Chris Roberts

California Gov. Gavin Newsom, declaring himself &#8220;<a href="https://www.sfchronicle.com/sf/bayarea/heatherknight/article/Gavin-Newsom-Care-Court-mental-health-16973070.php">disgusted</a>&#8221; with the state of San Francisco’s streets, last week jumped into a fraught debate over how to combat the drug addiction crisis with a new program that would allow judges to sentence those with substance abuse and mental health issues to treatment.&nbsp;&nbsp;

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<p>California Gov. Gavin Newsom, declaring himself "<a href="https://www.sfchronicle.com/sf/bayarea/heatherknight/article/Gavin-Newsom-Care-Court-mental-health-16973070.php">disgusted</a>" with the state of San Francisco’s streets, last week jumped into a fraught debate over how to combat the drug addiction crisis with a new program that would allow judges to sentence those with substance abuse and mental health issues to treatment.&nbsp;&nbsp;</p>

<p>California Gov. Gavin Newsom, declaring himself &#8220;<a href="https://www.sfchronicle.com/sf/bayarea/heatherknight/article/Gavin-Newsom-Care-Court-mental-health-16973070.php">disgusted</a>&#8221; with the state of San Francisco’s streets, last week jumped into a fraught debate over how to combat the drug addiction crisis with a new program that would allow judges to sentence those with substance abuse and mental health issues to treatment.&nbsp;&nbsp;</p>

Newsom’s <a href="https://sfstandard.com/public-health-safety/homelessness/explainer-gov-newsoms-controversial-plan-to-compel-people-into-drug-mental-health-treatment/">CARE Court program</a>, which he plugged once again in his <a href="https://www.youtube.com/watch?v=GDKPJHkK520">State of the State Address</a> Tuesday night and still requires approval by the legislature, is the latest push from politicians intent on helping those deemed unable or unwilling to help themselves. It comes a little over two months after current Mayor London Breed garnered national attention by <a href="https://sfstandard.com/public-health/breed-declares-state-of-emergency-in-the-tenderloin/">declaring a state of emergency in the city’s Tenderloin</a> district and vowing to end the city’s de-facto tolerance of public drug sales and consumption—or, as she put it, <a href="https://sfstandard.com/city-hall/mayor-announces-crackdown-on-tenderloin-crime-in-fiery-press-conference/">“all the bullshit that has destroyed our city.”</a>

<p>Newsom’s <a href="https://sfstandard.com/public-health-safety/homelessness/explainer-gov-newsoms-controversial-plan-to-compel-people-into-drug-mental-health-treatment/">CARE Court program</a>, which he plugged once again in his <a href="https://www.youtube.com/watch?v=GDKPJHkK520">State of the State Address</a> Tuesday night and still requires approval by the legislature, is the latest push from politicians intent on helping those deemed unable or unwilling to help themselves. It comes a little over two months after current Mayor London Breed garnered national attention by <a href="https://sfstandard.com/public-health/breed-declares-state-of-emergency-in-the-tenderloin/">declaring a state of emergency in the city’s Tenderloin</a> district and vowing to end the city’s de-facto tolerance of public drug sales and consumption—or, as she put it, <a href="https://sfstandard.com/city-hall/mayor-announces-crackdown-on-tenderloin-crime-in-fiery-press-conference/">“all the bullshit that has destroyed our city.”</a></p>

Breed’s suggestion that extra police officers would <a href="https://missionlocal.org/2022/01/mayor-breeds-prior-tenderloin-police-blitzes-promised-lots-delivered-little/">be deployed to the Tenderloin</a> to arrest more drug dealers in the area—already the city’s epicenter for drug arrests—struck a nerve. So did her declaration that anyone caught using drugs out in the open would be presented with two options: get help or go to jail.&nbsp;

<p>Breed’s suggestion that extra police officers would <a href="https://missionlocal.org/2022/01/mayor-breeds-prior-tenderloin-police-blitzes-promised-lots-delivered-little/">be deployed to the Tenderloin</a> to arrest more drug dealers in the area—already the city’s epicenter for drug arrests—struck a nerve. So did her declaration that anyone caught using drugs out in the open would be presented with two options: get help or go to jail.&nbsp;</p>

“We are not giving people the choice anymore,” she said. “We are not going to walk by and let someone use in broad daylight.”

<p>“We are not giving people the choice anymore,” she said. “We are not going to walk by and let someone use in broad daylight.”</p>

A man wearing multiple hospital wristbands, including a yellow “Fall Risk” bracelet, sleeps on the ground in the Tenderloin on March 5, 2022. | Dan Fenstermacher


<figure class="wp-block-image size-large"><img src="https://content.sfstandard.com/wp-content/uploads/2022/03/TenderloinCompelledTreatment_DanFenstermacher_SFS-22-2500x1667.jpg" alt="" class="wp-image-41483"/><figcaption><em>A man wearing multiple hospital wristbands, including a yellow “Fall Risk” bracelet, sleeps on the ground in the Tenderloin on March 5, 2022. | Dan Fenstermacher</em></figcaption></figure>


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<figure class="wp-block-image size-large"><img src="https://content.sfstandard.com/wp-content/uploads/2022/03/TenderloinCompelledTreatment_DanFenstermacher_SFS-22-2500x1667.jpg" alt="" class="wp-image-41483"/><figcaption><em>A man wearing multiple hospital wristbands, including a yellow “Fall Risk” bracelet, sleeps on the ground in the Tenderloin on March 5, 2022. | Dan Fenstermacher</em></figcaption></figure>

Breed’s speech was interpreted as an endorsement of what centrist Democrats, moderate Republicans and desperate family members of people with intractable substance-abuse problems across the country are demanding—a legally binding means of forcing people to address their addiction problems.

<p>Breed’s speech was interpreted as an endorsement of what centrist Democrats, moderate Republicans and desperate family members of people with intractable substance-abuse problems across the country are demanding—a legally binding means of forcing people to address their addiction problems.</p>

Embraced by President Joe Biden during the 2020 election cycle, “mandatory treatment” is framed as a kinder and gentler alternative to imprisonment and a responsible way to address the ugly status quo in neighborhoods like the Tenderloin or Skid Row in Los Angeles. Many drug addiction specialists disagree, pointing to research that concludes forced treatment doesn’t work, and even going so far as to call it incarceration in disguise.

<p>Embraced by President Joe Biden during the 2020 election cycle, “mandatory treatment” is framed as a kinder and gentler alternative to imprisonment and a responsible way to address the ugly status quo in neighborhoods like the Tenderloin or Skid Row in Los Angeles. Many drug addiction specialists disagree, pointing to research that concludes forced treatment doesn’t work, and even going so far as to call it incarceration in disguise.</p>

In San Francisco, efforts to force people into rehab are further complicated by logistical issues—it’s not clear whether there are enough treatment beds, even for those who <em>want</em> them—as well as medical questions. While some treatment programs offer patients drugs like methadone or Suboxone to help manage withdrawal symptoms, others expect people to go cold turkey.

<p>In San Francisco, efforts to force people into rehab are further complicated by logistical issues—it’s not clear whether there are enough treatment beds, even for those who <em>want</em> them—as well as medical questions. While some treatment programs offer patients drugs like methadone or Suboxone to help manage withdrawal symptoms, others expect people to go cold turkey.</p>

Add it all up, and a policy conundrum emerges: Mandatory treatment is an increasingly popular talking point and a seemingly common-sense approach to the twin crises of opioid overdoses and <a href="https://www.sfexaminer.com/findings/meth-san-franciscos-drug-crisis-within-a-drug-crisis/">ballooning stimulant abuse</a>. Yet many experts in the field reject the approach, and it is far from clear if and how it might ultimately make a difference, either for individual drug users or for conditions on the city’s streets.

<p>Add it all up, and a policy conundrum emerges: Mandatory treatment is an increasingly popular talking point and a seemingly common-sense approach to the twin crises of opioid overdoses and <a href="https://www.sfexaminer.com/findings/meth-san-franciscos-drug-crisis-within-a-drug-crisis/">ballooning stimulant abuse</a>. Yet many experts in the field reject the approach, and it is far from clear if and how it might ultimately make a difference, either for individual drug users or for conditions on the city’s streets.</p>


<h4 class="wp-block-heading" id="h-tough-love"><strong>Tough Love</strong></h4>


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<h4 id="h-tough-love"><strong>Tough Love</strong></h4>

Currently, in the United States, substance use disorder is grounds for involuntary commitment in more than 30 states. Allowing a nonviolent offender to choose treatment over jail is already a key component of diversion programs in San Francisco.<br>Proponents say mandatory treatment would help make San Francisco a place where it’s easy to get well, instead of merely get high. When juxtaposed against the city’s grim death toll from drug overdoses—1,350 people dead over the past two years, almost double the deaths attributed to Covid, <a href="https://sf.gov/news/sf-drug-overdoses-decline-first-time-three-years-city-overdose-prevention-efforts-intensify">according to the San Francisco Department of Public Health</a>—using the police and the courts to herd recalcitrant drug users into treatment looks to many like the humane choice.

