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Dope Sick: What Can a City Like San Francisco Do About Its Injection-Drug Problem?

San Francisco is enduring its greatest public health crisis since the height of AIDS. Will we rise to the challenge, or turn away in revulsion?

Heaven and hell in a $10 bag: a tenth of a gram of Mexican black tar heroin, purchased by a user across the street from the San Francisco Public Library.

This story is part of our special report on the private tragedies and public toll of our injection drug epidemic. Read more of "One City, Under the Syringe" here.


Frank ambles across Market Street to the north side, by the BART entrance and the Burger King, across from the main branch of the San Francisco Public Library. A pleasant-looking, nicely dressed Latino man walks up to him. They clasp hands for a fraction of a second. During that brief exchange, Frank hands over a $10 bill and receives a tenth of a gram of Mexican black tar heroin, tightly wrapped in a plastic ball about the size of a pea. “That guy always treats me well,” Frank says as we walk up Grove Street. “He treats me with respect, not like I’m some lowlife.”

Frank is a 38-year-old former glassblower from Milwaukee, Wisconsin, who’s lived on the streets of San Francisco since 2013. He started taking Vicodin pills for carpal tunnel pain when he was about 20 and “didn’t know anything about addiction.” He soon graduated to OxyContin. When that got too expensive, he started snorting heroin. By 24, he was shooting it. He’s been addicted ever since, using three or four times a day—“Breakfast, lunch, and dinner,” he says. 

“There’s an alley here I use a lot,” Frank says, still steering us up Grove toward the Civic Center and bustling Hayes Valley “It’s cool. Even if somebody sees you, nothing happens.” We turn left on Polk, then right on Dr. Tom Waddell Place. He sits down on the sidewalk, shooing some pigeons away, then reaches into his backpack and pulls out a white plastic box the size of a first aid kit, in which he keeps his works. He carefully unwraps the little plastic ball, revealing a small brownish blob. He places the heroin in the cooker, adds some water, and heats it with a lighter until it dissolves. He draws the mixture into a syringe.

Frank takes a broken piece of mirror from the plastic box. Looking intently at himself and blowing out one of his cheeks, he slowly inserts the needle into the left side of his neck, probing for a vein. Because he’s trashed his other veins, he has to shoot in his neck or groin. It’s dangerous work. He moves the needle around, looking for the blood in the syringe that will tell him he’s hit the vein. But he can’t find it. He tries the other side of his neck, again blowing out his cheek and slowly pushing in the needle. As he peers into the mirror, a policeman appears at the end of the alley. Frank pulls the needle out of his neck, quickly puts it into the box, and gets to his feet. We walk to another alley, near Gough. Frank decides to shoot in his groin this time. He spreads his legs, pulls his pants down, and feels for the vein in his groin with his finger. He carefully inserts the needle. Blood appears. “That’s it,” he says. He pushes the plunger in.

Frank pulls his pants back up and puts the syringe back into his kit. There is no obvious change in his face or behavior. Perhaps he looks a little bit more relaxed, but it’s hard to tell. We head back down to the Civic Center. I ask him what he’s going to do now before he crashes out in his sleeping spot over near Octavia. “I’ll walk back over to Octavia, do some panhandling,” he says. Frank won’t steal—it’s a point of pride with him. This shot will last for four or five hours, and he needs more money so he can do it all over again. The dealers, he says, are “open 24-7.” And if he doesn’t score? “I’ll wake up at one in the morning, sick, and I won’t be able to sleep again,” he says. “I’ll cry—not like horrible tears, I just feel terrible.” What about the morning? Does he feel sick then too? “Yeah,” he says. “This is what I have to deal with every day. Every day, I’m sick a lot more than I’m high.”


There are thousands of people like Frank in San Francisco. No one knows just how many; 22,500 is the official estimate, but many think that figure is too high. One expert says 10,000 is a better guess. Dr. Barry Zevin, the medical director of street medicine and shelter health for the San Francisco Department of Public Health, says there are a minimum of 1,000 homeless people who inject heroin and/or methamphetamine. Thousands more users are marginally housed. Close to 3,500 people are in methadone treatment programs, and many others are receiving buprenorphine, the other effective chemical treatment for heroin addiction. Untold numbers are untreated, or have relapsed. And there’s an invisible throng of more stable users whose use is secret.

