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.”
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?”
“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.”
“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.
As is so often the case in San Francisco, it appears city government has allowed the ants to make off with the picnic. Rather than developing a solid planning process for the allocation of $13.9 million a year (and rising) in treatment-on demand funds, the Health Department has assigned the task to a “council” of competing interest groups, all vying for a helping from this big pot of money. The Health Department's description of the program as “grass roots” is an understatement, critics say. In reality, they say, the city has virtually handed the program to a loose confederacy of nonprofits dependent on public funds for their survival. [page]
Until last month, there had been no money designated toward planning for the treatment on demand program, and there still has been no money allocated toward evaluating which treatment services work, and which do not. As a result, some of the most effective modalities, such as methadone maintenance, have received just a trickle of funding, while other, less effective services, such as “education” programs aimed at preventing drug use, have gotten more money than they probably deserved.
San Francisco's treatment on demand program has the opportunity to be “lauded as a national model,” as Supervisor Gavin Newsom has suggested, but it also runs the risk of being used as an example of how good ideas can go horribly wrong.
“My fear about San Francisco,” says Herbert Kleber, director of the substance abuse division at Columbia University, “is that it's going to throw away all this money, and discourage other cities that might want to try this.”
More important than the example San Francisco sets for other cities, however, is the grave need S.F. has for these services. Earlier this year, Public Health Director Mitchell Katz declared that San Francisco leads the nation in emergency room visits for heroin, speed, and LSD. Drug-related injuries lead all other categories in admissions to General Hospital. There are now an estimated 14,000 heroin users in San Francisco, and the city's heroin-related death rate is three times higher than the state average. Experts say the flow of heroin into the city has yet to reach its peak, and without the proper services in place, the death toll is likely to rise.
It's just after Thanksgiving, and the Treatment on Demand Planning Council is meeting in a conference room within the offices of the city's Community Substance Abuse Services. Outside the room, a buffet has been laid out with a spread of Aram sandwiches, pale vegetables with ranch dip, and a few random dishes such as yams and pecan pie, no doubt left over from the holiday. The conference room is small, and seems smaller with the 40-some-odd people crowded inside around a long wooden table.
The planning council is in charge of allocating the large sums of money flowing into the treatment on demand program. Comprising the city's drug treatment world, it bears the loose resemblance of a United Nations meeting. You've got the two jail-treatment guys, both African-American, one sharply dressed, the other enormous and wearing a fedora. You've got a representative for the homeless, and a few ambassadors for the gay, lesbian, bisexual, and transgender communities. A variety of white people are in attendance with earnest expressions of understanding, as well as a few down-and-out members of the public who have come to ask where in the hell they can find treatment in this town.
The council has gathered to discuss the priorities for the next budget cycle. Item by item, the group goes down a list of 19 services, chosen as priorities from the last meeting. Tonight each member will rate each of the proposed treatments from most important to least important, and from this grading process, a final tally will decide what programs get funded next year. These recommendations will go straight to the mayor, virtually unchanged, in the planning council's budget proposal. The mayor often revises the proposal, sending it back to the council, which can either accept it or lobby for more money. Throughout the process, however, it is the council and the mayor negotiating the treatment on demand budget, with program staff acting only as intermediaries in the dialogue.
Second from the top of the preliminary council priority list is a program called “Culturally competent treatment services for Samoans,” with an estimated cost of $100,000. A thin Asian man with long, flowing hair asks the difference between treatment services for Samoans and treatment services for Asian women, the last item on the list.
A large woman turns to the man. “I don't know what your problem is,” she says loudly. “Do you got something against Samoans? Samoans don't get anything in this town.”
“Bam,” one of the jail guys whispers to the other.
With every item on the list, there is at least some disagreement as to validity. A methadone-in-jail treatment program costing an estimated $270,000 comes under fire as somebody suggests that with so few methadone slots available in the city, a person might be tempted to commit a crime to get into the program. There is also some question of its cost.
“Every fiefdom, I mean organization, has a different way of adding these things,” the sharply dressed jail guy says.
“Looks like I'm going to have to do some more 'advocating,'” the big jail guy says, putting quotation marks around the word by raising his arms and scratching the air with two fingers of each hand.
Farther down the list is a program described as “Long term and permanent housing with supportive treatment for homeless people.” It is being pushed by the Coalition on Homelessness. A representative from the gay, lesbian, bisexual, and transgender community points out that at $1.3 million, this homeless program is estimated to cost $26,000 per person per year, and there is not even any mention of drug treatment in the proposal.
“You better put harm reduction in there somewhere,” somebody says.
“Good idea,” the woman from the coalition says. “Let's make it 'long term housing and harm reduction for homeless people.'”
