San Francisco Substance Use Update, 2019

The Annual David E. Smith, MD Symposium

Tomás J. Aragón, M.D., Dr.P.H.

June 28, 2019, UCSF Mission Bay, San Francisco, California
Health Officer, City & County of San Francisco
Director, Population Health Division (PHD)
San Francisco Department of Public Health
https://taragonmd.github.io/ (GitHub page)

PDF slides produced in Rmarkdown LATEX Beamer—Metropolis theme

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Social determinants

United States

California

San Francisco

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Acknowlegments

• Dr. David E. Smith & Smith Family Foundation

• San Francisco Marin Medical Society
• University of California, San Francisco
• California Association of Alcohol and Drug Program Executives
• California Society of Addiction Medicine
• Drug Policy Alliance and Dr. Marsha Rosenbaum
• Harm Reduction Center, SF AIDS Foundation1
• San Francisco DOPE Project, Harm Reduction Coalition2
• Dr. Nadine Burke Harris, California Surgeon General
• Reverend Charles Grays, Spiritual leader, San Francisco
1
https://www.sfaf.org/locations/harm-reduction-center/
2
https://harmreduction.org/issues/overdose-prevention/dope-sf/
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Social determinants

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Inter-generational, life course roots of health and well-being, 1960s, 2004, 2016

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Physical and behavioral health outcomes with 4 or more ACEs
Bucci et al. Toxic Stress in Children and Adolescents, Advances in Pediatrics. 2016;63:408

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 Social determinants of toxic stress and behavioral health outcomes
Bucci et al. Toxic Stress in Children and Adolescents, Advances in Pediatrics. 2016;63:408
Behavioral health outcomes
• Alcoholism
• Anxiety
• Bipolar disorder
Social determinants
• Depression
1. Structural trauma, • Difficulty controlling anger
discrimination, racism • Hallucinations
• High stress
2. Inter-generational • Panic reactions
transmission • Post-traumatic stress disorder
• Smoking
3. Life course • Substance abuse
neurodevelopment • Suicide
• Bullying
4. Exploitation of
• Dating violence
neuro-vulnerabilities • Delinquent behavior
• Learning difficulties
• Physical fighting
• Weapon-carrying 7
United States

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New York Times, June 2019: Teenage Drug and Alcohol Use Is Falling
Percent of 10th graders who have used various substances in the last year

Zendaya as Rue, left, and Hunter Schafer as Jules, in

the HBO teenage drama “Euphoria.”
Source: New York Times (June 23, 2019).
https://www.nytimes.com/2019/06/23/upshot/
euphoria-hbo-teens-sex-drugs.html 9
New York Times, June 2019: Suicide Among Teenagers Is Rising
Suicides per 100,000 among those 15 to 19 years old

Source: New York Times (June 23, 2019).

https://www.nytimes.com/2019/06/23/upshot/euphoria-hbo-teens-sex-drugs.html

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Depression and anxiety in young adulthood according to cannabis use

Gobbi G et al. Association of Cannabis Use in Adolescence and Risk of Depression, Anxiety, and
Suicidality in Young Adulthood: A Systematic Review and Meta-analysis. JAMA Psychiatry. 2019 Feb
13. doi: 10.1001/jamapsychiatry.2018.4500. PubMed PMID: 30758486. 11
Suicidal ideations and attempts according to cannabis use

Gobbi G et al. Association of Cannabis Use in Adolescence and Risk of Depression, Anxiety, and
Suicidality in Young Adulthood: A Systematic Review and Meta-analysis. JAMA Psychiatry. 2019 Feb
13. doi: 10.1001/jamapsychiatry.2018.4500. PubMed PMID: 30758486. 12
Pain in the Nation: Building a National Resilience Strategy, June 2019
Alcohol and Drug Misuse and Suicide and the Millennial Generation—A Devastating Impact

http://paininthenation.org/
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Alcohol and Drug Misuse and Suicide and the Millennial Generation
Pain in the Nation: Building a National Resilience Strategy (http://paininthenation.org)