<p>Currently, in the United States, substance use disorder is grounds for involuntary commitment in more than 30 states. Allowing a nonviolent offender to choose treatment over jail is already a key component of diversion programs in San Francisco.<br>Proponents say mandatory treatment would help make San Francisco a place where it’s easy to get well, instead of merely get high. When juxtaposed against the city’s grim death toll from drug overdoses—1,350 people dead over the past two years, almost double the deaths attributed to Covid, <a href="https://sf.gov/news/sf-drug-overdoses-decline-first-time-three-years-city-overdose-prevention-efforts-intensify">according to the San Francisco Department of Public Health</a>—using the police and the courts to herd recalcitrant drug users into treatment looks to many like the humane choice.</p>

Officer O’Brien speaks through a glass window with a woman reporting a sexual assault on March 5, 2022 at the Tenderloin Police Station. The alleged attack occurred in the Tenderloin in the previous week. | Dan Fenstermacher


<figure class="wp-block-image size-large"><img src="https://content.sfstandard.com/wp-content/uploads/2022/03/TenderloinCompelledTreatment_DanFenstermacher_SFS-2-2500x1667.jpg" alt="" class="wp-image-41480"/><figcaption><em>Officer O’Brien speaks through a glass window with a woman reporting an alleged sexual assault on March 5, 2022 at the Tenderloin Police Station. | Dan Fenstermacher</em></figcaption></figure>


Mandatory treatment is having a moment locally, in part due to some very vocal advocates. Chief among them is Michael Shellenberger, the Berkeley-based author of the <a href="https://sfstandard.com/perspectives/dueling-perspectives-sanfransicko/">anti-progressive polemic<em> San Fransicko</em></a>, who argues that hands-off “harm reduction” programs—which emphasizes keeping users healthy through efforts such as needle exchanges and <a href="https://sfstandard.com/public-health/safe-consumption-controversy/">supervised consumption sites</a>, rather than threatening them with punishment—is what created the Tenderloin’s sidewalk morality play. Mandatory treatment is a key mechanism for ending the mayhem, he argues.<br>And San Francisco isn’t the only place where the idea is gaining ground. <a href="https://vancouversun.com/news/daphne-bramham-compulsory-addiction-treatment-high-on-canadians-priority-list">Recent polling reveals</a> compulsory treatment is extremely popular in Canada, even as the country has embraced a full range of harm reduction programs that in some cities extends even to guaranteeing <a href="https://time.com/6108812/drug-deaths-safe-supply-opioids/">a clean supply of heroin and other drugs</a>.

<p>Mandatory treatment is having a moment locally, in part due to some very vocal advocates. Chief among them is Michael Shellenberger, the Berkeley-based author of the <a href="https://sfstandard.com/perspectives/dueling-perspectives-sanfransicko/">anti-progressive polemic<em> San Fransicko</em></a>, who argues that hands-off “harm reduction” programs—which emphasizes keeping users healthy through efforts such as needle exchanges and <a href="https://sfstandard.com/public-health/safe-consumption-controversy/">supervised consumption sites</a>, rather than threatening them with punishment—is what created the Tenderloin’s sidewalk morality play. Mandatory treatment is a key mechanism for ending the mayhem, he argues.<br>And San Francisco isn’t the only place where the idea is gaining ground. <a href="https://vancouversun.com/news/daphne-bramham-compulsory-addiction-treatment-high-on-canadians-priority-list">Recent polling reveals</a> compulsory treatment is extremely popular in Canada, even as the country has embraced a full range of harm reduction programs that in some cities extends even to guaranteeing <a href="https://time.com/6108812/drug-deaths-safe-supply-opioids/">a clean supply of heroin and other drugs</a>.</p>

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<blockquote class="twitter-tweet" data-width="500" data-dnt="true"><p lang="en" dir="ltr">If we truly care about the lives being lost on the streets we need to persuade our fellow citizens not just that the lives of addicts and the untreated mentally ill matter, but also that many of them can only be saved by police officers arresting them.<br><br>/END</p>&mdash; Michael Shellenberger (@shellenberger) <a href="https://twitter.com/shellenberger/status/1495796480019693569?ref_src=twsrc%5Etfw">February 21, 2022</a></blockquote><script async src="https://platform.twitter.com/widgets.js" charset="utf-8"></script>

Powerful anecdotes help make the case for forced treatment. Tom Wolf, a recovering opioid addict who spent time homeless in the Tenderloin, <a href="https://sfstandard.com/public-health-safety/recovering-heroin-addict-san-francisco-failing-drug-users/">credits the police officer</a> who arrested him in 2018—triggering a journey from county jail, where he was forced to stay clean, to rehab and onto sobriety, where he is today—with saving his life.&nbsp;

<p>Powerful anecdotes help make the case for forced treatment. Tom Wolf, a recovering opioid addict who spent time homeless in the Tenderloin, <a href="https://sfstandard.com/public-health-safety/recovering-heroin-addict-san-francisco-failing-drug-users/">credits the police officer</a> who arrested him in 2018—triggering a journey from county jail, where he was forced to stay clean, to rehab and onto sobriety, where he is today—with saving his life.&nbsp;</p>

Wolf’s experience has turned him into a minor local celebrity. He is frequently quoted in the media, and he appears as a main character in <em>San Fransicko</em>. Wolf is also featured in a new documentary alongside celebrity doctor <a href="https://www.dailynews.com/2021/04/18/dr-drew-pinskys-nomination-to-la-countys-homeless-commission-sparks-pushback/">Drew “Dr. Drew” Pinsky</a>, a mandatory-treatment advocate who was briefly floated as a candidate for Los Angeles County’s homeless commission.

<p>Wolf’s experience has turned him into a minor local celebrity. He is frequently quoted in the media, and he appears as a main character in <em>San Fransicko</em>. Wolf is also featured in a new documentary alongside celebrity doctor <a href="https://www.dailynews.com/2021/04/18/dr-drew-pinskys-nomination-to-la-countys-homeless-commission-sparks-pushback/">Drew “Dr. Drew” Pinsky</a>, a mandatory-treatment advocate who was briefly floated as a candidate for Los Angeles County’s homeless commission.</p>

Wolf himself is presented as a folksy data point supporting involuntary treatment—even though he admits that voluntary treatment is preferable.

<p>Wolf himself is presented as a folksy data point supporting involuntary treatment—even though he admits that voluntary treatment is preferable.</p>

“I can line up at least 10 people right now that got clean in handcuffs. But voluntary treatment is always better,” he said in an interview with The Standard.

<p>“I can line up at least 10 people right now that got clean in handcuffs. But voluntary treatment is always better,” he said in an interview with The Standard.</p>

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Wolf went into involuntary treatment via a city drug court. Of the 90 people who started his abstinence-based Salvation Army rehab program, 22 completed it, he said, although one of the 22 recently relapsed and is currently in treatment at Walden House.&nbsp;

<p>Wolf went into involuntary treatment via a city drug court. Of the 90 people who started his abstinence-based Salvation Army rehab program, 22 completed it, he said, although one of the 22 recently relapsed and is currently in treatment at Walden House.&nbsp;</p>

Then again, he continued, “Here I am, four years later, clean and sober. How’s that for evidence, buddy?”

<p>Then again, he continued, “Here I am, four years later, clean and sober. How’s that for evidence, buddy?”</p>

Addiction medicine specialists generally agree that entering treatment voluntarily is far more likely to succeed than any form of coercion, but some support for “tough love” approaches can also be found in academic circles. Keith Humphreys, a professor of psychiatry and behavioral sciences at Stanford University who studies addiction and has helped lay the intellectual foundation for drug-policy reforms including marijuana legalization, is among those who say it can work.

<p>Addiction medicine specialists generally agree that entering treatment voluntarily is far more likely to succeed than any form of coercion, but some support for “tough love” approaches can also be found in academic circles. Keith Humphreys, a professor of psychiatry and behavioral sciences at Stanford University who studies addiction and has helped lay the intellectual foundation for drug-policy reforms including marijuana legalization, is among those who say it can work.</p>

He points to a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3578041/">2015 article in the Journal of Substance Abuse Treatment</a> which found that among 160 people enrolled in treatment between 2007 and 2010, “those who were mandated” were more likely to finish their programs.

