We need a new social contract for fentanyl intervention.

Anthony Bourdain once described San Francisco as a city of sinners: “It’s grimy. You guys have actual street hookers in this center of town. It’s a two-fisted, heavy-drinking, three-martini, big-steaks, heavy-smoking, old-school 20s mentality town.” He admired our appetite for indulgence and freedom. That appetite is still alive, from our thriving music scene to street corners. But fentanyl is not the kind of indulgence a city craves - let alone survives.

Fentanyl is a deadly synthetic opioid up to 50X stronger than heroin per mg. and far easier to smuggle, distribute, and sell. It is highly addictive, highly destructive, and highly profitable. Its presence has created open-air drug markets where dealers operate with impunity, users collapse on sidewalks and streets resemble an open psych ward. 

Drug tolerance has been central to the ethos of San Francisco. We embraced cannabis long before legalization. We’ve woven psychedelics into the DNA of our city’s rich music history. We welcome counterculture, celebrate freedom of choice, and champion harm reduction over punishment. These values are rooted in compassion and skepticism of heavy-handed policing - and these are proud San Francisco values to their core.

But fentanyl has rewritten the rules – and our reflex to tolerate drug use now collides with a crisis killing us by thousands. San Francisco is on track for nearly 700 overdose fatalities this year. The live-and-let-live spirit that defines San Francisco must adapt to an era where fentanyl has made “live” the operative word.

San Francisco struggles to make the distinction between recreational drugs and the reality of the destruction of fentanyl. Our culture of drug tolerance now blurs into enabling. We want to avoid criminalizing addiction, and rightly so. We want people ready to receive help rather than forcing them into treatment. But in practice, this has meant paralysis: an inability to take meaningful action against the fentanyl crisis.

We need a new social contract on drug tolerance in San Francisco. Freedom cannot mean watching people die slowly on our sidewalks. When addiction strips someone of the ability to care for themselves, compassion must mean intervention. For some, that will require conservatorship – the only path to stability when all else has failed. It also means treating jail as an entry point for recovery. With 80% of people entering county jail reporting substance use, we should be building recovery-focused programs inside our jail systems and ensuring continuity of treatment after release. Bottom line: we must use every tool available to pull people back from the brink.

At a Stern Grove concert, I watched friends unpack a picnic basket – baguette, cheeses, bottles of wine. Just as casually and openly, they pulled out psychedelics. It feels harmless to share psychedelics with the wine and cheese. But a few miles away, fentanyl is ravaging families, neighborhoods, and the very soul of this city. We must establish and enforce a distinction between the drug tolerance of non-lethal drugs against the deadly and destructive fentanyl crisis unfolding on our sidewalks. Tolerance without boundaries isn’t compassion – it’s a death sentence occurring before our very eyes.

Lily Ho is an elected member of the San Francisco Democratic Party, and Co-Founder of Drug-Free Sidewalks.