‘They’re already on top of s---’: A night with The City’s Tenderloin street-care team

San Francisco Examiner

By Natalia Gurevich | Aug 7, 2024, Updated Aug 9, 2024

Source: https://www.sfexaminer.com/news/health/sf-night-navigation-team-links-opioid-users-to-treatment/article_27329ee2-54fd-11ef-8530-2734893ef23a.html

Each night, a white van carrying a handful of public-health workers pulls up to a Tenderloin street corner at around 7 p.m. Clad in black hoodies and gray hoodies, they emerge wielding clipboards, ready for a long night ahead.

They call out to passersby and walk up to groups posted up on the sidewalk at U.N. Plaza or at Market and McAllister streets, offering to connect people to substance-abuse treatment services and — within the last few months — to arrange remote appointments with doctors who can prescribe opioid-addiction medication.

This is the San Francisco Department of Public Health’s Night Navigation street-care team. The workforce-development nonprofit Code Tenderloin provides staffing, carrying out the agency’s latest pilot program: its Nighttime Telehealth initiative.

Since October 2023, the team has operated from 7 p.m. to 3 a.m. in the Tenderloin, reaching out to bystanders and neighborhood residents to connect them with city services. Since March, Night Navigation staffers have, from 8 p.m. to midnight, connected people who say they want addiction treatment with doctors for telehealth appointments.

The City says workers have, so far, facilitated 920 virtual visits. Eighty-five percent of patients have opted to begin treatment with buprenorphine — a common treatment for opioid-use disorder — and 315 people have picked up prescriptions for the medication. Another 33 people have started methadone treatment, which is only administered through licensed clinics.

San Francisco public-health officials said they’re encouraged by the Night Navigation team and Nighttime Telehealth program’s progress, but the scope of both has been limited so far. The City said it hopes to ultimately expand the programs in order to contend with its ongoing opioid crisis, with San Francisco on pace to record more fatal overdoses this year than all but one since officials started tracking such deaths in 2020: last year, when The City set a record with 810 overdose deaths.

“We know it sounds crazy, but we think it really works ... to actually meet people right at that time and connect them to help versus saying, ‘OK, we’ll get you to a clinic tomorrow,’” Donna Hilliard, the executive director of Code Tenderloin and the Night Navigation team supervisor, told The Examiner. “Everything changes within 24 hours.”

A night with the navigators

Night Navigation team members are primarily people whose lives have previously been affected by drugs or crime.

Fontaine Sherman said he used to sell crack cocaine in another city, allowing him to relate to people he meets in the Tenderloin. He said his daughter is also struggling with addiction to methamphetamines, and he “[tries] to connect with her, too” while she’s going through her experience in San Francisco.

Sherman said the people he encounters are largely looking for “someone to talk to” — but public drug use in San Francisco is not like anything he had previously experienced, he said.

“It’s way faster-paced,” he said. “Fentanyl is totally different.”

Fentanyl has been the primary driver of The City’s deadly drug overdoses, with nearly 72% of the deaths recorded this year attributed to the drug. That’s down from 2023, when almost 81% of San Francisco’s fatal overdoses were attributed to the opioid.

On a recent weeknight in U.N. Plaza, Nelly Pierce said she met lead night navigator Douglas Liu just 20 minutes after she smoked fentanyl. Pierce, seven months pregnant, estimated to The Examiner that she smokes a gram a day.

Liu connected Pierce with a doctor to discuss what medication and treatment would work best for her. She said she had previously been prescribed a buprenorphine treatment containing an overdose-reversal drug that made her feel very ill, preferring methadone but unable to maintain the necessary daily appointments.

“I hate doing dope,” said Pierce, who self-identified as a former heroin user. “But my body needs it.”

Liu said fentanyl users have a maximum of five years until the drug’s harsh qualities “start to break down the body,” leading to persistent body sores and circulation issues. Some patients have required foot amputations to address the latter.

This was a concern of one patient who spoke with Liu, who reported having trouble standing up due to issues with his feet. That patient, Theopolis Tolliver, told The Examiner that he had used fentanyl for around five years now, coming to San Francisco from Santa Rosa to follow the availability of the drug.

Now, at age 40, he said he’s going to try medication treatment.

