A coalition of addiction experts and treatment advocates is commending the San Francisco Department of Public Health for committing some of the $352 million opioid lawsuit settlement funds the city expects to receive over the next 18 years to expanding methadone treatment and addressing racial disparity in fatal overdoses.
“These efforts are instrumental in reaching underserved individuals,” the San Francisco Treatment on Demand Coalition wrote in a November letter to the department.
But the coalition criticized the department over its lack of transparency and community input.
“We are deeply concerned,” stated the letter. “Without transparency and accountability, the opportunity for meaningful change will be lost. A participatory approach is crucial to ensure that resources effectively address the needs of those most affected by the overdose crisis.”
The letter was signed by several organizations that offer services to people who use drugs, including the SF AIDS Foundation, Larkin Street Youth Services, Drug Policy Alliance, Tenderloin Neighborhood Development Corporation, Glide, Taxpayers for Public Safety, and Senior and Disability Action.
Nevertheless, in a response emailed to the Public Press this week, the public health department stated that it conducted community outreach and engaged with organizations that work with people who use drugs, without naming which organizations.
That engagement “resulted in feedback regarding naloxone access and distribution, as well as expansion of and access to treatment,” stated the email.
The John Hopkins Bloomberg School of Public Health in January 2021 issued five principles recommending how opioid litigation funds should be used. The principles were developed by a broad group of physicians, addiction medicine specialists, and recovery, treatment and harm reduction specialists.
One principle urges governments to “develop a fair and transparent process for deciding where to spend the funding” that “should be guided by public health leaders with the active engagement of people and families with lived experience, as well as other key groups.”
In its letter, the local coalition contrasted San Francisco’s alleged inaction with Los Angeles County, which held community listening sessions with local harm reduction providers and their program participants, and made its spending decisions transparent through public records.
San Francisco’s opioid settlement money becomes part of the city’s general fund. Public health and city officials have revealed spending decisions through piecemeal reporting in city documents, public announcements, budget discussions and mandated filings to the state.
Funding priorities
In May 2023, a city lawsuit secured a settlement with drugstore giant Walgreens worth $230 million over 14 years, with the vast majority coming in the first eight years. More than $60 million in opioid settlement funds serves as revenue in the city’s two-year budget, according to the controller’s office. Mayor London Breed’s budget plans allotted $45 million of the funds for initiatives addressing racial disparities in overdose deaths, a 24-hour-a-day telehealth prescription program and Tenderloin outreach “night navigators” to bring people into treatment.
Additionally, more than $121 million in state and federal settlements will go to San Francisco over the next 18 years, according to a dashboard tracking national settlements.
At least 70% of the state and federal settlement money must go to opioid remediation efforts defined in the final agreement as “care, treatment, and other programs and expenditures.” Funding police actions like arresting low-level drug dealers or jailing people with substance use disorders for refusing treatment is prohibited.
According to public health department reports filed with the California Department of Health Care Services in September 2023 and 2024, San Francisco plans to spend an undisclosed portion of the $11 million received so far on three programs.
Funds will go toward naloxone distribution, and overdose prevention and reversal training for tenants living in single room occupancy and permanent supportive housing buildings. A new contract with Delivering Innovation in Supportive Housing — aka DISH — posted on a city government website agrees to provide $2.6 million in opioid settlement money and $1.1 million from the Centers for Disease Control and Prevention over the next five years.
The previous contract with DISH began in February 2021 with services for three supportive housing buildings to address a soaring rate of fatal drug overdoses among residents. The new funding will enable expansion to 12 buildings, according to Mattie Loyce, DISH community development manager. Loyce said the biggest payoff has been the trust and rapport that’s grown between supportive housing residents and its staff.
“Peer networks that are focused on harm reduction in a way that’s supported by staff, that is pretty unique and unheard of,” she said. “Residents are recognizing that staff are actually open to this kind of relationship and open to supporting this kind of conversation and recognize that life is important to save. So, I think that is a really huge gift.”
Funding will also support prevention and education programs at the Homeless Children’s Network, a provider of behavioral health services to Black families in San Francisco. In 2024, from January through November, 589 people died from drug overdoses in San Francisco, a 22% drop from the 760 who died during the same period in 2023 — the worst year for fatal overdoses since record-keeping began in 2020. While the number of deaths declined, the racial disparity stayed the same: Black people make up nearly one-third of fatal overdoses in San Francisco while representing only 5% of the city’s population.
Although the health department report did not include a dollar amount, a December 2023 city press release announced that the Homeless Children’s Network would receive $450,000 annually over five years — totaling $2.25 million — to reduce racial disparities in drug overdose deaths through prevention, engagement and education.
A third plan will enable a partnership with UCSF to provide new methadone services in county jails, at the UCSF Bridge Clinic and out of mobile vans in areas like the Bayview and Sunnydale. Spending details were unavailable.
In addition to these activities, the Treatment on Demand Coalition urged the city to move away from arresting people with substance use disorders, adding that it exacerbates health disparities and disproportionately impacts Black and Brown communities.
The coalition recommended funding measures proposed in the community-involved Overdose Prevention Plan of 2022, which was designed in partnership with harm reduction organizations, treatment providers and affected communities.
“The implementation of this plan should closely follow the community-involved process that initially brought the plan to fruition,” stated the coalition letter.
The group expressed concern that a Behavioral Health Services presentation in September on overdose prevention did not mention overdose prevention centers called “wellness hubs” — a key part of the 2022 plan.
These sites would allow people to consume substances under supervision in case of overdose with opportunities to access detox, treatment and hygiene services, as well as counseling, housing and food.
The updated overdose prevention plan released in December omits wellness hubs while listing goals achieved, including 70 new residential stepdown beds, 40 new beds for Bayview women suffering from substance use and mental health disorders, and a new drop-in space with low-barrier therapy for people experiencing homelessness.
