Broken Fix

In a radical approach, San Francisco is making addiction a health issue rather than a law enforcement imperative. So far, though, treatment on demand has been a costly pipe dream.

He asks me for $10, though he hasn't told me his name. We're in the emergency room at San Francisco General Hospital. It's early one Friday evening, and the room is already packed with a motley array of bandaged heads and seeping sores. This guy's shuffling from person to person, asking, "You got a 10? I really need it," as if each were an old friend he had borrowed from before.

"Why?" somebody asks.

"My sister needs it," he says. "She's having a baby."

Sonda Andersson Pappan
James Stillwell, interim director of Community Substance Abuse Services.
Anthony Pidgeon
James Stillwell, interim director of Community Substance Abuse Services.

Details

RELATED LINKS

Community Substance Abuse Services Contractors
Treatment centers funded by the county, courtesy of the District Attorney's office Narcotics Unit Program

San Francisco Department of Public Health Resolution: 9a0525c
Full text of the DPH resolution supporting the development of a program for office-based physician prescription of methadone.


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He sits down in the chair next to me and plunges his attention into a tattered People magazine. He's white, a young man, not yet 30 years old, with a big red 49ers jacket and white Adidas. He wears a gold ring on his right ring finger, two little hands clasping a heart. He could be any middle-class Irishman from the Outer Sunset, except his socks are filthy, drooping around his ankles, and he faintly stinks. Under the white neon lights, tiny beads of sweat shine on his forehead as he flips through the pages of the magazine. Then suddenly he gags, leaning over the arm of the chair toward the wall. Once he recovers, he turns to me.

"Can you help me with $10?"

"I might if you'll let me ask you a few questions," I tell him. "Are you jonesing?"

He nods.

"How long has it been?"

"This morning," he says.

"You ever try treatment?" I ask him.

He gives me a funny look. "Do I look like I got AIDS or something?"

"I'm just wondering," I say.

"Yeah, I tried it," he says. "It didn't work."

"Why not?"

"I wasn't clean," he says. "They told me I had to be clean. So then I came back a few hours later, and they told me I'd have to come back tomorrow, so I said fuck it. Can I have my $10 now?"

I give him a $10 bill, and he's out the door.

Like any number of heroin addicts, this man has sought help and, for one reason or another, failed to get into the system. But considering that he is young, it's likely he will try to kick his habit again, and when he makes that decision, the San Francisco Health Department hopes to be there to catch him.

The city's substance abuse program has gone through a major overhaul in the last four years, expanding its budget by 88 percent, from $27 million to $51 million, largely in an ambitious attempt to provide what health care professionals call "treatment on demand": the ability to promptly place addicts in a recovery program when they ask for it. In a sharp departure from federal drug policies, the city is taking a radical approach to the war on drugs, making addiction a health issue rather than a law enforcement issue.

Mayor Willie Brown has made a strong commitment to the plan, earmarking almost $14 million a year specifically for treatment on demand services. The only other city in the country to even try something like this is Baltimore, which began a parallel program of its own in 1997, the same year as San Francisco. The two cities are gambling on the idea that pouring vast amounts of money into treatment services will dry up the local drug markets. It is a humanitarian approach with especially long odds, given the fact that only one in five substance users are clean a year after treatment.

Despite the low success rate, however, drug policy experts -- liberal and conservative -- tend to agree that attacking the drug epidemic from the treatment side is the most effective approach to the problem. Incarcerating nonviolent drug users has helped very few people, except for those who work in the prison industry; on the other hand, studies estimate that every dollar spent on treatment yields a $7 return. Even a report commissioned by former prison-happy Gov. Pete Wilson showed that the $209 million the state was spending on drug treatment services in 1992 was reaping a $1.5 billion savings, mostly in law enforcement costs.

But if experts evince clear agreement that treatment is a good idea, it is entirely unclear that San Francisco is implementing that idea well. Since the program's inception in 1997, $13.9 million has been added to the treatment on demand budget, and although it is still early to have a complete picture of the program's effectiveness, San Francisco is showing very few signs of progress on the drug abuse front. The city has opened just 1,248 new treatment slots, a surprisingly small, 22 percent increase over the number that already existed, considering the amount of money added to the program. Waiting lists for residential drug treatment still hover around 1,000 people long, and the waits can vary from four weeks up to six months. It is true that far fewer people have been sent from San Francisco to prison for drug-related offenses since the program began, which saves the state Corrections Department money. But that doesn't mean treatment on demand has cut into San Francisco's drug-related crime problem; there were more drug-related arrests in 1998 than any year in the 1990s. Similarly, the city's program has yet to make an apparent dent in the abuse of dangerous drugs: Drug-related visits to San Francisco General Hospital's emergency room are now more frequent than when the program began.

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