In addition to its duties deciding which services to fund every year, the planning council is ultimately responsible for the treatment on demand program's success. And make no mistake: With $13.9 million flowing into the program this year, people are looking for signs of success.
Mayor Brown, for one, was quick to declare the program a triumph, boasting that the city had achieved treatment on demand in his 1997 State of the City speech, according to newspaper reports. He was promptly corrected, however, by members of the planning council, who held a press conference to say that the city still had a long way to go before it could accurately make such a claim. Brown stubbornly clung to his statement. [page]
“They are just wrong,” Brown was quoted in both dailies as saying. “I checked. There has not been one clinic or one treatment facility that has turned anybody who walked in away.”
Actually, Brown was just wrong. Health care experts knew the city was far from achieving its goal two years ago, when it took months to get into a residential treatment program. The situation isn't much different today.
“If we're still talking about 1,000 people on the waiting lists — I'm sorry, that's not even close to treatment on demand,” says Patrick Murphy, an adjunct professor of politics at the University of San Francisco. John Newmeyer, an epidemiologist at the Haight Ashbury Free Clinic, is more blunt in his criticism of the program's progress.
“We should expect to see results the first year after treatment on demand begins,” he says. “But we're as bad off as when we began. Only the most persistent and healthy clients can get into one of these treatment slots.”
Considering the amount of money going into treatment on demand services, the city has made very little effort to measure the program's success. Jim Stillwell, interim director of the city's Community Substance Abuse Services, says San Francisco has received about $1 million in federal funds to assess the program on a “macro” level, charting how the system is doing as a whole in “performance measures,” but these gauges don't reveal much.
For instance, one performance measure the Health Department includes in its budget proposal is the percentage of successful treatment outcomes. In fiscal year 1998, the success rate was 50 percent, in 1999 it went up to 55 percent, and in 2000, the Health Department expects the percentage of successful treatment outcomes to be 60 percent. These numbers would constitute great news, if they showed the percentage of people who were clean after they entered treatment; in fact, they show only the percentage of people who completed a program.
Another Health Department measure of “success” seems similarly off-point. This method counts positive responses to the survey question, “Would you recommend clinic to a relative or friend?” This type of indicator might be helpful to, for instance, the marketing director of a hotel chain, but doesn't quite meet scientific standards for proof of efficacy of a public policy program.
The only way to truly gauge the success of a program, experts insist, is to track a sample of the clients through the process, from before they enter treatment to at least a year after they exit the system. The tracking can be as simple as testing whether the client stays clean, or as sophisticated as charting employment and income levels.
“It's a big added cost, but without a research approach to the evaluation process, you have no yardstick to measure which dollars are well spent,” says Peter Banys, a physician at the San Francisco Veterans Hospital who participated in the first phase of a preliminary feasibility study of the treatment on demand program. “All you get are testimonies saying, 'We do great work.' Just throwing dollars at something is not enough; you've got to see what's effective.”
Stillwell says the best type of evaluations are too expensive to implement at this stage of the game. But even without an evaluation process, San Francisco officials could and should know, in general terms, which types of programs are more or less effective than others. The planning council, however, has made some decisions about funding that seem to fly in the face of available research, namely those connected to the council's meager funding of methadone programs. As of fiscal year 1998-99, the planning council had spent only 3 percent of its money on methadone, one of the most researched and effective methods for treating heroin addiction, even though an estimated 38 percent of the city's substance abuse clients are heroin users.
On the other hand, the planning council spent a whopping 12 percent of its budget on prevention — in essence, teaching young people not to use drugs — which is on much more shaky ground in terms of proven effectiveness, does not open any new treatment slots for addicts, and is limited to a young population comprising only about 14 percent of the city's drug users.
Lee lingers outside the bleak facade of the clinic one cold Sunday morning, until a man inside sticks his head out and tells him to “beat rocks.” There is no loitering allowed outside the Bay Area Addiction Research & Treatment clinic. Lee smiles and ambles off, his pupils the size of pinpricks, high on the legal drug he has chosen over heroin.
Every day he comes for his daily dose of methadone syrup, which costs him $12 a cup. Lee says part of his General Assistance check is set aside to pay for his methadone maintenance program; he says he has to hustle for the rest, whether it's panhandling, or stealing if he has to. “But $12 ain't nothing compared to $30 or $40 a day I needed for heroin.”
Lee says he has been on and off methadone programs for five years or so. His current stint has lasted six months. He says he decided to seek treatment after a revelation. “I knew Jesus was coming … and I didn't want to die like that. I didn't want to die like that even if Jesus wasn't coming.”
