As a medical doctor working in San Francisco specializing in addiction medicine, I have seen patients overcome substance use issues. Very few of them did so without stable housing. Homelessness increases the chaos in someone’s life, and the more chaos there is, the harder it is to overcome a substance use problem.
Proposition F, a measure introduced in September by Mayor London Breed for the March 5 election, is likely to increase homelessness in our city and introduce new challenges in treating people struggling with addiction. The measure will mandate single adults who are suspected of using drugs to undergo screening for substance use disorder or risk losing the very public assistance that helps keep many of them from joining the ranks of the city’s unhoused.
Last year alone, there were over 800 overdose deaths in San Francisco. As a researcher and doctor who treats patients with substance use disorders in San Francisco, not a day goes by when I don’t grapple with these issues. I see how suffering from homelessness and substance use is worsening, and most of us who call this city home are looking for solutions to address these crises.
However, Proposition F is not the solution we need. In fact, it is more likely to create a new pathway to homelessness in San Francisco than to create a pathway to treatment.
Trent Rhorer, executive director of the San Francisco Human Services Agency, recently testified at a hearing that he expects some percentage of County Adult Assistance Program beneficiaries would lose their benefits due to these added requirements.
Losing monthly benefits would mean losing their housing, leading them to end up on the streets, further exacerbating the city’s homelessness crisis.
Another flaw in Proposition F lies in its assumption that there is sufficient addiction treatment infrastructure in the city. Unfortunately, based on my experiences as an addiction physician, the reality is quite different. The current wait time for a substance use treatment bed in San Francisco is already a substantial five to seven days, with wait times even longer for those with specific needs, such as women with histories of intimate partner violence who are seeking women-only programs.
Adding more individuals to an overloaded system will prolong these wait times and strain an already stretched health care and substance use treatment system.
The current behavioral health workforce is ill-equipped to handle the increased demand for screening. Properly trained clinical professionals are needed to accurately identify and diagnose individuals with substance use disorders and ensure they receive appropriate treatment.
There already is a dire shortage of behavioral health clinicians in San Francisco and adding to a strained system through Prop. F without adequate workforce preparation risks overwhelming health care workers. It is notable that the union representing health care professionals in San Francisco also opposes Prop. F.
As someone who’s seen many overcome their substance use issues, it’s important to emphasize that the bond between patients and their doctors is based on trust and understanding. But if voters approve Prop. F, patients may feel like their doctors are part of a system that puts their support at risk. Patients may trust their doctors less, making them not want to seek help and worsening their health and substance problems. Also, dealing with these new rules could make patients feel more stressed, anxious and hopeless, making it harder for them to get better through treatment.
Lost in all of this is that the city of San Francisco developed an Overdose Prevention Plan in 2022 that includes four strategic areas leveraging evidence-based solutions to address drug use, including bolstering the city’s addiction treatment systems. The plan was approved by the mayor and supported by the Board of Supervisors.
The problem? City leaders never fully committed to following through on the plan. It’s gathering dust on the shelf while we debate the latest pseudo-solution.
The Overdose Prevention Plan involves bolstering our existing treatment systems, including increasing linkages into treatment across all hospitals, emergency departments and other treatment facilities citywide. It also involves establishing evidence-based contingency management programs, a new treatment program introduced as a recent Medicaid pilot to provide financial incentives for people to quit using drugs. Additionally, the plan aims to address the severe shortage of mental health services by improving access to therapists, psychiatrists and counselors, so patients wouldn’t have to wait weeks or months to get help.
Instead of coming up with ineffective and misguided pseudo-solutions to our overdose crisis, San Francisco can and should follow the plan that city leaders already approved.
Whatever Proposition F's intentions, the likeliest consequences from its implementation are increased homelessness and straining our already underfunded treatment system.
A more thoughtful and comprehensive approach that considers the nuances of the issue, prioritizes access to treatment and ensures a fair and accurate screening process is essential. Policymakers and advocates must aim to address legitimate concerns with our overdose and drug crisis by advocating for sustainable solutions that don’t exacerbate the existing crisis.
Dr. Leslie W. Suen, M.D., M.A.S. is a primary care and addiction medicine doctor and an assistant professor at the University of California San Francisco. She is a Public Voices Fellow on homelessness of the OpEd Project in partnership with the UCSF Benioff Homelessness and Housing Initiative.