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Alcohol and Drug Misuse and Suicide and the Millennial Generation
Pain in the Nation: Building a National Resilience Strategy (http://paininthenation.org)

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Alcohol and Drug Misuse and Suicide and the Millennial Generation
Pain in the Nation: Building a National Resilience Strategy (http://paininthenation.org)

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California

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California Opioid Overdose Surveillance Dashboard
URL: https://discovery.cdph.ca.gov/CDIC/ODdash

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San Francisco

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San Francisco overdose deaths, 2006–2017

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SF Community Health Needs Assessment, 2019 (http://www.sfhip.org/)

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Overdose deaths in San Francisco, 2011-2018
Erin Allday, San Francisco Chronicle, June 23, 2019

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San Francisco Harm Reduction
Harm Reduction Center, SF AIDS Foundation
(https://www.sfaf.org/locations/harm-reduction-center)
SF DOPE Project, Harm Reduction Coalition
(https://harmreduction.org/issues/overdose-prevention/dope-sf)
Charles Hawthorne, Trainer, email: hawthorne@harmreduction.org
OVERDOSE
ADVISORY
San Francisco’s fentanyl supply is
VERY STRONG right now, containing
more fentanyl than we’ve previously
seen in other samples we’ve tested!
In the last week, we’ve seen an increase in overdose, and
10 people have died in from suspected opioid overdose in
San Francisco, almost all inside and alone.
REMEMBER TO BE CAREFUL, USE LESS & SLOW TO
START, TRY NOT TO USE ALONE, AND MAKE SURE
EVERYONE HAS NARCAN!
Fentanyl is a strong synthetic opioid, meaning the margin of error when using is
small. With the supply currently containing MORE fentanyl, that means it’s even
harder to dose. People are overdosing while injecting and smoking, so always
use with caution!
Need Narcan?
Go to any syringe access site (6th Street, Glide, Drug User’s Union, HYA, St. James)
for as many free injectable naloxone kits as you need!
Go to the CBHS Pharmacy at 1380 Howard, Mon - Fri 9am - 3:30pm for a free
training and nasal naloxone kit!
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San Francisco Harm Reduction
Low Barrier Buprenorphine Pilot Program (Dr. Barry Zevin, Street Medicine)
Between Nov, 2016 and Oct, 2017, 95 patients were evaluated and received at least
one prescription for buprenorphine.
(a) 36% of urine toxicology tests were opioid negative
(b) 34% with any F/U has at least one opioid negative test
(c) 14% of those with any F/U had had abstinence from opioids on all tests

Safety First: Real Drug Education for Teens (Dr. Marsha Rosenbaum & DPA)
Honest and accurate information to empower teens to reduce drug-related harms.

Mental Health Reform, Meth Task Force, and safe injection/consumption

(a) Dr. Anton Bland Nigusse, Director, Mental Health Reform
(b) Dr. Grant Colfax, Director of Health, Co-Chair, Methamphetamine TF
(c) AB-362 Controlled substances: Overdose Prevention Program
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Percent of high school students who currently use cannabis, San Francisco
Youth Risk Behavioral Survey, San Francisco Unified School District

50
Black/African American
Chinese
40 Filipino
Latino
Pacific Islander
30
Percent

White

20

10

0
2009−2011 2013−2015
Year
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Cannabis age-adjusted rates (per 10,000), San Francisco, 2006-2015
Cannabis Legalization in San Francisco: A health impact assessment, SFDPH 2017

Hospitalization Emergency department

80 80
Black/African American
Latino
60 60 White

Black/African American
40 Latino 40
White

20 20

0 0

2006−2010 2011−2015 2006−2010 2011−2015

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Reverend Charles Grays
SF Gate (2012): “Preacher delivers weekly bread for the needy”

SF Bayview (2016): Espanola Jackson, Chester Williams, Randolph

James, Charles Grays, and John Smith

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