He says treatment has helped him become better aware of himself, to know when to bathe and to take notice if he stinks while standing next to someone who doesn't. He says he has some ideas of how to make something of himself. He has come up with a few inventions, such as a recording device that would play the sounds of a mother's breath and heartbeat to help a baby sleep. He says he got the idea after reading Walden II by B.F. Skinner, the famed psychologist. [page]
Lee is one of the lucky few in San Francisco to get into a maintenance program that he could keep the rest of his life, if he wanted. Lee says he knows people who have been on methadone maintenance for 15 years. He was lucky because he got into the system before everyone else tried to get in. Now the wait for maintenance at the clinic is at least two weeks, an eternity for a junkie.
Only 1 percent of treatment on demand money was spent on methadone maintenance as of the last fiscal year, even though, at $4,000 annually, it's among the cheaper forms of treatment for heroin addiction, and one of the modalities proven most effective in studies going back decades. (Two percent of the city's treatment budget was spent on methadone detox, a 21-day weaning off heroin that most experts agree is ineffective.) Studies show methadone users earn twice as much income and their death rate is three times lower than heroin users, but of the estimated 14,000 heroin users in San Francisco, only about 2,500 have access to maintenance.
The shortage of treatment slots has only become more severe as heroin use has increased over the last few years. In 1999, nearly twice as many people visited the emergency room at General Hospital for cellulitis, a skin infection that can stem from heroin use, than two years ago, and opiate-related arrests last year were higher than any other year in the 1990s. Some experts, such as John Newmeyer of the Haight Ashbury Free Clinic, blame the shortage on the city's Community Substance Abuse Services' lack of foresight, and the failure of local politicians to push for more methadone clinics.
Others, such as Philippe Bourgois, a professor of anthropology at the University of California, San Francisco, blame the shortage of methadone programs on the treatment culture in California. Bourgois, who has worked with a group of heroin addicts in San Francisco as part of an anthropological research project, says California, particularly San Francisco, has always been hung up about methadone. “I'd say the policy-makers in San Francisco are in the mid- to extreme range of being anti-methadone,” he says. “Everyone's on the abstinence thing here, and methadone doesn't jive with that. In San Francisco, you've got the yogurt- and sprout-eating crowd, while in New York, they don't care, they'll just throw methadone at you. And, perhaps for that reason, they don't have the heroin problem we do.”
Stillwell, in defense of his department, says it's been difficult to find new locations for methadone clinics. Nobody wants an influx of junkies coming into the neighborhood, he says. He says he has also been working with Supervisor Newsom on legislation that would allow physicians in the city to prescribe methadone, opening hundreds of new methadone treatment slots. But when the treatment on demand program began, there were other needs to fill, and, Stillwell says, he has no regrets. “It would have been nice to fund everything at the same time, but of course that's not possible,” he says. “We had so many priorities, we simply couldn't do it all. Remember, if you always go for the quick fix, then you never force the big change.”
The three large men sitting around the table appear slightly sheepish as they describe the police pilot program called Campaign Against Drug Abuse, often known by the acronym CADA. “Sometimes I feel like the long-haired stepchild of law enforcement,” says Michael Ortiz, a burly officer with the state Department of Justice.
George Nazzal and Bob Hernandez, officers with the San Francisco Police Department, say they feel the same way. As part of the federally funded CADA program, they try to divert hard-core drug users into treatment programs, rather than send them to jail, and they say some of their colleagues accuse them of being social workers.
It's not the name-calling that bothers them. They seem a bit embarrassed by the fact that since the program began in April 1998, they have managed to place only four users in treatment. It took about a year to get the program up and running, they say, but once they were ready earlier this year, they couldn't find any clinic that would agree to take people in. Finally they forged a relationship with the McMillan Drop-In Center, which makes referrals to various treatment programs, but even then, they say they were told to bring people by only once or twice a month.
“When we started, we thought we'd be dropping them off by the truckload,” says Ortiz, “and everything would be hunky-dory, but it wasn't like that. The treatment centers were telling us that they didn't want to be inundated with people. So now we're limited to going out once or twice a month.”
CADA's problems underscore, once again, the city's failure to significantly expand its treatment capacity, even when two officers are willing to be called “social workers” to help the program along. The police have good reason to hope the city's treatment on demand program succeeds: They have no interest in arresting the same people over and over again. But some officers say nothing much has changed since the program began.
“Ask [the Community Substance Abuse Services] where the money goes,” says one officer, who chose to withhold his name. “Money seems to fly into that department and fly right back out.”
Even though the city continues to have a severe shortage of treatment slots that sabotages achieving true treatment on demand, the concept of favoring drug treatment over drug prosecution has had a major impact on incarceration rates. According to the California Department of Corrections, in 1998 San Francisco drug offenders spent half as much time in prison as they did in 1988, in terms of the number of convictions and the length of time served, and only a third as much time as they served in 1993. This drop in drug incarceration can be largely attributed to District Attorney Terence Hallinan's public declaration that he prefers to send nonviolent drug offenders to diversion programs rather than prison. [page]
The numbers show that Hallinan has kept his word. Last year, his office sent 228 drug offenders to prison to serve an average of 20 months, according to the state prison system, a steep drop from the 691 San Franciscans who served an average of 14.4 months in 1988, and an even steeper drop from the 832 people who served an average of 17.2 months in 1993.
