As Bay Area mothers of kids who’ve struggled with addiction, including some who are in recovery, incarcerated, homeless, or deceased, we truly appreciate the San Francisco city government’s efforts to find solutions to the addiction crisis.

We follow San Francisco’s addiction crisis closely because it affects our kids and thousands like them, and we worry that the crisis will grow, given trends in homelessness, drug supply, and mental health. Even an affluent and generous city like San Francisco has limits on how much it can spend, and we are eager to see the city embrace practical solutions.

The Budget and Legislative Analyst (BLA) report has some excellent information. We appreciate its analysis of the difficult dilemma about how to address the open drug scenes, which have been the focus of much of our advocacy over the past few years. We also appreciated the report’s highlighting Zurich’s comparatively robust focus on prevention and feel that it’s the most urgent Pillar for San Francisco to implement.

We share the report’s comments about the challenge of getting data from San Francisco’s programs. Simple things like the number of syringes distributed should be much easier to pin down — the report cites San Francisco syringe distribution of 113,000 in the fiscal year 2022–23 fiscal year, whereas public records indicate 3.4 million — and we hope that San Francisco will get a full accounting of its programs.

The report’s analysis on Supervised Consumption Sites (SCSs) is, however, unbalanced and omits material facts, leading to the misguided conclusion that “benefits of a safe consumption site in San Francisco, including lives saved, would outweigh the costs.”

From our perspective, SCSs would provide another signal that San Francisco is a safe haven for illicit drug use. Most of the kids of mothers in our group came to San Francisco from other cities and states to support their addiction, and we suspect they represent a much larger population. In the 2024 homeless Point-in-Time count, 41 percent of the homeless population in San Francisco surveyed said they were not from San Francisco, and 22 percent of respondents said an addiction led to their homelessness. This migration impact places a burden on the city, the frontline workers and the users themselves, who often deteriorate on the streets in spite of all the attempts to help them.

Aside from our personal testimony, the evidence on SCSs is far more extensive than the BLA report shows. Based on the facts we share below, we do not believe that SCSs would reduce drug use from public spaces, save lives, or that the harms outweigh the benefits. We appreciate your willingness to consider these facts in analyzing how SCSs would impact San Francisco.

Context

4 Pillars Table

After citing some of the ways that Zurich is completely different from San Francisco — a culture of prevention, residency requirements, shelter, and housing availability — it’s surprising that the BLA report would build scenarios for SCSs in San Francisco based on Zurich’s experience.

A more contextually relevant analysis of SCSs and the Four Pillars would include the city of Vancouver. Vancouver opened North America’s first SCS in 2003, and its City Council unanimously endorsed a Four Pillars strategy in 2005, providing nearly two decades of fact-base on how effective the strategy has been within its context.

Like San Francisco, and unlike Zurich, Vancouver has a cultural openness around drugs and migration. People who use drugs gravitate to culturally open communities — we know that from our kids, and it’s easy for them to stay if permitted to do so. This is one reason why Vancouver, like San Francisco, has large open drug scenes and tent encampments, even though both cities have laws against them.

These contextual factors also help explain why Vancouver’s commitment to SCSs has not correlated to a reduction in overdose mortality. Indeed, Vancouver has a high concentration of SCS compared to British Columbia and Canada, yet its opioid overdose rate is far higher — nearly four times Canada’s (see table below).

Open drug markets

Comparison of SCS table

Open drug markets, crime and violence can be prevalent around SCSs, and it’s incredibly difficult to manage with law enforcement, especially when SCSs are supposed to be a “health intervention.” The research on SCSs tends to overlook this effect, which is particularly ironic for historically marginalized communities like East Harlem, where the opening of OnPoint SCS was met with community outrage.

These societal issues are real and need to be factored into the total impact of SCSs.