<p>He points to a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3578041/">2015 article in the Journal of Substance Abuse Treatment</a> which found that among 160 people enrolled in treatment between 2007 and 2010, “those who were mandated” were more likely to finish their programs.</p>

“People are surprised by this only if they assume the typical person in addiction treatment came in with no pressure on them whatsoever, but that is rare,” he said in an email. “Usually the boss, the spouse, the kids leaned on them to go, or the grim reaper did when their doctor said, ‘I’ve looked at your liver tests, and if you keep this up, you won’t last another year.’”

<p>“People are surprised by this only if they assume the typical person in addiction treatment came in with no pressure on them whatsoever, but that is rare,” he said in an email. “Usually the boss, the spouse, the kids leaned on them to go, or the grim reaper did when their doctor said, ‘I’ve looked at your liver tests, and if you keep this up, you won’t last another year.’”</p>

“A court-mandate is formalized pressure,” he added. “But most people are under pressure of some form.”

<p>“A court-mandate is formalized pressure,” he added. “But most people are under pressure of some form.”</p>

<strong>Politics &amp; Practicality</strong>


<h4 class="wp-block-heading"><strong>Politics &amp; Practicality</strong></h4>


<h4><strong>Politics &amp; Practicality</strong></h4>

Statistically speaking, most efforts at treatment for substance-abuse fail. Half of people who enter treatment <a href="https://pubmed.ncbi.nlm.nih.gov/23995204/">don’t last a month</a> before they’re out of rehab and off the wagon. Some are kicked out for breaking curfew or relapsing. Others are simply disinterested in whatever was on offer.<br><br>Some programs are “abstinence-based,” meaning a client fails and is kicked out if they relapse at any time during their stay, be it three weeks or ninety days.<br>Other programs offer what drug researchers call “evidence-based” treatment—that is, approaches current medical science says are most likely to work. For opioid users, evidence-based treatment would offer them opioid agonists like Suboxone, <a href="https://www.health.harvard.edu/blog/5-myths-about-using-suboxone-to-treat-opiate-addiction-2018032014496">a drug</a> that combines a long-release opioid, buprenorphine, with the overdose-reversing drug naloxone, better known by its brand name, Narcan.

<p>Statistically speaking, most efforts at treatment for substance-abuse fail. Half of people who enter treatment <a href="https://pubmed.ncbi.nlm.nih.gov/23995204/">don’t last a month</a> before they’re out of rehab and off the wagon. Some are kicked out for breaking curfew or relapsing. Others are simply disinterested in whatever was on offer.<br><br>Some programs are “abstinence-based,” meaning a client fails and is kicked out if they relapse at any time during their stay, be it three weeks or ninety days.<br>Other programs offer what drug researchers call “evidence-based” treatment—that is, approaches current medical science says are most likely to work. For opioid users, evidence-based treatment would offer them opioid agonists like Suboxone, <a href="https://www.health.harvard.edu/blog/5-myths-about-using-suboxone-to-treat-opiate-addiction-2018032014496">a drug</a> that combines a long-release opioid, buprenorphine, with the overdose-reversing drug naloxone, better known by its brand name, Narcan.</p>

An individual takes shelter under a bed sheet across the street from the Tenderloin Police Station on Eddy Street on March 5, 2022. | Dan Fenstermacher


<figure class="wp-block-image size-full"><img src="https://content.sfstandard.com/wp-content/uploads/2022/03/TenderloinCompelledTreatment_DanFenstermacher_SFS-40-e1646802096668.jpg" alt="" class="wp-image-41493"/><figcaption><em>An individual takes shelter under a bed sheet across the street from the Tenderloin Police Station on Eddy Street on March 5, 2022. | Dan Fenstermacher</em></figcaption></figure>


For methamphetamine users, evidence-based treatment is in shorter supply, as there is no Suboxone equivalent for those dependent on speed. However, “<a href="https://www.npr.org/sections/health-shots/2021/09/30/1040412804/to-combat-meth-california-will-try-a-bold-treatment-pay-drug-users-to-stop-using">contingency management</a>,” recently legalized in California, in which meth users are literally paid to stay clean, has shown some promise.

<p>For methamphetamine users, evidence-based treatment is in shorter supply, as there is no Suboxone equivalent for those dependent on speed. However, “<a href="https://www.npr.org/sections/health-shots/2021/09/30/1040412804/to-combat-meth-california-will-try-a-bold-treatment-pay-drug-users-to-stop-using">contingency management</a>,” recently legalized in California, in which meth users are literally paid to stay clean, has shown some promise.</p>

In the U.S., most treatment options are not evidence-based. Research <a href="https://jamanetwork.com/journals/jama/fullarticle/2769709">recently published</a> in the Journal of the American Medical Association <a href="https://www.health.harvard.edu/blog/5-myths-about-using-suboxone-to-treat-opiate-addiction-2018032014496">found</a> only 29% of programs surveyed nationally offered long-term opiate-agonist therapy, with many more either not offering or “actively discourag[ing]” the treatment. Non-medical treatment is also the “most common detox pathway,” in San Francisco, according to the city’s Department of Public Health, though the agency declined to provide any figures.

<p>In the U.S., most treatment options are not evidence-based. Research <a href="https://jamanetwork.com/journals/jama/fullarticle/2769709">recently published</a> in the Journal of the American Medical Association <a href="https://www.health.harvard.edu/blog/5-myths-about-using-suboxone-to-treat-opiate-addiction-2018032014496">found</a> only 29% of programs surveyed nationally offered long-term opiate-agonist therapy, with many more either not offering or “actively discourag[ing]” the treatment. Non-medical treatment is also the “most common detox pathway,” in San Francisco, according to the city’s Department of Public Health, though the agency declined to provide any figures.</p>

Critics of mandatory treatment say the lack of evidence-based programs is yet another reason to avoid the practice.

<p>Critics of mandatory treatment say the lack of evidence-based programs is yet another reason to avoid the practice.</p>

“The literature does not support mandatory treatment on any level to help the public health situation,” said <a href="https://fcm.ucsf.edu/people/daniel-ciccarone-md-mph">Daniel Ciccarone</a>, a physician and professor of family community medicine at the University of California San Francisco, who studies drug addiction.&nbsp;

<p>“The literature does not support mandatory treatment on any level to help the public health situation,” said <a href="https://fcm.ucsf.edu/people/daniel-ciccarone-md-mph">Daniel Ciccarone</a>, a physician and professor of family community medicine at the University of California San Francisco, who studies drug addiction.&nbsp;</p>

Ciccarone doubts Newsom’s CARE program will work—even if it survives legal challenges and is accepted by the courts. “I think it is backwards and likely to fail,” said Ciccarone. “The solution to homelessness is housing; make it ‘supportive housing’ and couple it with substance treatment, case management and mental health services; anything short of that will be a revolving door.”

<p>Ciccarone doubts Newsom’s CARE program will work—even if it survives legal challenges and is accepted by the courts. “I think it is backwards and likely to fail,” said Ciccarone. “The solution to homelessness is housing; make it ‘supportive housing’ and couple it with substance treatment, case management and mental health services; anything short of that will be a revolving door.”</p>


<div class="wp-block-image cc_daniel_ciccarone"><figure class="alignright size-full is-resized"><img src="https://content.sfstandard.com/wp-content/uploads/2022/03/UCSF_20170927_Daniel-Ciccarone_057-2.jpg" alt="" class="wp-image-41503" width="356" height="376"/><figcaption><em>Photo courtesy of Daniel Ciccarone</em></figcaption></figure></div>


A 2015 meta-analysis of nine studies examining involuntary treatment around the world found that “evidence does not, on the whole, suggest improved outcomes related to compulsory treatment approaches, with some studies suggesting potential harms.” While the issue is under-studied in the United States, research from<a href="https://www.bmj.com/content/353/bmj.i2943.long"> Russia and </a><a href="https://pubmed.ncbi.nlm.nih.gov/31099592/">Mexico </a>published over the last decade agrees compulsory treatment is ineffective in solving drug addiction—and amounts to imprisonment in disguise.&nbsp;

<p>A 2015 meta-analysis of nine studies examining involuntary treatment around the world found that “evidence does not, on the whole, suggest improved outcomes related to compulsory treatment approaches, with some studies suggesting potential harms.” While the issue is under-studied in the United States, research from<a href="https://www.bmj.com/content/353/bmj.i2943.long"> Russia and </a><a href="https://pubmed.ncbi.nlm.nih.gov/31099592/">Mexico </a>published over the last decade agrees compulsory treatment is ineffective in solving drug addiction—and amounts to imprisonment in disguise.&nbsp;</p>

“Global evidence indicates that mandated treatment of drug dependence conflicts with drug users’ human rights and is not effective in treating addiction,” Karsten Lunze, a professor at the Boston University School of Medicine <a href="https://www.sciencedaily.com/releases/2016/06/160621115655.htm">found</a>.