Thus, thanks to Hallinan's stance on drug offenders, San Francisco is saving the state prison system money at a rate of $1,770 a month for every prisoner not sent to the pen. This type of savings is one of the rationales usually put forward for favoring treatment over prosecution. But at $2,060 per month per offender for residential treatment, the city is spending more trying to rehabilitate drug users than it would cost to incarcerate them. And judging from the city's arrest reports, the majority of San Francisco drug offenders are not getting into prison or treatment. They are staying on the street.
Drug-related arrests are on the rise, indicating that the criminal activity associated with drugs is not going away. Last year, police made 11,080 drug-related arrests, 6,806 for opiates, up from a high in 1996 when police made 9,977 drug-related arrests, 6,163 for opiates. Police blame the rise on an increase in drug trafficking, which has lowered the price of heroin. Nevertheless, the numbers do not reflect well on the city's efforts to reduce crime through treatment on demand.
A young Latina rolls into the emergency room on a gurney, screaming, and she won't stop. She screams, she takes a breath, then she screams again. Her face is covered with acne. She continues wailing, putting the ordinarily thick-skinned hospital staff on edge. The woman behind the front desk covers her ears. Some of the patients lift their heads off their pillows to see what's going on.
“Her brain is frying on crack,” says David Fleming, the assistant nurse in charge of the floor. “She was probably doing S'mores [a quick succession of hits boosting the high]. Finally it just overloads the body.”
Fleming says the staff will give her a dose of droperidol to knock her out; they'll examine her when she wakes up in a few hours. The problem is, he has no place to put her. All 40 beds are filled. He has two patients plastered on alcohol and chained to their beds. One with a sailor's mouth has peed on the floor. He has six patients in for abscesses, the result of slamming heroin into the muscle after all the veins in a body have given out. He has one patient who has overdosed on his girlfriend's morphine. Now the screaming crack overdose makes 10 out of 40 patients whose primary reason for admittance to the hospital is drug- or alcohol-related. And this is at 6 p.m. on a Monday night.
In theory, treatment on demand is supposed to reduce the number of these types of episodes, but since 1997, the number of drug and alcohol visits to the San Francisco General emergency room has gone up, while the total number of visits has remained level. Alcohol-related visits have increased by almost a thousand, from 3,373 episodes in 1997 to 4,218 episodes in 1999. Visits for cellulitis have shot from 781 visits in 1997 to 1,436 this year. The numbers have risen in every other substance-related category too, from general opiate dependency to cocaine.
“Treatment on demand,” Alan Gelb, chief of the emergency room, says skeptically. “Will you define that for me? Because I see a lot of people who want treatment and can't get it. If you want treatment on demand, then you better be ready to demand real, real hard.”
Gelb's opinion of the city's treatment services seems to be shared throughout the emergency room. Of course, at General Hospital, the staff's job is to catch the people who have fallen down, and the workers have not felt any lightening of the load yet.
Two years into treatment on demand, it may be too early to expect to see results from this potentially groundbreaking program. But with millions of dollars a year, and a piece of the city's quality of life on the line, San Francisco at least deserves a solid game plan and a decent evaluation process from the city's Substance Abuse Services. After all, it doesn't have to be this way.
Baltimore, for example, has taken a different tack. That city, struggling with a drug epidemic as bad as San Francisco's, has chosen a more centralized method of managing its program over our grass-roots approach. San Francisco health officials criticize the Baltimore program for its top-down style, but at least Baltimore is making an effort to be accountable to its citizens.
Baltimore is spending $1 million a year on an extensive three-year evaluation process it began the first year of its treatment on demand program, according to the city's health commissioner, Peter Beilenson. The results are expected to be available in the year 2001. In the meantime, the system is managed by a central body of health officials that keeps close tabs on every one of the program's components, he says, monitoring retention rates and taking urine samples for every type of treatment. Baltimore has spent even more money than San Francisco on its program, hiking its budget from $16 million to $33 million. And as a result, the number of treatment slots has jumped from 4,000 in 1997 to 7,000 today, according to the commissioner. There are still long waits for residential and methadone treatment, but at least the citizens of Baltimore will be able to see the results of their tax dollars at work when the city's treatment evaluation comes out. [page]
What results can San Franciscans expect to see?
“That's a tough one,” says Stillwell. “It'll be in the little things. Maybe our parks will be a little cleaner, maybe the line at General Hospital won't be quite as long ….”