“I’ve been wanting to do it for a minute now,” Tolliver, a self-identified former heroin user, said. “I’m kind of ready to get on with my life. I’m really far behind.”

If not treatment, shelter

Not everyone the team speaks with says they are ready to get treatment.

Johnathan Evans told The Examiner that he was just looking for a warm place to sleep and some help getting food. He said he continues to use crystal methamphetamine after crushing his foot in a workplace accident.

“[Meth] is the whole reason I’ve been able to get up,” he said, but he also said he smokes weed to help with blood circulation.

“[Meth] helps me maintain,” he said.

Despite his declining an offer of treatment, the team found Evans a bed at a shelter and transported him there. Liu said that’s not an uncommon occurrence.

“People can’t always make rational decisions in all this instability,” he said. “The body’s worn out, nobody can think when a person hasn’t eaten or they haven’t slept.”

After getting some rest and a meal, Liu said, patients are sometimes more inclined to think about their overall health. That, he said, is one of the team’s primary goals.

Others who opt to receive treatment, such as Pierce, are taken to a hotel in the Tenderloin that’s part of the Department of Public Health’s RESTORE program. The site is a noncongregant shelter with 20 beds, where people can stay in their own rooms for up to seven days while they begin taking medication for their opioid addictions. They also meet with a case manager to address other needs.

“Seven days is the length of a microdose of buprenorphine,” said Taylor Cuffaro, a nurse practitioner with San Francisco Community Health Center who works at the site. Oublic-health officials asked The Examiner not to share its location due to concerns about the residents’ privacy.

During that week, Cuffaro said, patients gradually receive more medication each day while weaning themselves off the opioids they’re using.

“At about day six, you’ve stopped entirely the opioid that you’ve been using on the street,” Cuffaro said. “At that point, your body has become accustomed to the buprenorphine in its system, and we’ve got you at a decent steady state of medication.”

During that time, public-health department and Community Health Center nurses are available to help occupants with any potential withdrawal symptoms and other medical concerns. Cuffaro said that often, once patients have a good night’s sleep and are starting on their opioid-treatment medications, they’re able to turn their attention to issues they otherwise might’ve ignored.

“Then they’re like, ‘Oh, my knee,’ or ‘I was supposed to see a nephrologist for my kidney two years ago,’” they said. “We really integrate them back into their primary care in that week.”

If occupants feel that they’re still not ready once they arrive, they can check themselves out before the week is up. Those who complete the full week are then connected to some type of residential-treatment bed, shelter or other housing, usually within 36 hours.

Sometimes people stay longer if they aren’t connected to places that meet their specific needs, such as one resident who Cuffaro said has been at the Tenderloin hotel for nearly a month while awaiting a shelter that will house them, their partner and their service animal.

“We will not kick you out on the street if you want residential treatment, and we’re the ones that don’t have the bed available,” Cuffaro said.

Growing pains

In its first year of operations, the Night Navigation team and its associated programs have clear limitations.

The team has access to one transport van, leading to long wait times for people who’ve decided to accept treatment. The Tenderloin hotel itself has only 20 available beds for occupants transported there by the Night Navigation team. Furthermore, the telehealth program only has one physician on call during a typical night. Officials said the team coordinates around a dozen calls a night, organizing 27 on its most productive one.

There remains a shortage of available shelter and beds citywide. San Francisco has a little more than 2,500 residential treatment beds and about 3,900 shelter beds. It also has an estimated unhoused population of around 8,300 people, of which nearly 4,000 are sheltered. Twenty-three percent of the people who have died of overdoses this year had no fixed addresses, a far higher percentage than unhoused residents represent in San Francisco’s overall population.

The Tenderloin also continues to be the neighborhood in which many of The City’s drug-overdose deaths are occuring. Of the 374 fatal overdoses recorded through June, 229 were located in ZIP codes that are in the neighborhood.

A Department of Public Health spokesperson said officials hope to expand the programs in the neighborhood based on the preliminary success of the first few months. The spokesperson said the department intends to add more treatment beds at more sites, hire additional staff and train additional physicians for the telehealth calls.

Participants in the programs said they’re already making a difference. Pierce, the pregnant mother, said she was looking forward to working with her case manager to restart methadone treatment and regularly visit a doctor.

“They’re already on top of s---,” she said.