San Francisco's overdose death rate has skyrocketed, but it's not the highest in the U.S.

San Francisco is on track to reduce the number of fatal overdoses this year, marking a promising turnaround in the city's drug epidemic. But progress alone is unlikely to be enough to shake the city's status as the epicenter of the overdose crisis in the United States, cemented by a major spike last year.

San Francisco's overdose rate rose to 88 deaths per 100,000 residents in 2023, up from 73 last year, making the city's overdose rate the fifth-highest of any large county in the U.S. last year, according to newly available full-year data from the U.S. Centers for Disease Control and Prevention.

The increase bucked last year's national trend, with the CDC reporting the first decline in fatal drug overdoses since 2018. The CDC estimates the final tally will be more than 108,000 deaths last year, slightly less than the 111,000 in 2022. Nationally, the fatal overdose rate in 2023 was 31 deaths per 100,000, about a third of San Francisco's figure.

The CDC data for SF are generally less current than the San Francisco Office of the Chief Medical Examiner's numbers, which are generally higher because the health department conducts additional testing to detect overdoses not included in the CDC data. The OCME counted 810 deaths from accidental drug overdoses in 2023, about 100 more than the 713 reported by the CDC.

While the city believes its overall numbers are more reliable, experts say the numbers collected by the federal government are the best available for comparing rates between counties. (For more on the CDC's numbers, see the Chronicle's national overdose tracker.)

Experts are reacting with caution to the decline in overdose deaths in the United States, pointing out that the number is still alarmingly high, especially compared to pre-pandemic numbers, and that it is too early to say whether the decline will continue.

And not everywhere has there been a decline in deaths. In addition to San Francisco, fatal overdoses also rose in Portland's Multnomah County and Seattle's King County. The overdose rate in Baltimore, the highest of any large U.S. county and city, rose again after declining in 2022.

In several counties on the East Coast and in Appalachia that were originally hot spots of the overdose epidemic, fatal overdoses have declined. Marion County (Indianapolis), Shelby County (Memphis) and Philadelphia all saw slight declines in fatal overdoses.

Those numbers could be influenced by different jurisdictions' varying ability to detect and report fatal drug overdoses. Brendan Saloner, a substance use disorder researcher at the Johns Hopkins University School of Public Health, said while optimists might see the data as a sign that the crisis has turned a corner, he believes it's too early to celebrate.

Saloner said the rising numbers of fatal overdoses in West Coast counties are partly due to the growing dominance of fentanyl, a powerful synthetic opioid that is now responsible for the vast majority of overdose deaths. Fentanyl was first prevalent on the East Coast, and overdose deaths only began to rise west of the Mississippi after the substance gained a foothold in counties there several years later.

“San Francisco had the advantage (for a long time) of being insulated from this problem,” said Brendan Solaner. “Now it's hitting us really hard.”

Fentanyl is still the leading cause of overdose deaths in the U.S., but health officials must also contend with a “rapidly changing drug supply,” Saloner said. In East Coast cities like Philadelphia and Pittsburgh, animal tranquilizers like xylazine and medetomidine have contributed to overdose deaths.

San Francisco health officials have stressed the importance of monitoring these substances, even though they have not yet been detected to the extent seen in some other regions. Informing the public about the presence of new drugs is also important to limiting the number of overdoses, Saloner said, as are long-term solutions such as medication-assisted treatments.

San Francisco's overdose epidemic is also exacerbated by the housing crisis, according to Solaner, as people most at risk of a fatal overdose often also struggle to afford basic necessities. Overdoses are a leading cause of death among the homeless, a group that has grown larger in San Francisco over the past decade.

Reach Christian Leonard: [email protected]