For some San Franciscans, the drug crisis is just part of city life. They see people shooting guns in front of their homes and businesses. I often see people falling asleep on sidewalks in high places. In some cases, we may check your pulse. “That’s when I first found the body,” said Adam Mesnick, owner of a local deli.
However, the city’s drug crisis is relatively new. In 2018, San Francisco’s overdose death rate was roughly in line with the national average. Last year’s death rate was more than double the national level.
I recently spent some time in San Francisco to understand what’s going on. In today’s newsletter, I would like to discuss one of the factors that contributed to the urban crisis: culture.
Culture may sound like an abstract concept, but it is important for drug policy. Let’s think about smoking. In 1965, more than 42 percent of American adults smoked cigarettes. In 2021, fewer than 12 percent of people did so. The country did not criminalize tobacco. Although policy changes such as tax increases also played a role, much of the decline was caused by sustained public health campaigns that led most Americans to refuse to smoke.
In San Francisco and other liberal cities, the opposite shift is occurring when it comes to hard drug use. Culture has become more tolerant of people’s drug use. When we asked people living on the streets why they were in San Francisco, the most common answer was that they knew they could avoid the legal and social penalties that come with addiction. Some came from closer to Oakland, believing San Francisco to be more tolerant. Keith Humphreys, a drug policy expert at Stanford University, told me that San Francisco is “on the cusp of a pro-drug culture.”
destigmatizing drug use
San Francisco’s changes are rooted in broader efforts to destigmatize addiction. Some experts and activists argue that a punitive, nonjudgmental approach to drug use, a “love the sinner, hate the sin” attitude, can help people get treatment.
But over time, these efforts in liberal cities have expanded from drug users to drug use itself. Activists in San Francisco are now referring to “bodily autonomy,” arguing that people have the right to put what they choose into their veins and lungs. They no longer desire to hate sin. They say it’s no one’s business but the drug user’s.
As an example of this shift, in early 2020, advocacy groups installed billboards downtown promoting the use of naloxone, an antidote for overdoses. It depicted happy young people enjoying a high together. The sign read, “Be careful not to overdose.” “Take turns with multiple people.” Here, drug use was not dangerous, as long as users had someone to check on them when they were high.
This shift is also being seen among San Francisco’s pharmaceutical service providers. Michael DiCepola, director of medical access for the program GLIDE, said his organization wants to make it safer for people to use drugs. Abstinence, he argued, was not necessarily the right goal. When one client declared he wanted to quit drugs, GLIDE suggested a “more realistic goal,” DiCepola explained.
Stigma without criminalization
The experience of other countries shows that it is possible to relax drug laws without relaxing attitudes, as many liberals hope. In 2000, Portugal removed the threat of prison sentences for drug use. However, the country remains a Catholic-majority, socially conservative country that largely disdains the practice.
Portugal’s system reflects this attitude by encouraging people to stop using drugs. Even harm reduction programs, aimed at keeping people alive rather than getting them off drugs, work with national treatment systems to help people stop using drugs.
In San Francisco, harm reduction programs such as GLIDE do not require staff to refer people to treatment. They argue that such pushiness can scare away customers who aren’t interested in quitting drugs. They often cite the drug policy of British Columbia, a world leader in harm reduction. But British Columbia set a record for overdose deaths last year.
I go into more detail about the differences between San Francisco and Portugal in this new article in the Times’ Upshot section, including a graph comparing overdose death rates across Europe.
Related: Oregon authorities have declared a 90-day state of emergency over fentanyl in Portland as part of an effort to reduce public drug use.
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