It's not yet clear if the small decline in deaths — about 60 fewer in 2021 than 2020 — is proof that the city's various response programs are making a dent.
"I think this was a rapid period of learning and growth for everyone in health," said Dr. Hillary Kunins, the city's director of Behavioral Health Services. "The city is responding to the overdose increases with expansion and intensification of what we believe scientifically works, as well as putting into place some new initiatives," she added.
Among the significant realizations was just how much isolation and distancing affects the risks of overdose. From March 2020 to February 2021, when the most restrictive stay-at-home rules were in place, the city averaged about 64 overdoses per month. From March to December 2021, that number dropped to 51.
The U.S. overall and California also saw a spike in deaths during the height of the pandemic, according to provisional data from the U.S. Centers for Disease Control and Prevention. But state and national level data aren't as current, so it's difficult to gauge how exactly they compare.
During the height of the pandemic, many treatment facilities and other service providers that help people with drug use disorders had reduced hours or shut down altogether, which research corroborates as having increased overdose risk.
A survey of California substance use treatment providers by UCLA and nonprofit researchers showed that more than half of the 133 providers that responded to the survey reported a decrease in the number of patients in the months following the March 2020 stay-at-home order. Nearly 60 percent of providers also reported that more patients were relapsing.
Among the facilities that said they lost patients, the average percent decrease was highest among pregnant women patients, followed by those who are involved in the criminal justice system, such as people who are in treatment as part of a court order in a criminal case.
More than 80 percent of survey respondents also reported that telemedicine use has increased since the stay-at-home order.
Kunins said many providers changed during the pandemic to create services to adapt to pandemic-era rules and limit in-person interactions. In many cases, that has meant services, including counseling and in some cases, prescribing medication, transitioned online. Methadone therapy has also become more flexible, requiring patients to show up in-person less.
"The behavioral health sector really aimed to preserve services in every way possible," she said. "The enormity of doing that as quickly as we and folks nationally did is unbelievable."
Examining the pandemic's impact on overdose mortality accelerated experts' understanding of the epidemic and forced changes in how people access care, including by moving services online. The lessons learned during the pandemic are helping the city and others reach more people who are at risk of overdose, the behavioral health director said.
The city expanded and intensified naloxone and fentanyl test strip distribution programs during this time, as well as engaging with more community organizations to deliver overdose prevention education. It established entirely new intervention programs, such as the Street Overdose Response Team that delivers care right on the streets where many people are at risk. "All of this began to happen in this period and will continue to happen again," she added.
The pandemic and its side effects, of course, were not the sole reason for the spike in overdose deaths in San Francisco, Kunins said. Mortality was already on an upswing, powered by the increasing influence of the synthetic opioid fentanyl, which is said to be about 50 times more potent than heroin, in the late 2010s.
"We see a steep increase starting in late 2018 and 2019. COVID happens, stay-at-home orders happen," she said. "Then we see another very steep increase up to the 700s, a shocking increase."
The overdose epidemic is still very much ongoing and its consequences will outlast the threats posed by the COVID-19 pandemic, she said. "As a society, as a city, we've gone through loss and grief and the consequences of physical isolation, and those are issues that don't just evaporate once the physical risk is over."
"I certainly hope fervently that we will continue to see numbers go down," Kunin said. "We are treating this as an emergency and as a crisis and doing all that we can to both intensify efforts that we believe are effective and to implement new efforts."
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