Open drug markets often persist around SCSs (see The Washington Post’s recent article on Portugal) because of a few inherent challenges. One is capacity: if the SCS is full, people may need to consume while waiting in line to prevent withdrawal. Another is drug dealing, which is often tolerated as an expected part of the model. (In East Harlem outside the front door of OnPoint, drug dealers now bring folding chairs and sit all day selling drugs freely.) That makes the neighborhood around the site a destination for anyone wanting to buy drugs including those who have no intention of using the SCS. A third is the immunity shield — there’s little chance police will arrest someone for using or dealing in small quantities around sites sanctioned for drug use, especially if loitering is a norm borne by capacity shortages. These indirect effects help illustrate why SCSs have not been shown to reduce overdose deaths at the population level.

When open drug markets occur around SCSs, neighbors are burdened with a constant threat of drug dealing nearby, an “environmental risk” of addiction to their families. Especially with the prevalence of other risk factors — such as economic stress, mental health issues (even ADHD is a risk for addiction) — adding an environmental risk of drug dealing nearby could have generational consequences for the neighborhood.

While cities like Zurich have ways to minimize this effect, in North America it has been a consistent pattern. This poses a huge dilemma for city planners about where to place the sites — should they be near neighborhoods that are “at risk” or “stable?” In both cases, the surrounding community is at greater risk of addiction due to the presence of drug dealing. See evidence below of public impacts from SCSs:

Harlem

– Violent assaults increased after OnPoint opened (see article).

– Open drug use around OnPoint, in a location that hadn’t had it before, in spite of “good neighbor” policies (see Greater Harlem Coalitions presentation).

– Neighbors have testified about the impact of OnPoint (see article).

– Al Sharpton called OnPoint’s placement in Harlem an example of “systemic racism” (see article).

– The Greater Harlem Coalition found that 75 percent of people using opioid treatment in the vicinity were from somewhere else (see article).

Harlem’s SCS and Vancouver’s Open

Vancouver

– In the 2023 Injecting Hope documentary, people struggling with homelessness and addiction report moving to Vancouver for the community lingering outside the SCS.

– In the Life on East Hastings documentary, open drug scenes persist near Vancouver’s SCSs six months after British Columbia re-criminalized open drug use in May 2024.

Toronto

– Toronto’s reported assault were 113 percent higher and robbery was 97 percent higher in neighborhoods near SCSs in 2023 (see article).

– Ontario confirmed in January 2025 that all government funded SCSs will be closing or converting into treatment centers (see article).

San Francisco

– Police incidents more than doubled in the immediate vicinity of the Tenderloin Center (TLC) (see graph).

– San Francisco’s proposed SCSs are easily accessible from public transportation and highways, and near neighborhoods and schools (see maps below).

Proposed Gubbio

Proposed 822

Capacity

As the BLA report notes, fentanyl (which is not yet prevalent in Zurich) is consumed every 1.5–2 hours (3–4 times more frequently than heroin) posing a greater challenge to having enough capacity to meaningfully reduce public consumption. Even if we assume that SCSs in San Francisco would only be used by the 3,600 people who are experiencing homelessness with a diagnosed opioid addiction (see BLA report page 105), one 40-seat SCS (the largest sized SCS in the BLA projection) would accommodate only 1 percent of that very specific target population. On this basis, San Francisco would need dozens of sites to meaningfully reduce public consumption.

Vancouver shows the challenge of capacity. After opening the first SCS in North America in 2003, today Vancouver has nine sites, which, based on the city’s population, would be the equivalent of 11 sites in San Francisco, and still Vancouver’s open drug scenes and tent encampments persist.

Mortality

The BLA report does not address the impact of SCSs on mortality sufficiently. Two major reviews of SCS literature — Rand’s 2018 systematic review of SCSs, “Assessing the Evidence on Supervised Drug Consumption Sites,” and the 2021 ICER study, “Supervised Injection Facilities and Other Supervised Consumption Sites: Effectiveness and Value” cited in the BLA report — find just three studies that make a credible attempt to show reduction in mortality, but each one of them is limited by the challenge of isolating other variables, such as changes in drug supply, policing, and Naloxone distribution programs. That is what led the Stanford–Lancet Commission on the Opioid Crisis in North America to conclude in a 2022 report: “There is no evidence that accessing a [supervised consumption] site lowers an individual’s risk of fatal overdose over time, or that sites lower community overdose rates.”

