Evaluating New Drug Policy Legislation
Substance use can be a coping mechanism, a way to self-medicate to soothe mental health symptoms, a means to dull pain, or to drown out recurring traumatic events. According to the 2022 Point-in-Time (PIT) Count, a small minority—about 12%—of unhoused people reported that substance use disorder led to their homelessness. For many more, substance use disorders developed when they became homeless, bringing health and socio-economic consequences.
There has been a strange debate brewing of late, pitting harm reduction against abstinence. It is strange because it has been recognized for decades that harm-reduction principles are a more effective means of achieving health goals for those with substance use disorders, and because harm reduction includes abstinence approaches.
In the Revolving Door study published by the Coalition on Homelessness, unhoused people reported a variety of ideas about the effectiveness or preferability of harm reduction versus abstinence-only treatment programs. Some find abstinence-only programs work for them, while others are more able to meet their health goals through harm reduction. In other words, a diversity of approaches is needed, which in itself is a core tenet of harm reduction. One size certainly does not fit all when it comes to individual relationships to drug use.
Last month Supervisors Matt Dorsey, Rafael Mandleman and Catherine Stefani introduced legislation to the Board of Supervisors proposing a citywide strategy to address substance use disorders and their impact on the community. The proposal—entitled San Francisco Recovers—aims to criminalize drug dealing, gives instructions to 12 different departments and six commissions on how to address substance use disorders, and redirects funds from opioid settlements to drug abatement. Like so many drug policies before it, this proposal relies too heavily on punishment while struggling to embrace the more visionary public health goals of harm reduction.
SAN FRANCISCO HAS A HARM REDUCTION POLICY
In order for us to dig into this legislation, it is important first to establish what our existing policy is in San Francisco and how we got here. Historically, recovery programs focused on abstinence, and many used shaming strategies to address substance use. While many of these programs have ended or evolved, a few privately funded “social model” recovery programs still exist in San Francisco. These programs focus on peer-to-peer interactions, where the drug user is held accountable to the impact their addictions have on their families and their communities. For some people, this form of recovery has worked, but for others—especially those from abusive backgrounds—this model has caused or exacerbated harm.
Before the 1990s, few treatment programs were trauma-informed, and for many people they simply didn’t work, or created more harm. Relapse was common. Disconnection from family and pre-existing support systems was encouraged. Those who relapsed were kicked to the curb, just as their need for treatment peaked. Many could not access treatment because it required them to quit using altogether; those unwilling to do so were excluded from support in addressing their disorder.
This all changed in the late 1990s with the popularization of harm reduction, a framework that focuses on improving health outcomes for people who use drugs and emphasizes working with people without judgment or coercion, and without requiring that they stop using drugs as a precondition of support. In the year 2000, San Francisco adopted a harm reduction policy, which continues to reflect best practices.
Many substance use programs are based on either harm reduction or abstinence-only philosophies. All licensed treatment programs are abstinence-based—you cannot use illegal drugs per state licensing restrictions. However, individuals are allowed to receive medical treatment that may involve the prescription of drugs often referred to as medically assisted treatment, such as methadone.
Harm reduction involves an approach that focuses on a range of personal goals and allows participants who are active users to obtain treatment. This can include abstinence, but also includes approaches like methadone, resources like syringe exchange or free condoms, as well as therapeutic approaches to group or individualized treatment where abstinence is not the only goal.
WHAT IS “SAN FRANCISCO RECOVERS”?
San Francisco Recovers fails to comprehensively align with the City’s existing harm reduction policy. The proposal offers tried and failed criminal justice strategies, an expansion of existing programs that have mixed results and a few innovative approaches, like supervised consumption facilities. The resolution has been framed as a start to a conversation; in reality, it is a very detailed start that puts forward a distinct world view.
The proposal calls on the Department of Public Health to provide on-demand clinical assessments of their needs for anyone seeking recovery and to make access to programs available 24/7. The resolution also proposes some great harm reduction approaches—such as giving users testing strips so they can test the drugs they use for fentanyl—and a pilot supervised consumption site where folks can use drugs in the presence of nurses who can monitor them for accidental overdoses.
A lot is known about what is wrong with our behavioral health system. In our Revolving Door report, most study participants reported that treatment is effective at helping them manage, reduce or abstain from substance use. However, long-term success is often contingent on participants’ ability to access stable, affordable housing upon exit from treatment, which is relatively rare.