<p>“Global evidence indicates that mandated treatment of drug dependence conflicts with drug users’ human rights and is not effective in treating addiction,” Karsten Lunze, a professor at the Boston University School of Medicine <a href="https://www.sciencedaily.com/releases/2016/06/160621115655.htm">found</a>.</p>

Given the doubts over the efficacy of involuntary treatment, why is it so alluring for some advocates?

<p>Given the doubts over the efficacy of involuntary treatment, why is it so alluring for some advocates?</p>

“On an individual level, you can always find someone who says they benefited from being shown ‘hard love,’ or ‘tough love,’ whether it was their family or a police officer or a court,” said Ciccarone. “It may actually work—politically,” he added. “From a public health point of view, will it reduce overdoses? Probably not.”

<p>“On an individual level, you can always find someone who says they benefited from being shown ‘hard love,’ or ‘tough love,’ whether it was their family or a police officer or a court,” said Ciccarone. “It may actually work—politically,” he added. “From a public health point of view, will it reduce overdoses? Probably not.”</p>

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<h4 class="wp-block-heading"><strong>No Moves Yet</strong></h4>


<p>Several months into Breed's Tenderloin emergency declaration, neither forced treatment nor the city's safe injection site have materialized.</p>

<p>Several months into Breed&#8217;s Tenderloin emergency declaration, neither forced treatment nor the city&#8217;s safe injection site have materialized.</p>

<p>Asked directly via email if Breed supports involuntary commitment for people with drug addiction—or if the police would begin funneling drug users into rehab, or when—Jeff Cretan, the mayor’s chief spokesperson, did not respond.&nbsp;</p>

<p>In an earlier email, Cretan pointed out that Breed has since 2019 supported a proposal from state Sen. Scott Wiener, a former city supervisor, to expand the state’s involuntary commitment laws to include “those who are truly suffering and unable to care for themselves,” including someone with a dual diagnosis of mental health and substance abuse issues.</p>


<figure class="wp-block-image size-full"><img src="https://content.sfstandard.com/wp-content/uploads/2022/03/HousingHereSay-45.jpg" alt="" class="wp-image-41500"/><figcaption><em>Speaker of the House Nancy Pelosi, State Sen. Scott Wiener and Mayor London Breed tour a new housing complex in San Francisco’s Sunnydale neighborhood on Oct. 14, 2021. | Camille Cohen</em></figcaption></figure>


<p>“The mayor has also said repeatedly that as we make more investments in housing, shelter and treatment, we need people to take those options when they are made available, and not be allowed to stay on the street,” Cretan added.</p>

<p>Spokespeople for District Attorney Chesa Boudin refused to discuss whether the city’s top prosecutor supports mandatory treatment, though Boudin did appear at a December press conference held by HealthRight360, one of the city’s leading treatment providers, in which involuntary treatment was cast as a regressive return to a punishment-first drug war paradigm.&nbsp;</p>

<p>Leo Beletsky, a professor of law and health sciences at Northeastern University who has extensively studied mandatory rehab, said the idea was ultimately something of a fig leaf—though maybe one that satisfies the current political zeitgeist.&nbsp;</p>

<p>Said Beletsky: “It’s much easier to say, ‘OK, well, we’re not going to incarcerate people, we’re just going to incarcerate them and call it treatment.’”</p>

core/column

<div class="wp-block-column" style="flex-basis:45%"><div style="height:18px" aria-hidden="true" class="wp-block-spacer"></div><h4><strong>No Moves Yet</strong></h4><p>Several months into Breed&#8217;s Tenderloin emergency declaration, neither forced treatment nor the city&#8217;s safe injection site have materialized.</p><p>Asked directly via email if Breed supports involuntary commitment for people with drug addiction—or if the police would begin funneling drug users into rehab, or when—Jeff Cretan, the mayor’s chief spokesperson, did not respond.&nbsp;</p><p>In an earlier email, Cretan pointed out that Breed has since 2019 supported a proposal from state Sen. Scott Wiener, a former city supervisor, to expand the state’s involuntary commitment laws to include “those who are truly suffering and unable to care for themselves,” including someone with a dual diagnosis of mental health and substance abuse issues.</p><figure class="wp-block-image size-full"><img src="https://content.sfstandard.com/wp-content/uploads/2022/03/HousingHereSay-45.jpg" alt="" class="wp-image-41500"/><figcaption><em>Speaker of the House Nancy Pelosi, State Sen. Scott Wiener and Mayor London Breed tour a new housing complex in San Francisco’s Sunnydale neighborhood on Oct. 14, 2021. | Camille Cohen</em></figcaption></figure><p>“The mayor has also said repeatedly that as we make more investments in housing, shelter and treatment, we need people to take those options when they are made available, and not be allowed to stay on the street,” Cretan added.</p><p>Spokespeople for District Attorney Chesa Boudin refused to discuss whether the city’s top prosecutor supports mandatory treatment, though Boudin did appear at a December press conference held by HealthRight360, one of the city’s leading treatment providers, in which involuntary treatment was cast as a regressive return to a punishment-first drug war paradigm.&nbsp;</p><p>Leo Beletsky, a professor of law and health sciences at Northeastern University who has extensively studied mandatory rehab, said the idea was ultimately something of a fig leaf—though maybe one that satisfies the current political zeitgeist.&nbsp;</p><p>Said Beletsky: “It’s much easier to say, ‘OK, well, we’re not going to incarcerate people, we’re just going to incarcerate them and call it treatment.’”</p></div>


<h4 class="wp-block-heading" id="h-insufficient-capacity-for-care"><strong>Insufficient Capacity </strong><br><strong>for Care</strong></h4>


<h4 id="h-insufficient-capacity-for-care"><strong>Insufficient Capacity </strong><br><strong>for Care</strong></h4>

<p>Advocates say what would work best in San Francisco, beyond solving underlying social problems like the housing crisis, is expanding the city’s treatment capacity and making sure that the programs adhere to best practices.</p>

<p>Data on the availability of treatment beds in San Francisco is sketchy, as are exact figures for how many programs are on offer in the city, but the available numbers are not encouraging. According to a recent statement provided by the DPH, the city has 2,200 “spaces” in its “residential care and treatment offerings,” with “over 400 spaces being added.”</p>

<p>However, according to a recent publicly available snapshot on <a href="https://findtreatment-sf.org/" target="_blank" rel="noreferrer noopener">findtreatment-sf.org</a>, the city advertised a capacity of 500 substance-use disorder treatment beds in three categories and had only a few dozen available. Of the 58 “detox now” beds, 48 offered medical detox. “There remains reduced capacity at some sites due to Covid and the required safety precautions,” DPH spokesperson Zoe Harris wrote in an email.</p>

<p>These figures only include treatment beds contracted by DPH and not beds offered by nonprofit service providers who might contract with the courts.</p>

<p>A <a href="https://sf.curbed.com/2018/5/9/17336090/san-francisco-needles-syringes-exchange-numbers-sf" target="_blank" rel="noreferrer noopener">2016 DPH estimate</a> put the number of intravenous drug users in San Francisco at roughly 22,000. That figure has been repeated as gospel ever since. The number of hard drug users who may snort or smoke their stuff is surely higher, especially considering that fentanyl and its analogs—often smoked rather than injected—didn’t really take off in the Tenderloin until around 2018, and drug experts like Daniel Ciccarone of UCSF identify stimulants as the current overdose crisis’ "fourth wave."nonprofit service providers who might contract with the courts.</p>

<p>A <a href="https://sf.curbed.com/2018/5/9/17336090/san-francisco-needles-syringes-exchange-numbers-sf" target="_blank" rel="noreferrer noopener">2016 DPH estimate</a> put the number of intravenous drug users in San Francisco at roughly 22,000. That figure has been repeated as gospel ever since. The number of hard drug users who may snort or smoke their stuff is surely higher, especially considering that fentanyl and its analogs—often smoked rather than injected—didn’t really take off in the Tenderloin until around 2018, and drug experts like Daniel Ciccarone of UCSF identify stimulants as the current overdose crisis’ &#8220;fourth wave.&#8221;nonprofit service providers who might contract with the courts.</p>

<p>Critics also question the city’s commitment to “social” or “non-medical” treatment programs–the most common approach, according to DPH–which don’t offer those struggling with an opioid addiction the option of an agonist like Suboxone.</p>

