For people struggling with addiction, keeping them alive, not pressuring them to recover, has been a central tenet of San Francisco’s official policy for years. But as overdoses continue to claim record numbers of lives, Mayor Daniel Lurie and City Hall allies have challenged, even overturned, some of those programs.
Top Lurie deputies doubled down on the administration’s stance last week. At a public forum at UC Law in the Tenderloin, they emphasized that in the era of fentanyl, recovery should be the city’s main focus.
“We really have to think about what is the best, most productive way to get people to break their addiction to fentanyl and be on a path of abstinence,” said Kunal Modi, the city’s chief of health and human services.
For decades, SF has focused on harm reduction, which began with AIDS crisis advocacy in the 1980s. It’s not just a philosophy to “meet drug users where they’re at,” as one advocacy group puts it. It’s a series of practices that include distribution of clean drug-use paraphernalia, a ready supply of overdose reversal medicine Narcan, and housing that doesn’t require sobriety.
But attitudes toward drug use, especially in public spaces, have shifted since the pandemic. There have been nearly 4,000 overdose deaths in SF since 2020. Then-Mayor London Breed said in 2024 that “harm reduction isn’t reducing the harm,” prompting criticism from some health practitioners.
Others, however, have welcomed the scrutiny. One is Keith Humphreys, a Stanford University professor and addiction researcher. He moderated last week’s panel discussion with Modi; SF Department of Public Health director Daniel Tsai; Steve Adami, executive director of The Salvation Army’s ‘Way Out’ initiative; Paula Lum, program director of UCSF’s Primary Care Addiction Medicine Fellowship; and St. Anthony Foundation chief medical officer Terry Osback.
To be clear, Humphreys, who also joined a Sept. 3 Frisc-sponsored discussion on addiction and recovery, has emphasized that some elements of harm reduction, like ready availability of Narcan, have saved numerous lives. But he and others believe fentanyl’s spread requires new strategies.
They got a boost from Sacramento last week. California lawmakers approved a bill, AB 255, to allow some public funds to flow into long-term recovery housing that emphasizes abstinence from drugs and alcohol.
To date, California (and San Francisco) have only funded low-income housing and shelter that offers residents healthcare and other services but does not require sobriety or other conditions to move in. This is a key tenet of harm reduction: People on the streets first need a roof over their heads before they can address substance abuse or other problems, an approach known as “housing first.”
The new bill, authored by Assemblymember Matt Haney, failed to gain traction in 2024 but got the votes it needed this year. Gov. Gavin Newsom has until Oct. 12 to sign it.
Update, 10/3/25: Gov. Gavin Newsom vetoed the bill saying it was “duplicative and costly” and that cities and counties are already allowed to spend state homelessness funds on sober housing. Haney told CalMatters that Newsom’s interpretation “was not the understanding” of housing providers and others.
Lurie’s moves
The Lurie administration’s first legislative push was what the mayor called a “fentanyl state of emergency” bill that gave him more leeway to spend money on crime, homelessness, and mental health services. It passed 10-1 and got Democratic Socialist Sup. Jackie Fielder’s vote even though she called it “an unprecedented transfer of power.”
In March, Lurie announced plans to reform and consolidate street teams working in seven different city departments, from addiction specialists to paramedics to street cleaners. Public health director Tsai said at last week’s forum that the administration needs better coordination between its agencies and services. “It is often incredibly difficult to navigate from one part of our program, right off the street, to the next,” Tsai said.
In April, a 24-7 “stabilization center” on Geary Street opened for people having mental health crises. In the same month, City Hall told health workers and contractors not to distribute drug paraphernalia, such as clean needles and foil for smoking fentanyl, in public. Any other handouts now must come with counseling and treatment referrals.
If Newsom signs the new Haney bill, City Hall will be able to put some money into permanent supportive housing that requires sobriety. Corporation for Supportive Housing director Sharon Rapport, who has opposed the use of public funds for sober housing, told The Frisc last year that “housing first” needs more funding: “We don’t have enough money for the services provided in the housing. It’s not the model that’s the problem, it’s the execution of the model.”
SF has 50 shelters with about 4,000 beds and more than 13,000 units of supportive housing spread across 150 buildings. According to Modi, 26 percent of the OD deaths in 2024 have taken place in permanent supportive housing. A Chronicle investigation found that a high number of deaths occur in city-funded SRO hotels.
The city doesn’t require Haney’s bill to put money into short-term abstinence-based treatment and residences. The Lurie administration is funding three new recovery centers, with 200 spots in all.
A sharp exchange
Critics say that adding conditions when offering help to drug users — whether handouts of smoking kits or housing access — is bad policy. UCSF’s Lum also said last week that recovery doesn’t necessarily mean abstinence. Instead, she asks patients what they need or want, which could include anything from residential drug treatment to clean drug supplies so that they can “use more safely.”
The Salvation Army’s Adami, whose organization is running two of the three new city-funded recovery centers, took exception and responded sharply to Lum: “I just want to ask people in recovery if you can smoke fentanyl safely.”
Lurie’s deputy Modi acknowledged “a lot of nuance” around drug policies, but not with fentanyl: “This is not heroin, this is not prescription opioids, this is 100 times the potency, and every time you’re using fentanyl you’re playing Russian roulette.”
Tension between harm reduction backers and Lurie’s allies has surfaced at various times this year. District 6 Sup. Matt Dorsey, a recovering addict and former police department spokesperson, has pushed to make recovery — or “long-term remission of substance use disorders” — the primary goal of SF’s drug policy. Some staunch harm reductionists saw it as a shot across their bow.
“No one dies from harm reduction,” said Patt Denning, a pioneer of the practice at SF’s Harm Reduction Therapy Center, at an April hearing on Dorsey’s resolution. Denning said the proposal would “scrub harm reduction” from SF public health policy.
It passed, but the resolution language went through revisions at the urging of some health officials. “We as doctors understand the importance of harm reduction and we also support the aspirational goal here of recovery first,” John Maa, former president of the San Francisco Marin Medical Society, said at the hearing.
The Lurie administration and allies have made a case, backed by voters, that SF needs to change practices and attitudes. But in the midst of a budget crunch, they still need to deliver health and homelessness services to prove the change is worthwhile. They’ve already backed away from one big promise: Lurie’s campaign pledge to add 1,500 shelter beds in his first six months.
An exchange during The Frisc’s Sept. 3 discussion encapsulated the complexity of the debate. Del Seymour, nicknamed “The Mayor of the Tenderloin” for his longtime neighborhood presence and advocacy, was homeless and addicted for 18 years before getting sober and starting a nonprofit.
He said it’s not helpful for someone trying to get clean to be around other users. He cited the Tenderloin Linkage Center, set up in 2022 as a place to find treatment and other services but ended up as a supervised drug-use site. (The head of the nonprofit running the site, which closed after 11 months, wrote that it was a success because staff reversed more than 300 overdoses without a single death.)
But Seymour also said barriers to housing aren’t helpful either. “If I’m laying in the street, and there’s a room across the street, and I crawl up there the best I can [and] apply for that room — and they say, ‘This is only for people that don’t use drugs’ — that makes no sense to me,” Seymour said.
Humphreys acknowledged that removing barriers to housing is a “godsend” for some, but SF “needs multiple options” — no easy feat for a city that has struggled with a housing shortage for decades.