When Mayor London Breed placed Proposition F on the March 2024 ballot, she framed it as a dose of tough-but-necessary love. The measure would send a message that “we are a city that offers help,” she wrote, “but not a city where you can just come and do whatever you want on our streets.”
If that were true, then the actions we are now taking to tackle addiction and provide social services to reduce street disorder would actually be working. Sadly, they’re not.
The measure requires those who are “reasonably believed to be dependent on illegal drugs to be screened for substance abuse,” and to participate in treatment programs. Failure to comply could cause a recipient to lose their aid, which includes cash for housing, utilities, food, employment assistance, and a host of other services.
The reality is that Proposition F is just the latest political theater when it comes to drug policy, where the imperative to win votes by looking tough is far greater than the desire to actually solve the problem.
What most voters probably didn’t realize is that the addiction screening is merely a self-reported questionnaire. There’s no urinalysis or blood draw required. Just the absurd idea that a person grappling with substance misuse would willingly check a box to receive treatment that may not work, at the risk of losing their benefits.
Proposition F might make San Francisco’s addiction problem look a whole lot smaller though; politicians could point out that most homeless people who appear to have drug problems actually “test” negative for them! (The test being that they checked off a box to say they’re not addicted.)
The measure is so flawed that a city employee union has filed suit and threatened a strike to block it from being implemented, arguing it is “all but impossible to execute fairly and consistently without substantial new investment in staffing, training, and worker safety.”
Forcing people into rehab—which is often unavailable in San Francisco even to those who actually want it—is not the answer. The idea that coerced treatment will solve public drug use and homelessness is based on a fundamental misunderstanding of what addiction is, why certain people become addicted, and what it takes to recover.
Addiction, by the most widely accepted definition, used by both the National Institute on Drug Abuse and psychiatry’s Diagnostic and Statistical Manual (now DSM-5), is compulsive drug use that continues despite negative consequences. That’s right: failure to respond to punishing experiences is built into drug addiction; the condition is literally defined by a sufferer’s lack of response to punitive measures. Think about it: People addicted to substances lose their families, spouses, homes, jobs, even their limbs to the disease. What about losing their welfare benefits or getting arrested? Would that be so special?
Some believe that punishments like incarceration can force people to “hit bottom,” which suddenly makes change stick. This is a cultural myth. There’s no correlation between the number of drug arrests that a state makes and rates of drug use or overdose. In fact, the U.S. arrests and incarcerates more people for drug-related crimes than any other country, while having the worst rates of overdose and opioid addiction.
Further, people with addiction typically relapse repeatedly, which is why it is often defined as a “chronic, relapsing” disorder. This occurs regardless of whether they have declared they are at “rock bottom” during care.
The mismatch between the idea that “bottom” prompts recovery and the near-universal experience of relapse leads supporters to talk about “bottoms with trap doors” or other tortured metaphors that attempt to save the concept. In reality, “hitting bottom” is a narrative device that can only be defined retrospectively and is often far from a person’s worst drug-related experience.
While some people’s recoveries involve clear turning points that show a “before” and “after,” many other paths involve three steps forward and two back, or a slow reduction of harm and return to functioning.
Moreover, people with resources—not those who are homeless, jobless, and lacking social support—are the ones more likely to overcome addiction. This is part of why criminalization is ineffective: a history of incarceration makes it harder to gain employment and housing, which are critical for lasting recovery.
So what makes people with addiction so impervious to punishment like the denial of city-provided assistance? To understand, we have to look at the root causes of this disorder, which tends to be an attempt to cope with emotional pain, not a lazy or callous drive to hedonism.
Most people with opioid addictions have suffered significant childhood trauma or have genetic risk often associated with predispositions to mental illnesses like depression, ADHD and anxiety disorders. Since early life trauma is the experience most likely to turn a psychiatric predisposition into a full-blown disorder, many addicted people have suffered both trauma and mental illness. Poverty and other causes of despair also increase addiction risks by causing distress.
Since people use drugs to relieve distress, making their lives worse only tends to exacerbate addiction. They don’t avoid treatment because being homeless and addicted is fun or because they are zombies with “brains hijacked by drugs.” They resist treatment because they don’t believe it will work better than drugs to cope with their trauma and psychological torment. And because, unfortunately, treatment has historically been harsh, punitive and dehumanizing, while drugs are, temporarily at least, an escape from pain.
Consider treatment from the patient’s perspective. Even now, rehab facilities are celebrated for being tough—using everything from bans on communication with loved ones and strictly enforced daily regimens to public humiliation, emotional attacks, and forced labor to try to make people “bottom out.” It is not surprising that people who are being asked to give up the one thing they see as making life bearable would try to avoid this type of “care.”
Or, consider treatment through a business lens. If people aren’t buying what you’re selling, do you pass a law forcing people to purchase an inferior product, or do you make a better widget instead? The widespread use of coercion—by the legal system, by schools, by families and employers—means that addiction treatment hasn’t had to be patient-centric. Coercion into treatment means that providers typically don’t have to answer to their patients—and this has created a generally low quality, often fraudulent system that is frequently divorced from the data on what works best.
In fact, being welcoming, empathetic and supportive of autonomy—the opposite of coercive—has been shown to produce the most effective treatments for substance abuse. These include compassionate and empowering care across the spectrum, and no-strings-attached access to medications like buprenorphine and methadone—proven to cut the death rate by 50 percent or more for those who stay on them. For those who are seeking immediate abstinence, evidence-based residential treatment, in which trained professionals tailor proven therapies like cognitive behavioral therapy and motivational enhancement therapy to individual patient needs, has been shown to be lasting and effective.
There are many wonderful, devoted people working in addiction treatment who are trying to improve outcomes for everyone. Measures like Proposition F are a misguided muddle that doesn’t benefit those suffering from addiction, or give those caregivers new tools or resources. Rather, they benefit politicians who want to claim to be doing everything they can while ignoring that it will take more than passing out questionnaires to address this crisis.
Those of us who see coerced drug treatment programs as counterproductive can, I guess, be grateful that Proposition F is merely political window-dressing. Because if it was enforced in the way that Mayor Breed suggested it would be, it wouldn’t work either.
But we should also be saddened and disappointed that the political capital and will to help people with addiction was wasted on this ineffective ballot measure.
If we want to actually solve the complex problems of addiction, homelessness and public disorder, we have to do what has been proven to work, not what sounds like it should work. Politicians should stop offering tough love to those who need real love and support in their struggle to change.
Maia Szalavitz is the author, most recently, of “Undoing Drugs: How Harm Reduction is Changing the Future of Addiction”