<p>Whatever the specifics of the treatment, unless the city built a new dedicated treatment facility or converted the San Bruno jail to a drug-rehab center—<a href="https://www.theatlantic.com/politics/archive/2019/11/going-jail-substance-abuse-treatment/602206/" target="_blank" rel="noreferrer noopener">a proposition some experts think is smart policy</a>—committing even a fraction of local addicts to treatment is not currently something the city can physically do.</p>

<div class="wp-block-column cc_insufficient_col" style="flex-basis:44%"><div style="height:14px" aria-hidden="true" class="wp-block-spacer"></div><h4 id="h-insufficient-capacity-for-care"><strong>Insufficient Capacity </strong><br><strong>for Care</strong></h4><p>Advocates say what would work best in San Francisco, beyond solving underlying social problems like the housing crisis, is expanding the city’s treatment capacity and making sure that the programs adhere to best practices.</p><p>Data on the availability of treatment beds in San Francisco is sketchy, as are exact figures for how many programs are on offer in the city, but the available numbers are not encouraging. According to a recent statement provided by the DPH, the city has 2,200 “spaces” in its “residential care and treatment offerings,” with “over 400 spaces being added.”</p><p>However, according to a recent publicly available snapshot on <a href="https://findtreatment-sf.org/" target="_blank" rel="noreferrer noopener">findtreatment-sf.org</a>, the city advertised a capacity of 500 substance-use disorder treatment beds in three categories and had only a few dozen available. Of the 58 “detox now” beds, 48 offered medical detox. “There remains reduced capacity at some sites due to Covid and the required safety precautions,” DPH spokesperson Zoe Harris wrote in an email.</p><p>These figures only include treatment beds contracted by DPH and not beds offered by nonprofit service providers who might contract with the courts.</p><p>A <a href="https://sf.curbed.com/2018/5/9/17336090/san-francisco-needles-syringes-exchange-numbers-sf" target="_blank" rel="noreferrer noopener">2016 DPH estimate</a> put the number of intravenous drug users in San Francisco at roughly 22,000. That figure has been repeated as gospel ever since. The number of hard drug users who may snort or smoke their stuff is surely higher, especially considering that fentanyl and its analogs—often smoked rather than injected—didn’t really take off in the Tenderloin until around 2018, and drug experts like Daniel Ciccarone of UCSF identify stimulants as the current overdose crisis’ &#8220;fourth wave.&#8221;nonprofit service providers who might contract with the courts.</p><p>Critics also question the city’s commitment to “social” or “non-medical” treatment programs–the most common approach, according to DPH–which don’t offer those struggling with an opioid addiction the option of an agonist like Suboxone.</p><p>Whatever the specifics of the treatment, unless the city built a new dedicated treatment facility or converted the San Bruno jail to a drug-rehab center—<a href="https://www.theatlantic.com/politics/archive/2019/11/going-jail-substance-abuse-treatment/602206/" target="_blank" rel="noreferrer noopener">a proposition some experts think is smart policy</a>—committing even a fraction of local addicts to treatment is not currently something the city can physically do.</p></div>

core/columns

<div class="wp-block-columns"><div class="wp-block-column" style="flex-basis:45%"><div style="height:18px" aria-hidden="true" class="wp-block-spacer"></div><h4><strong>No Moves Yet</strong></h4><p>Several months into Breed&#8217;s Tenderloin emergency declaration, neither forced treatment nor the city&#8217;s safe injection site have materialized.</p><p>Asked directly via email if Breed supports involuntary commitment for people with drug addiction—or if the police would begin funneling drug users into rehab, or when—Jeff Cretan, the mayor’s chief spokesperson, did not respond.&nbsp;</p><p>In an earlier email, Cretan pointed out that Breed has since 2019 supported a proposal from state Sen. Scott Wiener, a former city supervisor, to expand the state’s involuntary commitment laws to include “those who are truly suffering and unable to care for themselves,” including someone with a dual diagnosis of mental health and substance abuse issues.</p><figure class="wp-block-image size-full"><img src="https://content.sfstandard.com/wp-content/uploads/2022/03/HousingHereSay-45.jpg" alt="" class="wp-image-41500"/><figcaption><em>Speaker of the House Nancy Pelosi, State Sen. Scott Wiener and Mayor London Breed tour a new housing complex in San Francisco’s Sunnydale neighborhood on Oct. 14, 2021. | Camille Cohen</em></figcaption></figure><p>“The mayor has also said repeatedly that as we make more investments in housing, shelter and treatment, we need people to take those options when they are made available, and not be allowed to stay on the street,” Cretan added.</p><p>Spokespeople for District Attorney Chesa Boudin refused to discuss whether the city’s top prosecutor supports mandatory treatment, though Boudin did appear at a December press conference held by HealthRight360, one of the city’s leading treatment providers, in which involuntary treatment was cast as a regressive return to a punishment-first drug war paradigm.&nbsp;</p><p>Leo Beletsky, a professor of law and health sciences at Northeastern University who has extensively studied mandatory rehab, said the idea was ultimately something of a fig leaf—though maybe one that satisfies the current political zeitgeist.&nbsp;</p><p>Said Beletsky: “It’s much easier to say, ‘OK, well, we’re not going to incarcerate people, we’re just going to incarcerate them and call it treatment.’”</p></div><div class="wp-block-column cc_insufficient_col" style="flex-basis:44%"><div style="height:14px" aria-hidden="true" class="wp-block-spacer"></div><h4 id="h-insufficient-capacity-for-care"><strong>Insufficient Capacity </strong><br><strong>for Care</strong></h4><p>Advocates say what would work best in San Francisco, beyond solving underlying social problems like the housing crisis, is expanding the city’s treatment capacity and making sure that the programs adhere to best practices.</p><p>Data on the availability of treatment beds in San Francisco is sketchy, as are exact figures for how many programs are on offer in the city, but the available numbers are not encouraging. According to a recent statement provided by the DPH, the city has 2,200 “spaces” in its “residential care and treatment offerings,” with “over 400 spaces being added.”</p><p>However, according to a recent publicly available snapshot on <a href="https://findtreatment-sf.org/" target="_blank" rel="noreferrer noopener">findtreatment-sf.org</a>, the city advertised a capacity of 500 substance-use disorder treatment beds in three categories and had only a few dozen available. Of the 58 “detox now” beds, 48 offered medical detox. “There remains reduced capacity at some sites due to Covid and the required safety precautions,” DPH spokesperson Zoe Harris wrote in an email.</p><p>These figures only include treatment beds contracted by DPH and not beds offered by nonprofit service providers who might contract with the courts.</p><p>A <a href="https://sf.curbed.com/2018/5/9/17336090/san-francisco-needles-syringes-exchange-numbers-sf" target="_blank" rel="noreferrer noopener">2016 DPH estimate</a> put the number of intravenous drug users in San Francisco at roughly 22,000. That figure has been repeated as gospel ever since. The number of hard drug users who may snort or smoke their stuff is surely higher, especially considering that fentanyl and its analogs—often smoked rather than injected—didn’t really take off in the Tenderloin until around 2018, and drug experts like Daniel Ciccarone of UCSF identify stimulants as the current overdose crisis’ &#8220;fourth wave.&#8221;nonprofit service providers who might contract with the courts.</p><p>Critics also question the city’s commitment to “social” or “non-medical” treatment programs–the most common approach, according to DPH–which don’t offer those struggling with an opioid addiction the option of an agonist like Suboxone.</p><p>Whatever the specifics of the treatment, unless the city built a new dedicated treatment facility or converted the San Bruno jail to a drug-rehab center—<a href="https://www.theatlantic.com/politics/archive/2019/11/going-jail-substance-abuse-treatment/602206/" target="_blank" rel="noreferrer noopener">a proposition some experts think is smart policy</a>—committing even a fraction of local addicts to treatment is not currently something the city can physically do.</p></div></div>

The politics of addiction: Newsom sees forced treatment as a solution, but doctors have their doubts

Josh Koehn

The most important phone call of <a href="https://sfstandard.com/search/?query=london%20breed">London Breed</a>’s career went to voicemail. So did the next call. And the next.&nbsp;

<p>The most important phone call of <a href="https://sfstandard.com/search/?query=london%20breed">London Breed</a>’s career went to voicemail. So did the next call. And the next.&nbsp;</p>

San Francisco police had already been dispatched to Breed’s apartment in the middle of the night when she finally picked up the phone and got an inkling of just how drastically her life was about to change. Earlier in the evening of Dec. 11, 2017, Mayor Ed Lee had suffered a heart attack while grocery shopping. As president of the Board of Supervisors, Breed was first in line to the throne.&nbsp;

<p>San Francisco police had already been dispatched to Breed’s apartment in the middle of the night when she finally picked up the phone and got an inkling of just how drastically her life was about to change. Earlier in the evening of Dec. 11, 2017, Mayor Ed Lee had suffered a heart attack while grocery shopping. As president of the Board of Supervisors, Breed was first in line to the throne.&nbsp;</p>

She arrived at Zuckerberg San Francisco General Hospital in an ashen state, according to one of the many city officials who stood vigil that night. Doctors were struggling to keep Lee alive, but word was spreading that he would be severely incapacitated even if he survived. Breed joined the mayor’s chief of staff, Jason Elliott, and another advisor in a conference room as they waited for news. At 1:11 a.m, Lee’s heart took its last beat.

