Board of Supervisors Hearing on Drug Treatment Sparks Debate on Harm Reduction, Abstinence

Amid a growing overdose crisis in San Francisco, a Board of Supervisors hearing on Thursday evolved into a robust debate on the role of harm reduction and drug abstinence in public health services, and what must be done to stem fatalities and guide more individuals into care.  

In a four-hour hearing, the Board’s public safety committee scrutinized overdose prevention policies at the Department of Public Health and other agencies that come into contact with people at risk of overdose. They also revisited Proposition T, a 2008 ballot measure that required DPH to provide enough low-barrier substance abuse treatment “to meet demand,” and to report annually on its progress in that goal. 

The consensus? The spirit of that law—if not the letter—simply isn’t being met thirteen years later. And San Francisco’s current approach to addiction treatment is leaving far too many people at risk.

“I don’t believe anyone walking around the city believes we are meeting the need for drug treatment or mental health services,” said Supervisor Catherine Stefani (District 2). Stefani, along with others on the committee, expressed frustration at receiving DPH’s latest Proposition T report several months late.

“This is not a ‘check-the-box’ activity,” Stefani added. 

Dr. David Pating, an addiction specialist at DPH, identified a number of potential gaps in San Francisco’s system of care. In particular, the city’s transitional treatment options—which assist people in remaining healthy and avoiding relapse after completing intensive residential treatment—should be augmented, according to Pating. 

“There are still people on the street who need to be outreached, in the Bayview, and in other communities,” said Pating. “We’re obviously missing people and need to bring them in.” 

The shortfalls may run deeper than that, according to some Supervisors and residents who chimed in during public comment.

“I’m seeing around me growing questions and concerns around harm reduction, and whether it is actually serving [treatment goals]: Are we inducing demand for treatment, or are we inducing demand for drugs?” asked Supervisor Rafael Mandelman. “I think that there are questions about that from my colleagues, and from myself…we need to be clear that we’re measuring outcomes, and be able to show that to people.” 

In 2000, DPH formally adopted a harm reduction policy in the treatment of HIV, sexually transmitted diseases and substance abuse. That policy dictates that all DPH providers, including outside contractors, must incorporate harm reduction into their programs. In practice, those providers may supply clean needles and drug supplies, the overdose-reversing drug Naloxone, and other services aimed at encouraging safer use, saving lives and “meeting people where they are” should they wish to get clean. 

But at the hearing, some members of the public—several of whom said they were in recovery—criticized DPH’s approach as a homogenous framework that simply won’t work for everyone.

“Harm reduction is good, but harm reduction is not a one-size-fits-all. In the Black community, we get clean more or less by abstinence,” said Phelicia Jones, an activist who also works in rehabilitation services at San Francisco County Jail and is the founder of Wealth and Disparities in the Black Community. “You can’t have people who are seeking abstinence-based policies…and have harm reduction folks right there with you.” 

That sentiment was echoed by others on the call, who said they’d had trouble accessing addiction treatment in San Francisco, either by way of long wait times, or by finding that the programs did not match with their goals. By contrast, others said that they’d found success in harm reduction as an entry point to care. 

DPH maintains 496 treatment beds for substance use disorder, which are a mix of withdrawal management, short-term residential treatment and transitional treatment that combines a temporary living environment with continued treatment. There are 70 total beds available currently.

“I think it comes down to a values question at the Department of Public Health,” said Steve Adami, Director of the Re-Entry Division at San Francisco’s Adult Probation Department. “People who are in the trenches doing the work—Glide, Felton [Institute], AIDS Foundation, DOPE Project—they’re saving lives every single day. For those who want to escape that, there is no outlet. It’s one lane.” 

“You cannot put somebody who does not want to be around opiates in a place where people are on pain management, Methadone and Suboxone,” Adami added. 

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