April 2025, Mayor Daniel Lurie announced an official kibosh on the mobile vans where such drug paraphernalia were to be liberally distributed. Addiction treatment and counseling must also be offered. However, harm reduction activists appear to be circumventing the mayor’s policy changes by operating outside the order. Instead of driving the drug use supplies and naloxone to neighborhoods with a high concentration of dealers and addicts, the San Francisco AIDS Foundation has started camping in nonprofit organizations that have different missions. The community advocate, who goes by the handle JJ Smith on X, found San Francisco AIDS Foundation workers within the boundary of Martin de Porres House of Hospitality, a free restaurant rooted in Catholic doctrine, where they had not been previously. A sign reading, “Start Here! Counseling & Treatment Access Point,” led straight to their table filled with aluminum foil, Meth bubbles, and glass pipes. And naloxone, of course.
As for SFDPH, at this juncture, they still have no stated target for the number of people they want to free from drug addiction. Their goal of distributing 149,171 doses of naloxone to groups that reject recovery, however, will almost certainly be achieved.
* 621 doses per day multiplied by $12 per dose equals $7,452