In fact, in both the Rand and ICER reviews, the study linking SCSs to reduction in overdose mortality considered the most reliable, Reduction in overdose mortality after the opening of North America’s first medically supervised safer injecting facility: a retrospective population-based study published in 2012 in The Lancet and referenced in the BLA report, was criticized by researchers from Australia, California, and Canada, in a subsequent Lancet article, Overdose deaths and Vancouver’s supervised injection facility,

for having “serious errors” including ignoring confounding effects such as the trend of declines in overdose deaths preceding the opening of Insite, reduction in heroin supply, increased policing around the site, and displacement of drug users to other areas of Vancouver.

Moreover, if Insite did have a positive effect, the question is why, after opening eight more SCSs, Vancouver has not achieved a reduction in overdose rate relative to the province or country. In fact, Vancouver has been more vulnerable to overdose risk as seen in recent overdose spikes. As the British Columbia’s Coroner’s Service noted of 2023, while “no area of B.C. was spared the devastation caused by toxic drugs in 2023, [t]he Vancouver-Centre North local health area, which includes Vancouver’s Downtown Eastside, reported a rate of death more than 12 times greater than the provincial average.”

Toronto, which opened nine SCSs between 2017–19, offers a more recent example. A 2024 study, “Overdose mortality incidence and supervised consumption services in Toronto, Canada: an ecological study and spatial analysis” was conducted between May 1, 2017 and Dec. 31, 2019 and found a significant reduction in mortality around the SCSs. Yet the authors also point out that the effect can’t be separated from the simultaneous Naloxone distribution in the SCS communities. If the SCSs did have a positive impact, it didn’t last — by 2020, Toronto’s overdose rates were significantly higher than Ontario’s. (Furthermore, crime was so rampant that the government announced it is shutting them all down.) Toronto’s experience underscores the Stanford-Lancet statement once again, that SCSs have not been shown to reduce overdose deaths at the population level (see graph).

This appears to be playing out in East Harlem as well. East Harlem has seen an increase in overdose deaths since OnPoint opened, and the rate of increase is faster than Central Harlem’s and New York City’s. (Graph courtesy of the Greater Harlem Coalition.)

In San Francisco, there’s much debate about the impact of the TLC, which was active from Jan. 22, 2022 through Dec. 04, 2022. Some have said that the TLC led to a decline in overdose deaths. The data suggest otherwise.

San Francisco’s overdose deaths had been declining for nine months prior to the opening of the ICER, driven by a massive Naloxone distribution program that started in January 2021. Once the Tenderloin Center (TLC) opened, the city’s overdose deaths plateaued and then started to rise again (see graph).

While TLC proponents point to the number of overdoses reversed in the TLC, compared to other programs the impact was small — roughly 5 percent of the total reversed in the city during that time. Also, there’s the question of whether SCSs are a bridge to treatment or a crutch to delay it. During the TLC’s operation, treatment declined across most modalities (see graph),

and it’s possible that the decline in treatment led to more overdose deaths.

After the TLC closed, San Francisco’s overdose deaths continued to spike up, leading proponents to say it was due to the TLC’s closing. But the spike was similar to other West Coast hotspots (see graph), suggesting that there may have been a change in the drug supply that affected users throughout the region.

Clearly there are vocal advocates pushing for SCSs in San Francisco, but the evidence shows they would do more harm than good. Instead of pursuing SCSs, let’s use this moment to create a truly visionary new model that uplifts rather than poisons its neediest.

Jacqui Berlinn is a Bay Area mother of Corey, an unsheltered resident in San Francisco; Gina McDonald is Bay Area mother of a Sam, in recovery after surviving on the streets of San Francisco; Tanya Tilghman, is a San Francisco mother of Roman, currently incarcerated in San Francisco after relapsing; Ellen Grantz, San Francisco mother of two teenagers in San Francisco public schools; Liz Breuilly, is a Bay Area homeless outreach and missing persons search specialist.

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