Among major cities, few have been harder hit by the drug crisis than San Francisco. Drug overdoses have soared in the City by the Bay over the past several years, and public drug use has turned some neighborhoods into near no-go zones. Last week, Mayor London Breed announced a new proposal to bring the drug problem under control: require recipients of county welfare to seek drug treatment.

“No more handouts without accountability,” Breed said at a press conference. “People are not accepting help. Now, it’s time to make sure that we are cutting off resources that continue to allow this behavior.”

Details remain to be ironed out, but under the mayor’s plan, new applicants to the County Adult Assistance Program (CAAP) would get screened for substance use disorders. If diagnosed, recipients would have to enter treatment to receive benefits. Treatment would cover a range of options, “from residential treatment, medical detox, medically assisted to outpatient options.” Participants would not need to be perfectly sober but would have to “try” to stay clean to continue to receive benefits.

Commentators, left and right, were quick to jump on the political significance of Breed’s proposal. Politico’s Dustin Gardiner framed it as a “seismic shift to the right” for the mayor, who faces a tough uphill battle for reelection amid surging overdoses and public disorder.

About 5,200 San Franciscans receive CAAP benefits. Done right, Breed’s approach could do some real good. But the specifics of the program matter.

Clearly, San Francisco needs to do something. From January to August, the city coroner ruled 563 deaths accidental overdoses. The same period last year saw 400; in 2021, the figure was 435. The increase is driven by the arrival of fentanyl on the West Coast, which has driven potency up and prices down. The problem is worsened by San Francisco’s open-air drug markets in its Tenderloin and South of Market neighborhoods, a problem the city is only belatedly working to get under control. It is also driven by drug addiction, which poses a major risk for overdose death.

As I have argued, treating and preventing addiction is the only way to make a real impact on the current crisis. And addiction is a major problem in San Francisco: the San Francisco Health Network reported nearly 12,000 patients with substance use disorders in 2021, only 39 percent of whom received treatment. More than 7,000 of the city’s nearly 19,000 homeless residents reported a substance use disorder as of last year. 

Why aren’t people getting treatment? In part, the problem is one of demand: people often do not want to enter treatment or feel unable to do so. What Breed’s policy will do to demand is likely to be the major point of dispute around it. Proponents will point to people who need to be nudged into services because offering isn’t enough. At the press conference, Breed claimed that “last week alone, 80 people were contacted and touched out on the streets, asked if they wanted services, provided treatment on demand, and only one agreed.” Opponents will argue that attaching drug-testing requirements to services will reduce, not increase, demand, by discouraging people who use drugs from seeking services in the first place, for fear of arrest or other sanction or simply because they do not wish to stop using. And opponents will argue that attaching strings to benefits runs the risk of penalizing those people.

Both arguments may well be true. Some people will not enter treatment unless pushed, and others will avoid service because of treatment requirements. Good program design means minimizing both. 

Breed can mitigate concerns by clear, deliberate messaging about how program participants who get a substance use disorder diagnosis will be treated. The program will also need to identify credible messengers who can assure CAAP recipients that a diagnosis will not mean arrest, and that relapse—which many will experience—will not cost them benefits on which they depend. More generally, individuals in CAAP-facilitated treatment need to be shielded against criminal-justice involvement stemming from their addictions. That will require substantial interagency coordination.

Another concern raised by critics of Breed’s proposal is whether the city has enough treatment beds. Under a 2008 ballot proposition, San Francisco must provide adequate treatment capacity to meet demand. But the city has only about 300 residential treatment and withdrawal beds available, 90 percent of which are usually in use. This doesn’t seem to be a problem currently: the median time to admission into withdrawal-management and opioid-treatment programs is less than one day, and four days for residential treatment. But Breed needs to coordinate with the state (as she’s indicated she will) to ensure that an influx of new demand from CAAP doesn’t swamp the system.

Lastly, the program’s success or failure depends on clear articulations of what “trying” treatment means. Medical detox on its own is not treatment, and individuals who go through it alone may be at heightened risk of overdose (due to reduced tolerance). Breed’s office needs to be clear that the goal is minimizing overdose risk through minimizing harmful consumption. Participants need to meet, and the program needs to facilitate, measurable goals toward that end.

That said, Breed’s approach has potential. One of the challenges with reducing overdose is identifying people at substantial risk. Local-government agencies—police, social workers, hospitals—often know these people, but limited interagency coordination may mean that they get passed around until they die, rather than getting preventative support. Using public-service receipt—a key touchpoint between government and people at risk—as an opportunity for diversion to treatment could save lives and give suffering people the support they need.

Photo by Justin Sullivan/Getty Images


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