<p>She arrived at Zuckerberg San Francisco General Hospital in an ashen state, according to one of the many city officials who stood vigil that night. Doctors were struggling to keep Lee alive, but word was spreading that he would be severely incapacitated even if he survived. Breed joined the mayor’s chief of staff, Jason Elliott, and another advisor in a conference room as they waited for news. At 1:11 a.m, Lee’s heart took its last beat.</p>

“I told her: ‘You’re the mayor now,’” Elliott recalled. “And that was the beginning.”

<p>“I told her: ‘You’re the mayor now,’” Elliott recalled. “And that was the beginning.”</p>

Breed showed grace under pressure in the role of acting mayor and rallied the city in the days to come. But in short order, Breed’s colleagues would turn against her, forcing her to mount a historic campaign to become San Francisco’s first elected Black woman mayor. She was propelled into office by a diverse but&nbsp;moderate-leaning coalition of voters, garnering strong support from women&nbsp;and people of color as well as real estate and business interests. But the honeymoon would be brief.

<p>Breed showed grace under pressure in the role of acting mayor and rallied the city in the days to come. But in short order, Breed’s colleagues would turn against her, forcing her to mount a historic campaign to become San Francisco’s first elected Black woman mayor. She was propelled into office by a diverse but&nbsp;moderate-leaning coalition of voters, garnering strong support from women&nbsp;and people of color as well as real estate and business interests. But the honeymoon would be brief.</p>

core/video

<figure class="wp-block-video"><video autoplay controls loop muted src="https://content.sfstandard.com/wp-content/uploads/2023/06/BreedProfile05312023_VIDEO_LEE_DEATH.mp4"></video><figcaption class="wp-element-caption">After the death of San Francisco Mayor Ed Lee on Dec. 12, 2017, London Breed addresses the media after assuming the role of acting mayor. | Courtesy SFGovTV</figcaption></figure>

<div class="wp-block-column"><figure class="wp-block-video"><video autoplay controls loop muted src="https://content.sfstandard.com/wp-content/uploads/2023/06/BreedProfile05312023_VIDEO_LEE_DEATH.mp4"></video><figcaption class="wp-element-caption">After the death of San Francisco Mayor Ed Lee on Dec. 12, 2017, London Breed addresses the media after assuming the role of acting mayor. | Courtesy SFGovTV</figcaption></figure></div>

<div class="wp-block-columns"><div class="wp-block-column"><figure class="wp-block-video"><video autoplay controls loop muted src="https://content.sfstandard.com/wp-content/uploads/2023/06/BreedProfile05312023_VIDEO_LEE_DEATH.mp4"></video><figcaption class="wp-element-caption">After the death of San Francisco Mayor Ed Lee on Dec. 12, 2017, London Breed addresses the media after assuming the role of acting mayor. | Courtesy SFGovTV</figcaption></figure></div></div>

Breed’s handling of Covid was widely praised, but the vulnerabilities of a local economy disproportionately dependent on tech would soon be exposed. For years, San Francisco’s tax coffers had been bursting at the seams, but a debt was coming due amid a new era of remote work. All the while, the widening gulf between haves and have-nots coupled with hopeless bureaucratic stonewalling had exacerbated issues around housing, homelessness, drug addiction and property crime.

<p>Breed’s handling of Covid was widely praised, but the vulnerabilities of a local economy disproportionately dependent on tech would soon be exposed. For years, San Francisco’s tax coffers had been bursting at the seams, but a debt was coming due amid a new era of remote work. All the while, the widening gulf between haves and have-nots coupled with hopeless bureaucratic stonewalling had exacerbated issues around housing, homelessness, drug addiction and property crime.</p>

Five and a half years after Lee’s death, Breed now stands at the helm of a city in turmoil.&nbsp;

<p>Five and a half years after Lee’s death, Breed now stands at the helm of a city in turmoil.&nbsp;</p>

San Francisco’s reputation as a bastion of innovation and liberalism has given way to narratives about wasted potential and American rot. The city is on pace for a record-setting 800 drug <a href="https://sfstandard.com/public-health/man-dies-of-possible-drug-overdose-at-downtown-san-francisco-bart-station/">overdose deaths</a> this year; tents, discarded needles, artless graffiti, psychotic breakdowns and sidewalk scat are common even in some affluent neighborhoods. Property crime is rampant, and—despite <a href="https://sfstandard.com/business/san-francisco-home-listings-way-down-as-mortgage-lock-in-scares-off-sellers/">a dip in the market</a>—the idea of owning a home in the city remains a pipe dream for most as median home prices hover at around $1.3 million.

<p>San Francisco’s reputation as a bastion of innovation and liberalism has given way to narratives about wasted potential and American rot. The city is on pace for a record-setting 800 drug <a href="https://sfstandard.com/public-health/man-dies-of-possible-drug-overdose-at-downtown-san-francisco-bart-station/">overdose deaths</a> this year; tents, discarded needles, artless graffiti, psychotic breakdowns and sidewalk scat are common even in some affluent neighborhoods. Property crime is rampant, and—despite <a href="https://sfstandard.com/business/san-francisco-home-listings-way-down-as-mortgage-lock-in-scares-off-sellers/">a dip in the market</a>—the idea of owning a home in the city remains a pipe dream for most as median home prices hover at around $1.3 million.</p>

Major retailers such as <a href="https://sfstandard.com/business/downtown-san-francisco-whole-foods-market-closing/">Whole Foods</a>, <a href="https://sfstandard.com/business/nordstrom-to-shutter-both-san-francisco-downtown-stores-citing-deteriorating-conditions-report/">Nordstrom</a> and <a href="https://sfstandard.com/business/downtown-san-francisco-old-navy-flagship-store-closing-after-26-years/">Old Navy</a> have decided to shutter their flagship stores. Remote work has <a href="https://sfstandard.com/business/downtown-san-francisco-vacancies-hit-record-high-as-city-nears-breaking-point/">emptied out almost a third of San Francisco’s office space</a>, contributing to <a href="https://sfstandard.com/politics/city-hall/san-franciscos-deficit-swells-to-780m-in-latest-sign-of-budget-distress/">a $780 million budget deficit</a> and leaving Downtown skyscrapers to sit like ghost towns with panoramic views of the bay.

<p>Major retailers such as <a href="https://sfstandard.com/business/downtown-san-francisco-whole-foods-market-closing/">Whole Foods</a>, <a href="https://sfstandard.com/business/nordstrom-to-shutter-both-san-francisco-downtown-stores-citing-deteriorating-conditions-report/">Nordstrom</a> and <a href="https://sfstandard.com/business/downtown-san-francisco-old-navy-flagship-store-closing-after-26-years/">Old Navy</a> have decided to shutter their flagship stores. Remote work has <a href="https://sfstandard.com/business/downtown-san-francisco-vacancies-hit-record-high-as-city-nears-breaking-point/">emptied out almost a third of San Francisco’s office space</a>, contributing to <a href="https://sfstandard.com/politics/city-hall/san-franciscos-deficit-swells-to-780m-in-latest-sign-of-budget-distress/">a $780 million budget deficit</a> and leaving Downtown skyscrapers to sit like ghost towns with panoramic views of the bay.</p>

More than three-quarters of San Franciscans <a href="https://sfstandard.com/business/heres-how-san-francisco-officials-are-doing-on-their-plan-to-save-downtown/">believe the city is on the wrong track</a>, a recent poll showed, and Breed’s approval numbers are plunging.&nbsp;

<p>More than three-quarters of San Franciscans <a href="https://sfstandard.com/business/heres-how-san-francisco-officials-are-doing-on-their-plan-to-save-downtown/">believe the city is on the wrong track</a>, a recent poll showed, and Breed’s approval numbers are plunging.&nbsp;</p>

Breed’s tough talk on crime and blame game with “lefty” political opponents is wearing thin. Frustrated residents are questioning her vision for the city and turning a critical eye to her performance. Meanwhile, potential challengers are kicking the tires on campaigns to defeat her in 2024.&nbsp;

<p>Breed’s tough talk on crime and blame game with “lefty” political opponents is wearing thin. Frustrated residents are questioning her vision for the city and turning a critical eye to her performance. Meanwhile, potential challengers are kicking the tires on campaigns to defeat her in 2024.&nbsp;</p>

Over six months, The Standard interviewed more than 50 people close to Breed, from friends and neighbors in the Western Addition housing project where she grew up to associates and colleagues in City Hall. The portrait that emerged from these conversations is that of a sharp-tongued but sincere leader. Breed is charming, intuitive, community-driven and wickedly funny, a people person just as capable of connecting with minimum-wage <a href="https://sfstandard.com/public-health/can-san-franciscos-new-welcome-ambassadors-uplift-the-citys-image/">street ambassadors</a> as high-society <a href="https://sfstandard.com/politics/elections/wealthy-san-franciscans-battle-it-out-november-ballot-measures/">power brokers</a>.

