Manny’s, a civic discussion gathering spot and eatery located in San Francisco’s Mission District, is hosting a series called Understanding Addiction. The first event, held Sept. 2, 2025, was “The Demonization of Harm Reduction.” Joe Eskenazi, Mission Local’s managing editor and columnist, led the hour-long talk between Dr. Daniel Ciccarone and Dr. Nicky Mehtani.
Ciccarone is a professor of family and community medicine at the University of California, San Francisco (UCSF), and Mehtani is an assistant professor in the UCSF Division of General Internal Medicine at San Francisco General Hospital.
After decades of entrenchment, harm reduction methodologies are under intensifying scrutiny and political pressure. Donald Trump has pulled federal funding for drug consumption sites, and the Substance Abuse and Mental Health Services Administration has been forced to retract support for a variety of harm reduction strategies.
Locally, San Francisco Mayor Daniel Lurie has attempted to rein in the more controversial approaches. In April 2025, he launched the Breaking the Cycle initiative to address addiction and homelessness. Per the ordinance, city-funded harm reduction programs must stop distributing drug-use supplies in public. Harm reduction activists who had insisted that encouraging recovery was stigmatizing are now required to offer counseling and connections to treatment before distributing supplies.
In San Francisco, the shift away from harm reduction is driven by increasing anger and declining trust in experts who have failed to deliver results. The squalid and illegal drug scene has continued unabated in many of the city’s neighborhoods.
To date, 3,874 people have lost their lives in the city to overdose since 2020. A July 2025 GrowSF poll found 81 percent of San Francisco respondents said open-air drug use and fentanyl dealing is an “extremely” or a “very serious” problem.
Unable to dispute facts and feelings, people in the harm reduction industry are experiencing rising hostility.
Eskenazi started the discussion by asking the panelists to define harm reduction. According to Mehtani, it is a public health approach that supports dignity and shows people they matter even if they’re using drugs. The intention, she said, is to increase engagement and care, healing, and recovery.
According to Ciccarone, it’s a philosophy born from the HIV/AIDS crisis in the 1980s when, in an effort to stave off blood-borne disease, fresh syringes were given without question or judgment. This is when the “meeting people where they’re at” message began.
Today in San Francisco, the overt misery surrounding drug use is clear, noted Eskenazi, asking how help is measured.
“You have to work in the real world, trying to intervene,” said Ciccarone. “To reduce risk. To do that we really get with the people. ‘What do you like, not like about your drug?’ San Francisco has some unique elements, but a lot of places are going through the same. Homelessness, displacement of the poor, gentrification. There are hundreds of Tenderloins in this country, though San Francisco is a bit worse.”
Eskenazi asked if those involved in harm reduction have a blind spot in the community, to which Ciccarone said yes, to some degree. He explained that they’ve been focused on keeping people alive, not on how society at large has been impacted.
“If we distribute smoking paraphernalia, how does that look?” said Ciccarone.
Mehtani admitted that people in the harm reduction world haven’t listened to the public enough. Because of that, they are now being demonized.
Still, Mehtani insists that harm reduction isn’t causing drug addiction or enabling it. She sympathizes with people wanting to point fingers at harm reduction but doesn’t believe it is to blame. Instead, she cited complex issues such as the housing crisis, income inequality, poverty, the increasing potency of the drug supply, as well as the desire to use drugs to alleviate pain and unaddressed trauma.
And what of the pain and trauma of the nondrug-using community? Ciccarone believes that fixing the open drug scene that has decimated neighborhoods with crime and squalor is not the harm reductionists’ responsibility. “Leaders can get together to focus on public safety and nuisance,” he said. “It bristles me, the us versus them.”
Maybe “harm reduction” has become a toxic term.
Then Eskenazi asked the panelists if they had lost control of the word. Maybe “harm reduction” has become a toxic term.
Without hesitation, Ciccarone agreed. “There’s an ideological shift,” he said, explaining that it evokes the debate over rights. Should people who use drugs on the street have the same rights as other people, he asked but did not answer.
The topic of compelled treatment was next.
An opinion essay in The New York Times had been published the day of the event and made the case for mandated recovery. It was written by Keith Humphreys, a professor of psychiatry at Stanford University and former senior drug policy adviser in the Obama administration.
Mehtani rejected the premise, insisting that mandatory treatment doesn’t work any better than voluntary treatment. “But one article says there is a somewhat better outcome?” she asked. “That’s not good evidence.” She compared it to jail, which she said makes drug use worse.
Ciccarone said he has tremendous respect for Humphreys but also believes mandatory treatment is wrong. “People are frustrated, so we’re grasping at straws now,” he said. “It won’t work. But even if it does, and it’s 15 percent, 25 percent better, he’s not counting on it costing two to six times more than voluntary treatment because the people have to go through the court system first.”
But fentanyl has broken the mold, said Eskenazi, and both panelists agreed. This synthetic opioid is a historic foe — highly potent and addictive — and it keeps killing, said Ciccarone.
Yet despite the continued suffering and deaths, Mehtani maintained that the problem is not about the drug, whatever the substance may be, but something deeper. “What harm reduction does is restore dignity, that you matter,” she said.
The event concluded with a brief overview of the panelists’ thoughts on what would actually work.
Mehtani advocated for “more connection” and psychedelic therapies. Ciccarone promoted the four-pillars approach, which involves the combination of drug use sites, law enforcement, prevention, and treatment. “There should be mild, medium, or heavy handholding,” he said, also saying that curtailing the supply of illegal drugs from China and Mexico may be part of a solution.
Although Mehtani and Ciccarone lamented a negative attitude toward harm reduction, skepticism about its efficacy is deepening. San Franciscans wonder what harm, specifically, is being reduced as the mental and physical health of thousands of drug addicts deteriorates on the city’s stage, for all to see.