New data reveals how many serious drug users at risk of overdose live in San Francisco

San Francisco Chronicle​

16-05-2025

Kevin Monroe first tried methamphetamine 25 years ago and he's been battling addiction ever since. Over that time, the 47-year-old has been to treatment programs a half-dozen times, secured stable housing at a city-subsidized hotel and achieved several longer stints of sobriety, including 10 years, five years and most recently, a year and a half.
But each time, the pull of meth and crack — both highly addictive stimulants — has proved too strong to shake.
'It's the high, the intensity, that rush you get,' Monroe said before adding that he'd like to return to treatment again soon.
Monroe is one of an estimated 37,500 San Franciscans suffering from drug addiction who are at risk of an overdose, according to a new analysis by UCSF and the Department of Public Health. That figure, which includes people served by the health department and those who have commercial insurance, suggests that most illicit drug users are housed since the city only counts about 8,200 homeless people, a minority of whom report using drugs or alcohol.
While Mayor Daniel Lurie devotes much time and attention to responding to residents' complaints about open drug use among people on the streets, the new analysis also captures people like Monroe, who solely use in their homes but are also in need of support.
'Certainly people experiencing homelessness who have addiction are at very high risk for overdose and other serious health consequences, but that's not the whole story,' said Dr. Hillary Kunins, San Francisco's behavioral health director. 'Not all people who are homeless have addiction, and many people who are housed, unfortunately, also have addiction, and all of that group needs — and can get — treatment.'
Of the estimated 37,500 serious drug users at risk of an overdose, about 15,000 are believed to be served by city's health department, the analysis found. Kunins said the new estimate, which was produced using statistical modeling, will help officials determine unmet need and the various kinds of additional treatment beds and options that should be prioritized.
'This will become another datapoint to think about as we are really trying to aggressively get people into effective treatment and sustained recovery,' she said.
Dr. Paul Wesson, an epidemiologist at UCSF who performed the modeling on behalf of the city, analyzed electronic health records, overdose deaths and nonfatal overdose responses by first responders. The method he used — known as capture-recapture — is commonly used in health care and wildlife research to estimate a population size when it's impossible to count every person or animal.
In this case, Wesson said many people who experience addiction may try to stay under-the-radar because of stigmatization or criminalization, making it difficult to understand the full scale of those at-risk of serious health consequences, including emergency room visits and overdoses.
The last time the city released a similar estimate was around 2017, when the city initially began considering opening a safe injection site for supervised drug use. The Department of Public Health estimated at that time about 22,500 San Franciscans injected drugs, according to a city report. That was before the proliferation of fentanyl caused a spike in fatal overdoses and before smoking became the more popular form of using street drugs.
Overdose deaths nationally, as well as in San Francisco, saw a promising drop in 2024 but they've been back on the rise during the first three months of this year. Black San Franciscans experience fatal overdoses at a vastly disproportionate rate. Homeless advocates have raised concerns that recent enforcement efforts against open-air drug users would lead more people to use indoors alone, raising their risks of overdose.
The new analysis reflects city data on overdose deaths that shows about 3 in 4 people dying of drug overdoses have a fixed address, meaning they are not homeless. A disproportionate number of people die of overdoses in city-funded hotels where the city provides permanent, subsidized housing for people who were formerly homeless. Officials in recent years have implemented new overdose prevention services, including adding naloxone stations at subsidized housing sites citywide and providing overdose response training for residents and staff, but the problem persists.
Ensuring that drug users who are housed receive treatment also could play a key role in preventing further homelessness. A survey of homeless people in San Francisco last year found that 19% of those interviewed said that drug or alcohol use was the primary reason they became homeless.
The Department of Public Health in recent years has increased access to various forms of treatment, including residential treatment, medication-assisted treatment for opioid users and contingency management for stimulant users, but barriers still remain. Despite a 2008 voter mandate to provide immediate treatment to those who seek it, people seeking residential care still face an average wait time of four days, according to a report from the Department of Public Health.
Lurie and the public health department are working to continue to reduce wait times and expand access to treatment with the addition of hundreds of new beds in the coming months, neighborhood-based street outreach teams and more direct counseling and treatment offerings tied to the distribution of smoking supplies.