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Board of Supervisors hearing on drug treatment sparks debate on harm reduction, abstinence

Source: Nick Otto for the Washington Post/Getty Images

Amid a growing overdose crisis in San Francisco, a Board of Supervisors hearing on Thursday evolved into a robust debate on the role of harm reduction and drug abstinence in public health services, and what must be done to stem fatalities and guide more individuals into care.  

In a four-hour hearing, the Board’s public safety committee scrutinized overdose prevention policies at the Department of Public Health and other agencies that come into contact with people at risk of overdose. They also revisited Proposition T, a 2008 ballot measure that required DPH to provide enough low-barrier substance abuse treatment “to meet demand,” and to report annually on its progress in that goal. 

The consensus? The spirit of that law—if not the letter—simply isn’t being met thirteen years later. And San Francisco’s current approach to addiction treatment is leaving far too many people at risk.

“I don’t believe anyone walking around the city believes we are meeting the need for drug treatment or mental health services,” said Supervisor Catherine Stefani (District 2). Stefani, along with others on the committee, expressed frustration at receiving DPH’s latest Proposition T report several months late.

“This is not a ‘check-the-box’ activity,” Stefani added. 

Dr. David Pating, an addiction specialist at DPH, identified a number of potential gaps in San Francisco’s system of care. In particular, the city’s transitional treatment options—which assist people in remaining healthy and avoiding relapse after completing intensive residential treatment—should be augmented, according to Pating. 

“I don’t believe anyone walking around the city believes we are meeting the need for drug treatment or mental health services. This is not a ‘check-the-box’ activity.”

Supervisor Catherine Stefani

“There are still people on the street who need to be outreached, in the Bayview, and in other communities,” said Pating. “We’re obviously missing people and need to bring them in.” 

Man holding paper leans over to hooded individual sitting on the sidewalk
Paul Harkin, director of harm reduction at GLIDE, speaks with people on a popular alley way with drug users in the Tenderloin. | Getty Images | Source: Nick Otto for the Washington Post/Getty Images

The shortfalls may run deeper than that, according to some Supervisors and residents who chimed in during public comment.

“I’m seeing around me growing questions and concerns around harm reduction, and whether it is actually serving [treatment goals]: Are we inducing demand for treatment, or are we inducing demand for drugs?” asked Supervisor Rafael Mandelman. “I think that there are questions about that from my colleagues, and from myself…we need to be clear that we’re measuring outcomes, and be able to show that to people.” 

In 2000, DPH formally adopted a harm reduction policy in the treatment of HIV, sexually transmitted diseases and substance abuse. That policy dictates that all DPH providers, including outside contractors, must incorporate harm reduction into their programs. In practice, those providers may supply clean needles and drug supplies, the overdose-reversing drug Naloxone, and other services aimed at encouraging safer use, saving lives and “meeting people where they are” should they wish to get clean. 

But at the hearing, some members of the public—several of whom said they were in recovery—criticized DPH’s approach as a homogenous framework that simply won’t work for everyone.

“Harm reduction is good, but harm reduction is not a one-size-fits-all. In the Black community, we get clean more or less by abstinence,” said Phelicia Jones, an activist who also works in rehabilitation services at San Francisco County Jail and is the founder of Wealth and Disparities in the Black Community. “You can’t have people who are seeking abstinence-based policies…and have harm reduction folks right there with you.” 

That sentiment was echoed by others on the call, who said they’d had trouble accessing addiction treatment in San Francisco, either by way of long wait times, or by finding that the programs did not match with their goals. By contrast, others said that they’d found success in harm reduction as an entry point to care. 

DPH maintains 496 treatment beds for substance use disorder, which are a mix of withdrawal management, short-term residential treatment and transitional treatment that combines a temporary living environment with continued treatment. There are 70 total beds available currently.

“I think it comes down to a values question at the Department of Public Health,” said Steve Adami, Director of the Re-Entry Division at San Francisco’s Adult Probation Department. “People who are in the trenches doing the work—Glide, Felton [Institute], AIDS Foundation, DOPE Project—they’re saving lives every single day. For those who want to escape that, there is no outlet. It’s one lane.” 

“You cannot put somebody who does not want to be around opiates in a place where people are on pain management, Methadone and Suboxone,” Adami added. 

“You cannot put somebody who does not want to be around opiates in a place where people are on pain management, Methadone and Suboxone.”

— Steve Adami, Director of Re-Entry Services at San Francisco’s Adult Probation Department

In a statement following the hearing, HealthRight 360, a major provider of addiction treatment, behavioral health services and primary medical care in San Francisco, called any differences of opinion between abstinence and harm recovery a “false dichotomy” and called for increased capacity in San Francisco’s system of care along with increased medication-assisted treatment. 

“Individual experiences of recovery are meaningful, but not at the expense of discarding what decades of research has taught us about what works in responding to problematic drug use, and what doesn’t work,” the statement said.

In the background of Thursday’s hearing were rising calls for a new approach to drug addiction in San Francisco, where fatal overdoses are on track to exceed last year’s historic high of 713

A majority of those deaths were attributed to fentanyl, a highly potent, synthetic opiate that has become embedded in San Francisco’s drug supply

Fentanyl, which can kill a person in minutes and in doses as small as 2mg, presents new challenges for overdose prevention, namely providing a rapid enough response. Among other safety measures, fentanyl users are encouraged to use in the presence of others who can reverse an overdose if needed. 

On Wednesday, Jacqui Berlinn, a Bay Area mother whose fentanyl-addicted son lives on the streets of San Francisco, organized a rally in the midst of the infamous open-air drug markets concentrated in the Tenderloin. 

Local authorities cleared the area at Turk and Hyde streets, normally packed with drug dealers and their customers, to allow a group of people deeply affected by the fentanyl crisis to speak out, listen and call for urgent change. 

“[My son] says he comes here because it is the easiest place for him to access what he needs and wants in order to continue his drug addiction. And I want that to change,” Berlinn told Here/Say. “I don’t know what else to do other than to call on the experts and the politicians, and just society, and the community, to help make changes and maybe save my son’s life and the lives of others in the same situation.”

On Thursday, the Board of Supervisors committee advanced an ordinance to require city departments to submit overdose prevention policies, which will be heard at an upcoming meeting of the full board. 

Are you or someone you know in need of drug addiction counseling or treatment? The San Francisco Department of Public Health can connect those seeking help to a “warm line” for non-emergency peer counseling at 1-855-845-7415. More information about substance abuse residential treatment and bed availability can be found at