The DOPE Project was built on a strong legacy of harm reduction efforts in San Francisco as well as other cities (Santa Cruz, California; Chicago, Illinois), States (New Mexico), and countries (Australia, England, Canada).
In 1993, youth outreach workers in San Francisco first distributed overdose prevention education flyers developed by the Santa Cruz Needle Exchange in California. In 1998, in response to increasing fatal overdoses among young IDUs in the Haight Ashbury district, syringe exchange street outreach workers in San Francisco began conducting monthly overdose prevention trainings targeting young IDUs. Education materials were adapted from materials developed in Santa Cruz, California, Chicago, and Australia–early innovators in overdose prevention. Using supplies from peers in the harm reduction community, street-based syringe exchange workers in San Francisco began incorporating training in naloxone into their monthly overdose trainings for young IDUs.
What began as a community-led response among outreach workers and researchers, soon gained institutional support from local public health and substance use treatment officials.
Research combined with policy advocacy and direct service work made the DOPE Project possible by getting buy-in from the local health department, drug user and HIV researchers, harm reduction organizations, and drug users who utilize those services.
Research played a critical role in building the case for overdose prevention interventions in San Francisco. In the early-1990’s, empirical evidence among HIV and drug use researchers and prevention workers suggested that IDUs, while targeted for HIV prevention, were dying instead of heroin-related overdose. However, little research had been done to assess the incidence of fatal and nonfatal overdose among IDUs in the U.S. Research and pilot overdose prevention projects conducted in San Francisco by the University of California San Francisco (UCSF)’s Urban Health Study throughout the late 1990s and early 2000s were instrumental in demonstrating the need for overdose prevention, the overdose risk experienced by drug users, and the likelihood that overdose prevention interventions could be successfully adopted by drug users.
In July, 1999, the San Francisco Treatment on Demand (TOD) Planning Council tasked a diverse committee with developing recommendations for a response to the city’s “heroin epidemic.” The Heroin Committee comprised researchers, clinicians, drug treatment providers, outreach workers, social service providers, drug users, and others who developed recommendations for addressing heroin-related issues in San Francisco, including overdose prevention. Several of the Heroin Committee’s recommendations were funded and implemented, including citywide overdose awareness campaign. The campaign featured billboards, bus shelter ads, and free, 20-minute phone cards, which were distributed by programs serving injection drug users (IDUs), with pre-recorded messages encouraging users to “fix with a friend.”
As DOPE project founder Rachel McLean noted,
“It’s about being entrepreneurial. You knock on lots of doors and whichever opens, you walk through.”
Rachel had written a school paper on the problem of overdose for a public health class, and then written a follow-up paper describing a programmatic response to the problem, which she summarized in a one pager she gave to the Heroin Committee. Two years later, the public health department had some spend-down money at the end of the fiscal year (as health departments frequently do in June, which can be an excellent source for small and pilot projects), and staff remembered her proposal and asked her to start the overdose prevention project she had recommended.
In December 2001, the TOD planning council allocated $30,000 in city seed funding to establish a comprehensive overdose prevention program to put the committee’s remaining, unfulfilled overdose recommendations into practice.
In January 2002, the DOPE Project began with a team of eight overdose trainers conducting trainings on overdose recognition, management, response, and prevention for program participants and workers of syringe exchange programs, homeless shelters, drop-in centers, drug treatment programs, pretrial diversion programs, and other venues serving people at risk for drug overdose. The curriculum, which was adapted from materials from the Santa Cruz Needle Exchange, Chicago Recovery Alliance, San Francisco Needle Exchange, and other programs, included rescue breathing, safely calling 911, overdose myths and prevention, but did not include naloxone administration. Trainings typically lasted 30-45 minutes for program participants and 1.5 hours for providers.
In 2003, researchers from the Urban Health Study presented the findings of their naloxone pilot study conducted in 2001 to the Director of the San Francisco Department of Public Health (SFDPH). The findings of the naloxone pilot study, along with an article by Scott Burris on exploring the legal implications for physicians of prescribing take-home naloxone to heroin users, proved instrumental SFDPH’s decision to give the green light for a citywide take-home naloxone program in San Francisco.
In late 2003, the DOPE Project began providing naloxone by prescription through this collaboration with Dr. Josh Bamberger, medical director of the SFDPH’s Housing and Urban Health program. DOPE trainers provided the overdose prevention and response education, and the Nurse Practitioner at the site would complete a “clinical registration” form with the person, and sign off on the naloxone prescription.
In June 2005, the DOPE Project became a program of the Harm Reduction Coalition, and in 2010, the city changed its policy to allow DOPE trainers to distribute naloxone directly under a standing order without a medical provider present.