Second in a series about San Francisco’s drug overdose crisis.
“We have to make better and more consequential interventions on the demand side — and yes, that means we have to be arresting drug users.”
— District 6 Supervisor Matt Dorsey
Every time a pedestrian dies in San Francisco, it makes the news — their names, their loved ones, their stories. Organizations like Walk SF hold vigils for the victims, coordinate protests calling for streets to be “calmed” or even closed, and push City Hall to do more. I’ve written about many of these cases, from Mary Fong Lau, who killed a family of four while speeding through West Portal, to Troy McAlister, who mowed down Hanako Abe and Elizabeth Platt in a crosswalk while fleeing police. Between 2020 and 2025, a total of 72 pedestrians died in San Francisco, and every single one is a tragedy.
But the pedestrian deaths pale in comparison to the 4,090 people during those same five years who died of accidental drug overdoses in San Francisco. That’s more than two people per day, and yet you never hear a word on the news about those individuals — their names, their loved ones, their stories. Only one organization, Mothers Against Drug Addiction and Deaths (MADAAD), regularly speaks out about the overdose crisis, holds vigils for the victims, and pushes for City Hall to do more. Over the past two years, the Voice has worked with MADAAD cofounder Gina McDonald on a series about the drug overdose epidemic.
Our first column exposed that the top five providers accounted for nearly 70 percent of drug fatalities inside Permanent Supportive Housing (PSH). When that article ran on Aug. 28, 2025, there had been 3,772 total deaths. As of this second column, total deaths have climbed to 4,090. Shockingly, 959 of those deaths — 23 percent of the total — occurred inside PSH units. Let that sink in. Nearly one in four overdose deaths in San Francisco happens behind closed doors in the very housing meant to help one of the most vulnerable populations.
According to data from the San Francisco Office of the Chief Medical Examiner and analyzed by McDonald and the Voice, the overdose death rate inside PSH stands at a staggering 1,392 per 100,000 residents (based on 11,485 PSH units). That is 17 times higher than San Francisco’s citywide rate of 82 per 100,000 — and a jaw-dropping 60 times higher than the 2024 national rate of 23 per 100,000. One look at the death rate comparison chart tells the brutal truth: the PSH bubble is so enormous it swallows the others. This is not marginal risk. This is mass death concentrated in taxpayer-funded housing.
The concentration is even worse when you drill down. Episcopal Community Services (ECS) alone recorded 190 overdose deaths at their PSH properties. Tenderloin Housing Clinic (THC) recorded 177. Together with Tenderloin Neighborhood Development Corporation (TNDC), a small number of providers are associated with the majority of these fatalities. Specific buildings — Kelly Cullen Community, Rene Cazenave Apartments, Arlington Residence, and others — have become ground zero for preventable tragedy.
This is the deadly legacy of California’s ideological “housing-first” approach, where high-risk individuals are whisked into rooms, handed keys, and allowed to die alone with their fentanyl. Housing-first is meant to be low barrier, but when it comes to drugs, it is no barrier. Substance abuse is not only allowed in PSH units it is actively assisted through the constant distribution of free paraphernalia — from pipes and foil for smoking to syringes and straws for shooting and snorting, respectively — near or even inside the properties. “Housing first, morgue second” isn’t not just a catchy slogan that I made up, it is the grim truth playing out in building after building across the city’s poorest neighborhoods.
Nationally, overdose deaths have been dropping, with experts pointing to the increased use of naloxone (NARCAN) to reverse overdoses to the supply of fentanyl drying up as the current administration targets the illicit drug trade, forcing dealers to sell less of the deadly opioid. In San Francisco, numbers have also declined since the 2023 peak, but the city still has the second-highest rate of fatal overdoses among large county-level U.S. jurisdictions (Baltimore is number one). Even with overdoses going down slightly, the body count inside San Francisco’s PSH has remained stubbornly stable. The administrations of both Mayor London Breed and Mayor Daniel Lurie promised to solve the fentanyl genocide, but they simply warehoused it, and people continue dying behind closed doors at alarming rates.
Dollars and no sense
Between 2020 and 2025, San Francisco allocated approximately $1.5 billion to permanent supportive housing initiatives. This includes $850 million in the 2020–21 budget, $852 million in 2021–22, $713 million in 2023–24, and $677 million in 2024–25. Additionally, the city received $230 million in grants from California’s Project Homekey. Despite that, San Francisco has a death rate 60 times higher than the rest of America.
When we look at the State of California as a whole, $37 billion has been spent on housing and homelessness programs over the past five years, while the homeless population grew from under 49,000 in 2020 to more than 66,000 in 2025.
While fentanyl is a problem in every county in the Bay Area, it is not seen at San Francisco levels anywhere else. For example, Santa Clara County, with a population of 1.9 million — more than double that of San Francisco — had a five-year total of roughly 1,585 overdose fatalities. The main reason for the lower number is a lack of tolerance — both dealers and users are arrested in Santa Clara and other stricter counties. San Francisco has gained a reputation for cheap drugs, generous cash subsidies, and lax enforcement, making it a magnet for fentanyl users across the United States.
San Francisco urgently needs a fundamental course correction: rigorous screening and resident matching, mandatory treatment pathways, onsite medical personnel, 24/7 support staff trained in addiction, and genuine drug-free housing options for those who choose recovery. Officials must stop pretending that providing a key to an addict is sufficient when fentanyl follows them into the room. The overdose death rate chart is damning. The provider bar charts are heartbreaking. The individual facility numbers are unacceptable. For those seeing the despair, it’s infuriating. Meanwhile, Mayor Lurie and the Board of Supervisors continue throwing millions of taxpayer dollars at the same incompetent providers running the very buildings where the majority of overdose deaths occur. That must end.
One thousand deaths inside in six years
Nearly one thousand people have died inside PSH units in just six years. Every additional death is not just a statistic, but preventable failure of policy and total moral negligence. If officials are serious about saving lives, they need to send a message with loud actions rather than hollow words: If you want to get clean and becoming a self-sufficient, functioning member of society there is help for you, but if you want to continue using drugs, you will go to jail. Upon release you will get a bus ticket back to where you came from, along with a stayaway order from San Francisco. Oh, and when you get home, tell your friends.
One potential change on the horizon, though not a panacea, is a new proposal from Supervisor Dorsey that would halt funding for new PSH facilities unwilling to evict residents for drug use. San Francisco currently follows state guidelines, which state that the use of alcohol or drugs can’t be the sole reason for eviction.
“California law requires that the use of illicit drugs on site cannot be grounds for eviction, that addiction is treated as part of people’s lives,” Dorsey, a recovering addict himself, said. “But we have populations that have sensitivities we want to be responsive to. This is just making sure that for those people who want a drug-free residential community, they’ll have an option.”
The ordinance would also require the Department of Homelessness to survey PSH residents, determining their interest in living in either “Drug-Tolerant PSH or Drug-Free PSH.” Dorsey expects that survey to demonstrate a demand for drug-free housing, pointing to a 2024 poll of the city-funded THC in which 71 percent of the 450 residents surveyed said they would prefer to live in a drug-free building. Incidentally, THC had 177 overdose deaths between 2020 and 2025, giving them the grim title of second highest on the PSH provider list.
Gina McDonald, cofounder, Mothers Against Drug Addiction and Deaths contributed to this story.