<p>Over six months, The Standard interviewed more than 50 people close to Breed, from friends and neighbors in the Western Addition housing project where she grew up to associates and colleagues in City Hall. The portrait that emerged from these conversations is that of a sharp-tongued but sincere leader. Breed is charming, intuitive, community-driven and wickedly funny, a people person just as capable of connecting with minimum-wage <a href="https://sfstandard.com/public-health/can-san-franciscos-new-welcome-ambassadors-uplift-the-citys-image/">street ambassadors</a> as high-society <a href="https://sfstandard.com/politics/elections/wealthy-san-franciscans-battle-it-out-november-ballot-measures/">power brokers</a>.</p>

However, behind closed doors, some of Breed’s strongest traits cut both ways. The 48-year-old mayor’s bluntness can complicate collaboration. Breed doesn’t micromanage, but some say she over-delegates leadership to overwhelmed department heads and staff who are running on fumes. Supporters praise her willingness to try new strategies to confront the generational crises plaguing San Francisco, though they admit the implementation can be scattershot.&nbsp;

<p>However, behind closed doors, some of Breed’s strongest traits cut both ways. The 48-year-old mayor’s bluntness can complicate collaboration. Breed doesn’t micromanage, but some say she over-delegates leadership to overwhelmed department heads and staff who are running on fumes. Supporters praise her willingness to try new strategies to confront the generational crises plaguing San Francisco, though they admit the implementation can be scattershot.&nbsp;</p>

Mayor London Breed speaks during a press conference about the state of smalls businesses in the SoMa district of San Francisco, on Wednesday, June 8, 2022. | Camille Cohen/The Standard


<figure class="wp-block-image size-full"><img src="https://content.sfstandard.com/wp-content/uploads/2023/06/INLINED1_NEW_BreedProfile11142022.jpg" alt="Mayor London Breed speaks about the state of small businesses in the South of Market area of San Francisco on June 8, 2022" class="wp-image-171134"/><figcaption class="wp-element-caption">Mayor London Breed speaks about the state of small businesses in the South of Market area of San Francisco on June 8, 2022. | Camille Cohen/The Standard</figcaption></figure>


The mission of being mayor is deeply personal for Breed. Unlike most of the city’s politicians, her life was profoundly shaped by many of the same ills now roiling San Francisco: poverty, addiction, crime, mental illness and housing and economic instability.

<p>The mission of being mayor is deeply personal for Breed. Unlike most of the city’s politicians, her life was profoundly shaped by many of the same ills now roiling San Francisco: poverty, addiction, crime, mental illness and housing and economic instability.</p>

“You grow up a certain way, and you remember it like it was yesterday,” Breed said in an early June interview with The Standard. “The fact that I even graduated from high school and ended up in college and graduated from college—for me, it’s a big deal. And it also makes me live like I have nothing to lose.”

<p>“You grow up a certain way, and you remember it like it was yesterday,” Breed said in an early June interview with The Standard. “The fact that I even graduated from high school and ended up in college and graduated from college—for me, it’s a big deal. And it also makes me live like I have nothing to lose.”</p>

A ballot measure passed last year pushed the mayor’s race to 2024, extending the tightrope Breed must traverse to reelection. To secure a second term and become the longest-serving San Francisco mayor in almost a century, Breed will need to solve—or at least alleviate—the problems of a broken city that have been decades in the making.

<p>A ballot measure passed last year pushed the mayor’s race to 2024, extending the tightrope Breed must traverse to reelection. To secure a second term and become the longest-serving San Francisco mayor in almost a century, Breed will need to solve—or at least alleviate—the problems of a broken city that have been decades in the making.</p>

This is far from the only time Breed has faced extreme pressure. But even some of her most ardent supporters are uncertain if she’s capable of answering the call.

<p>This is far from the only time Breed has faced extreme pressure. But even some of her most ardent supporters are uncertain if she’s capable of answering the call.</p>

“Is there a feeling of vulnerability?” asked one of the mayor’s closest allies, who spoke on the condition of anonymity. “One hundred percent, yes.”

<p>“Is there a feeling of vulnerability?” asked one of the mayor’s closest allies, who spoke on the condition of anonymity. “One hundred percent, yes.”</p>

Chapter I: ‘You Can’t Mess With Her’


<h2 class="wp-block-heading" id="h-chapter-i-you-can-t-mess-with-her">Chapter I: ‘You Can’t Mess With Her’</h2>


<p>“The reason she doesn’t go into that is because it’s not just her story. It’s her mother’s story. It’s her family’s story.&#8221; 
</p>
<p class="quote-attribution"> — Sheryl Davis, executive director of the San Francisco Human Rights Commission</p>

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<div class="quote-container">
<p>“The reason she doesn’t go into that is because it’s not just her story. It’s her mother’s story. It’s her family’s story." 
</p>
<p class="quote-attribution"> — Sheryl Davis, executive director of the San Francisco Human Rights Commission</p>
</div>

<div class="quote-container">
<p>“The reason she doesn’t go into that is because it’s not just her story. It’s her mother’s story. It’s her family’s story.&#8221; 
</p>
<p class="quote-attribution"> — Sheryl Davis, executive director of the San Francisco Human Rights Commission</p>
</div>

The mayor is fiercely protective about telling her family’s story—in part due to the tragedies she endured, but also because she herself doesn’t have all the answers.

<p>The mayor is fiercely protective about telling her family’s story—in part due to the tragedies she endured, but also because she herself doesn’t have all the answers.</p>

Breed’s mother was absent much of her childhood and their relationship is complicated. The mayor does not know the identity of her father. She recently took a DNA test and learned she is half Jewish, a discovery she revealed privately to a group traveling with her on a <a href="https://sf.gov/news/mayor-breed-lead-mission-strengthen-relations-san-franciscos-sister-city-haifa#:~:text=Haifa%20has%20been%20a%20sister%20city%20of%20San%20Francisco%20since%201973.">Sister City trip to Haifa, Israel</a>, in May.

<p>Breed’s mother was absent much of her childhood and their relationship is complicated. The mayor does not know the identity of her father. She recently took a DNA test and learned she is half Jewish, a discovery she revealed privately to a group traveling with her on a <a href="https://sf.gov/news/mayor-breed-lead-mission-strengthen-relations-san-franciscos-sister-city-haifa#:~:text=Haifa%20has%20been%20a%20sister%20city%20of%20San%20Francisco%20since%201973.">Sister City trip to Haifa, Israel</a>, in May.</p>

“I don’t want to talk about my family in a way that throws them under the bus,” Breed told The Standard in the second of two sit-down interviews for this story. “The fact is, I don’t know my biological father, and I’ve recently made a discovery that I have not made public in any way.”

<p>“I don’t want to talk about my family in a way that throws them under the bus,” Breed told The Standard in the second of two sit-down interviews for this story. “The fact is, I don’t know my biological father, and I’ve recently made a discovery that I have not made public in any way.”</p>

Breed was born at Kaiser Hospital in San Francisco on Aug. 11, 1974, and spent her earliest years living with her grandmother, siblings and two aunts in a cramped apartment in Plaza East, one of the city’s toughest public housing projects and the epicenter of a murderous turf war between rival gangs.