This army of injection drug users used to be invisible. No more. Thanks to widespread development that has removed hiding places, a rise in the number of the chronically homeless, and perhaps more drug users, people can increasingly be spotted shooting up in public. The Civic Center, in particular, has become an open-air shooting gallery. Used syringes litter the streets. “I’ve lived all over the country, and this city has the biggest public injection scene that I’ve seen,” says Holly Bradford, who heads the San Francisco Drug Users Union, a Tenderloin needle exchange and advocacy group. “I’ve seen it in Cambodia and I’ve seen it in India. But I have not seen another place in America like this.”

Whatever the numbers, San Francisco’s injection drug situation is a full-blown public health crisis, one that every year blights thousands of lives, causes more than 100 overdose deaths, severely taxes our medical, social work, and criminal justice systems, and costs untold millions of dollars. No one can spend time with Frank—a decent, well-intentioned man whose life has been ravaged by addiction—without grasping the human tragedy of drug addiction and the urgent need to fight this problem.  

That’s why San Francisco has undertaken this project—a top-to-bottom examination of the city’s injection drug crisis, from the people battling addiction to the providers trying to help them. We chose to engage in this discussion now because our city stands at an important crossroads in that fight. 

It’s understandable that residents are sick of seeing desperate addicts on our streets, of having to walk past needles and human feces and motionless bodies. But rather than shunning people who use drugs, there’s a movement afoot to turn this crisis into an opportunity. San Franciscans are being urged to overcome their revulsion and educate themselves about the true nature of drug addiction—to see those who inject drugs not as criminals but as people, many of whom suffered abuse as children or became addicted after being prescribed opioids for chronic pain. At the same time, policy makers are increasingly open to innovative methods of treatment—including safe injection sites—that they might never have considered in the past. 

The good news is that the city is already embracing effective, evidence-based methods. Under the umbrella of harm reduction, a nonjudgmental approach that San Francisco was the first city in the country to adopt in 2000, the city employs a host of best practices—from a variety of treatment programs to medical street outreach to needle exchanges to the dissemination of anti-overdose drugs. Some of these programs, in particular needle exchanges, were once highly contentious. But these formerly controversial programs proved to be effective and are now widely accepted. 

Safe injection facilities, where people can inject themselves in sterile environments with trained staff and anti-overdose medicine present and health and counseling services available, may soon be permitted by both city and state legislators. As Lindsey J. Smith reports in “A Safe Place to Shoot Up,” almost 100 safe injection facilities have opened in Europe, Australia, and Canada. All have been outstanding successes.

But even though experts and users support safe injection sites, it won’t be easy for San Francisco to open them. Doing so will mean braving (groundless) claims that such sites enable drug abuse and enduring attacks from moralists who will howl that America’s most notoriously drug-friendly city is back to its overly permissive ways. And it will mean accepting the fact that safe injection sites are not a panacea. The most depressing fact about the disease of addiction is how many sufferers relapse. Dr. Brad Shapiro, medical director of the Opiate Treatment Outpatient Program at Zuckerberg San Francisco General, says that of the homeless or marginally housed patients who successfully exit methadone programs, 40 to 60 percent relapse, according to studies. With patients who have better resources and support, the figure might be half of that. Before or after they relapse, many die—of overdoses, of infections, of myriad physical breakdowns. “This is a really deadly disease,” Shapiro says. “It’s like getting cancer. You have a markedly decreased survival rate if you get this disorder.”

This story doesn’t necessarily have a happy ending. But this is the situation we find ourselves in. And so as the full dimensions of our city’s injection drug crisis come, literally, into view, San Francisco’s character will be tested as it has not been since the AIDS crisis. Thirty years ago, the city overcame its own homophobia, ignorance, and moralism to become the recognized world leader in the war against AIDS. Today it has a chance to do the same thing for an even more stigmatized disease. And to help people like Frank escape the life of sickness and misery that has enslaved them. 


Originally published in the October issue of San Francisco

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