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San Francisco’s “Pro-Drug Culture”

For some San Franciscans, a drug crisis is just part of city living. They see people shooting up in front of their homes and businesses. They often find someone dozing on a sidewalk, high. Sometimes, they check for a pulse. “That’s how I found my first dead body,” said Adam Mesnick, owner of a local deli.

But the city’s drug crisis is relatively new. In 2018, San Francisco’s overdose death rate roughly matched the national average. Last year, its death rate was more than double the national level.

I recently spent time in San Francisco to understand what is going on. In today’s newsletter, I want to explain one of the factors that has contributed to the city’s crisis: culture.

Culture can sound like an abstract concept, but it matters for drug policy. Consider smoking. In 1965, more than 42 percent of American adults smoked cigarettes. In 2021, less than 12 percent did. The country did not criminalize tobacco. And while policy changes like higher taxes played a role, much of the drop happened through a sustained public health campaign that led most Americans to reject smoking.

In San Francisco and other liberal cities, the opposite shift has happened with hard drug use. The culture has become more tolerant of people using drugs. When I asked people living on the streets why they are in San Francisco, the most common response was that they knew they could avoid the legal and social penalties that often follow addiction. Some came from as close as Oakland, believing that San Francisco was more permissive. As Keith Humphreys, a drug policy expert at Stanford University, told me, San Francisco “is on the extreme of a pro-drug culture.”

San Francisco’s change is rooted in a broader effort to destigmatize addiction. Some experts and activists have argued that a less punitive and judgmental approach to drug use would help users get treatment — a “love the sinner, hate the sin” attitude.

Over time, though, these efforts in liberal cities have expanded from users to drug use itself. Activists in San Francisco now refer to “body autonomy” — arguing that people have the right to put whatever they choose into their veins and lungs. They no longer want to hate the sin. They say it’s no one’s business but the drug user’s.

One example of this shift: In early 2020, an advocacy group put up a billboard downtown to promote the use of naloxone, an overdose antidote. It showed happy young people seeming to enjoy a high together. “Know overdose,” the billboard said. “Use with people and take turns.” Here, drug use wasn’t dangerous as long as users had someone to check on them while high.

The shift is also present in drug-related service providers in San Francisco. Michael Discepola, director of health access at the program GLIDE, said that his organization wants people to use drugs more safely. Abstinence is not always the correct goal, he argued. When one client declared that he wanted to quit drugs, Discepola explained, GLIDE suggested “more realistic goals.”

Other countries’ experiences show it is possible to relax drug laws, as many liberals want to do, without relaxing attitudes. In 2000, Portugal removed the threat of prison time for drug use. But it’s still a predominantly Catholic, socially conservative country that largely looks down on the practice.

Portugal’s system reflects those attitudes by pushing people to stop using drugs. Even its harm-reduction programs, which aim to keep people alive over getting them to quit drugs, work with the country’s treatment system to help people stop using.

In San Francisco, harm-reduction programs such as GLIDE do not require staff to guide people toward treatment. They argue that such pushiness could scare away clients who are not interested in quitting drugs. They often cite the drug policies of British Columbia, a global leader in harm reduction. But British Columbia set a record for overdose death rates last year.

I go into more detail about the differences between San Francisco and Portugal in this new story for The Times’s Upshot section, including a chart that compares overdose death rates across Europe.

Related: Oregon officials declared a 90-day state of emergency over fentanyl in Portland, part of an effort to reduce public drug use.

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