<p>Breed was born at Kaiser Hospital in San Francisco on Aug. 11, 1974, and spent her earliest years living with her grandmother, siblings and two aunts in a cramped apartment in Plaza East, one of the city’s toughest public housing projects and the epicenter of a murderous turf war between rival gangs.</p>

A booklet entitled “The New Western Addition Is a Good Place to Live” published in 1971, outlines new housing developments, apartments and public spaces as part of the larger Western Addition redevelopment project. London Breed was raised in the Western Addition’s Yerba Buena Plaza East housing project. | Courtesy San Francisco Redevelopment Agency


<figure class="wp-block-image size-full"><img src="https://content.sfstandard.com/wp-content/uploads/2023/06/INLINED2_NEW_BreedProfile11142022.jpg" alt="A booklet published in 1971 outlines new housing developments in the Western Addition. London Breed was raised in the neighborhood's Plaza East public housing project. | Courtesy San Francisco Redevelopment Agency" class="wp-image-171138"/><figcaption class="wp-element-caption">A booklet published in 1971 outlines new housing developments in the Western Addition. London Breed was raised in the neighborhood&#8217;s Plaza East public housing project. | Courtesy San Francisco Redevelopment Agency</figcaption></figure>


<figure class="wp-block-image size-full"><img src="https://content.sfstandard.com/wp-content/uploads/2023/06/INLINED2_NEW_BreedProfile11142022.jpg" alt="A booklet published in 1971 outlines new housing developments in the Western Addition. London Breed was raised in the neighborhood's Plaza East public housing project. | Courtesy San Francisco Redevelopment Agency" class="wp-image-171138"/><figcaption class="wp-element-caption">A booklet published in 1971 outlines new housing developments in the Western Addition. London Breed was raised in the neighborhood's Plaza East public housing project. | Courtesy San Francisco Redevelopment Agency</figcaption></figure>

<figure class="wp-block-image size-full"><img src="https://content.sfstandard.com/wp-content/uploads/2023/06/INLINED2_NEW_BreedProfile11142022.jpg" alt="A booklet published in 1971 outlines new housing developments in the Western Addition. London Breed was raised in the neighborhood's Plaza East public housing project. | Courtesy San Francisco Redevelopment Agency" class="wp-image-171138"/><figcaption class="wp-element-caption">A booklet published in 1971 outlines new housing developments in the Western Addition. London Breed was raised in the neighborhood&#8217;s Plaza East public housing project. | Courtesy San Francisco Redevelopment Agency</figcaption></figure>

“If you were not Black or didn&#8217;t live there, you could not come to these projects,” Breed said. “You had to say a name. There was a name that had to be used—otherwise, you couldn&#8217;t walk through there at all. You would get robbed. You would get beat up, everything.”

<p>“If you were not Black or didn't live there, you could not come to these projects,” Breed said. “You had to say a name. There was a name that had to be used—otherwise, you couldn't walk through there at all. You would get robbed. You would get beat up, everything.”</p>

<p>“If you were not Black or didn&#8217;t live there, you could not come to these projects,” Breed said. “You had to say a name. There was a name that had to be used—otherwise, you couldn&#8217;t walk through there at all. You would get robbed. You would get beat up, everything.”</p>

At 12 years old, Breed saw the corpse of a person who had been shot in the head. In her 20s, one of her brothers took part in a deadly robbery and was sentenced to prison. In 2006, Breed lost a younger sister to a drug overdose, and one of her cousins was killed by police. Over the years, officers were routinely called to help with one of Breed’s aunts, who suffered from mental illness and explosive fits of rage.

<p>At 12 years old, Breed saw the corpse of a person who had been shot in the head. In her 20s, one of her brothers took part in a deadly robbery and was sentenced to prison. In 2006, Breed lost a younger sister to a drug overdose, and one of her cousins was killed by police. Over the years, officers were routinely called to help with one of Breed’s aunts, who suffered from mental illness and explosive fits of rage.</p>

The kindness shown by these officers, including a cop whom Breed’s aunt lovingly nicknamed “Beefcakes,” shaped the mayor’s nuanced views on policing. As a supervisor, Breed called for a federal investigation into the <a href="https://www.sfweekly.com/archives/supervisor-london-breed-calls-for-a-federal-investigation-into-the-sfpds-shooting-death-of-mario/article_f8b7d433-ce35-5ddb-b5bb-d2fb8d563379.html" target="_blank" rel="noreferrer noopener">police killing of Mario Woods</a>; as mayor, she has advocated for a crackdown on people using drugs on the streets, expanding police surveillance tools and hiring more officers.

<p>The kindness shown by these officers, including a cop whom Breed’s aunt lovingly nicknamed “Beefcakes,” shaped the mayor’s nuanced views on policing. As a supervisor, Breed called for a federal investigation into the <a href="https://www.sfweekly.com/archives/supervisor-london-breed-calls-for-a-federal-investigation-into-the-sfpds-shooting-death-of-mario/article_f8b7d433-ce35-5ddb-b5bb-d2fb8d563379.html" target="_blank" rel="noreferrer noopener">police killing of Mario Woods</a>; as mayor, she has advocated for a crackdown on people using drugs on the streets, expanding police surveillance tools and hiring more officers.</p>

“Folks don’t realize that, by and large, Black people are pretty conservative when it comes to what public safety looks like,” said Sheryl Davis, the head of the city’s Human Rights Commission. “They’re not always against the police. They just don&#8217;t want the police to be brutalizing them.”

<p>“Folks don’t realize that, by and large, Black people are pretty conservative when it comes to what public safety looks like,” said Sheryl Davis, the head of the city’s Human Rights Commission. “They’re not always against the police. They just don't want the police to be brutalizing them.”</p>

<p>“Folks don’t realize that, by and large, Black people are pretty conservative when it comes to what public safety looks like,” said Sheryl Davis, the head of the city’s Human Rights Commission. “They’re not always against the police. They just don&#8217;t want the police to be brutalizing them.”</p>

Breed’s grandmother, Comelia Brown, was a Baptist faithful to the good book. Miss Brown—as she was known throughout the neighborhood—served as the family rock, the guiding light and the hammer that forged Breed into the person she is today.

<p>Breed’s grandmother, Comelia Brown, was a Baptist faithful to the good book. Miss Brown—as she was known throughout the neighborhood—served as the family rock, the guiding light and the hammer that forged Breed into the person she is today.</p>

“She was a church lady,” said Rev. Arnold Townsend, who was present at Breed’s baptism and helped officiate the funerals of the mayor’s grandmother and sister. “And in the Black community, that means a certain thing—very, very stern and can be quite severe when necessary.”

<p>“She was a church lady,” said Rev. Arnold Townsend, who was present at Breed’s baptism and helped officiate the funerals of the mayor’s grandmother and sister. “And in the Black community, that means a certain thing—very, very stern and can be quite severe when necessary.”</p>

Under her grandmother’s watch, Breed and her siblings were required to cook and clean, make their beds and go to school, or get out of the house. Miss Brown handed out whoopings and flushed her grandson’s drugs down the toilet. She scolded Breed when she felt embarrassed about buying groceries with food stamps, telling her granddaughter to hold her head high and focus on survival until the next step.

<p>Under her grandmother’s watch, Breed and her siblings were required to cook and clean, make their beds and go to school, or get out of the house. Miss Brown handed out whoopings and flushed her grandson’s drugs down the toilet. She scolded Breed when she felt embarrassed about buying groceries with food stamps, telling her granddaughter to hold her head high and focus on survival until the next step.</p>

A composite image of London Breed as a toddler with her grandmother, Comelia Brown, left, and a portrait of London Breed as a baby, right, that was published in the 1992 Galileo High School yearbook. | Courtesy London Breed


<figure class="wp-block-image size-full"><img src="https://content.sfstandard.com/wp-content/uploads/2023/06/INLINED3_BreedProfile11142022.jpg" alt="A composite image shows a picture of London Breed as a toddler with her grandmother, Comelia Brown, and a photo of London Breed as a baby that was published in the 1992 Galileo High School yearbook." class="wp-image-170713"/><figcaption class="wp-element-caption">A composite image shows a picture of London Breed as a toddler with her grandmother, Comelia Brown, and a photo of London Breed as a baby that was published in the 1992 Galileo High School yearbook. | Courtesy London Breed</figcaption></figure>


“Miss Brown was everybody’s mother and everybody’s grandmother in the community,” said Shawn Richard, a neighbor of Breed’s in Plaza East and the city’s first Black cannabis dispensary owner. “We respected that, and [Breed] was raised with values. You know, they had to go to church on Sundays, and the rest of us would go to church with them because Miss Brown demanded that.”

<p>“Miss Brown was everybody’s mother and everybody’s grandmother in the community,” said Shawn Richard, a neighbor of Breed’s in Plaza East and the city’s first Black cannabis dispensary owner. “We respected that, and [Breed] was raised with values. You know, they had to go to church on Sundays, and the rest of us would go to church with them because Miss Brown demanded that.”</p>

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