Time and again, housing has been shown across many jurisdictions and communities to be a key component of stabilization and improvement in health outcomes. Some people are able to address their substance use issues while homeless, but for most homeless people, their housing status acts as a barrier. Substance use disorders are frequently linked to trauma and adverse childhood events, and lengthy episodes of homelessness layer on additional trauma, yet nowhere in this resolution is there a call to coordinate exits from treatment programs into housing.
The resolution calls for sober housing—which we interpret as transitional housing—that would require a negative drug test in order to enter. Those on medication would also not be allowed into sober housing. The resolution is silent on the need for housing for everyone else. This is counterproductive because people who use drugs and are unhoused also need housing. It states that sober people who are allowed to enter into the housing who then relapse must be kicked out and placed in “fallback” housing. In addition, the recommendations as currently written are not fully compliant with state and federal laws and regulations, including the Americans with Disabilities Act. Housing and treatment programs cannot discriminate against people based on their history of substance use disorder or their use of medications for opioid use disorder (MOUD), such as methadone or buprenorphine.
Probably the biggest gap in San Francisco’s behavioral health system is dual diagnosis treatment. This is treatment for individuals with co-occurring substance use disorders and mental health diagnosis. The Department of Public Health reports that 66% of its mental health clients also have severe substance use disorders. Yet most programs focus either on substance use or mental health issues, ignoring their interplay. In fact the resolution mentions only in passing Mental Health SF, the major legislative overhaul to behavioral health. Despite the legislation calling for coordination between departments, it seems to ignore the presence of Mental Health SF, and does not identify how the bodies would coordinate with each other.
The recommendations in this proposal around criminalization and policing are particularly troubling, bringing back failed criminal justice strategies. One of the resolution’s most controversial elements is the establishment of “right to recovery” zones, which are areas of increased drug related criminal enforcement near treatment programs or harm reduction centers.
It also calls for increased electronic ankle monitors in criminal justice cases involving drug sales or possession. This surveillance mechanism has been found to decrease individuals ability to secure jobs, handle health care appointments, engage with children and take them to school and achieve self-sufficiency. Harvard recently published a study on electronic monitoring in San Francisco that found this kind of surveillance imposes greater social costs on defendants than pretrial incarceration, and amplifies racial and class-based inequalities by trapping subjects in interactions with law enforcement before they have even been convicted of a crime.
San Francisco Recovers also calls for coordinated approaches to eliminate concentrated drug markets, such as the “High Point Drug Market Intervention Strategy.” This is a strategy—implemented in High Point, North Carolina in 2004—to reduce drug-related crimes in the most violent sections of the city by building community resources. The idea is to start with crime mapping and undercover work, and then engaging community and offenders’ families into offering individuals who are arrested a “second chance” with housing, employment, substance abuse treatment and other services. The stated goal is to drastically transform the most troubled communities and reduce arrests. But if the offender returns to dealing, then they are subject to ongoing criminalization and targeted arrest. The original High Point intervention showed an increase in crime in the areas next to the target neighborhood, and evaluations of the effort have shown a small reduction in crime, but no long-term closure of drug markets, and also that the intervention contributed to increasing gun violence. While there are many positive elements of this model, if enacted, it needs to be rolled out with extreme care to avoid these problems.
Also suggested in the legislation is exploration of increased civil injunction cases against drug dealers. On the positive side, it calls for increased drug treatment services for people in jail and for assistance for folks who use drugs in securing and maintaining public benefits such as cash assistance and MediCal.
Lastly, the resolution calls for more job training in general, and for recovery counselors, as well as expanded staffing for Clean Slate, a program that allows people with criminal records to wipe their record clean. It also proposes more coordinated data collection on drug related criminal justice cases and transparency on reporting the number and impact of fatal overdoses.
EVALUATING THE LEGISLATION
Beyond the serious problems in this proposal’s approach to public health and criminal justice, we also see logistical challenges that need to be thought through. The legislation fails to call for Spanish- and Mayan-speaking programs. It also fails to ensure transparency into where empty treatment beds are and how to get into them, often referred to as real time inventory, and ensuring that programs have flexible durations beyond the short stays that MediCal pays for.
Substance use issues increased dramatically among unhoused people during the despair of the pandemic with the number reporting a substance use issue increasing from 42% in 2019 to 52% in 2022, according to the recent PIT Count. The SF Chronicle’s overdose tracking project reports that fatal overdoses skyrocketed from 222 in 2017 to 711 in 2020. Given the obvious crisis at hand, big bold steps are needed.
In the resolution, the language points out that a “political consensus seems to be a prerequisite for effective action”. However, this resolution has a long way to go to get to that political consensus. While there is plenty in the resolution to celebrate, the language needs some major reworking via consensus building with substance users, experts in the field and front line service providers.