More than a decade ago voters mandated that on-the-spot substance abuse treatment should be made available to every San Franciscan who needs it, but persistent barriers to accessing services have left this promise unfulfilled.
The ambitious plan to dramatically expand residential and nonresidential treatment and detox centers in San Francisco to offer services at “every door” in The City’s system of care, referred to as “Treatment on Demand,” was conceived in 1997 and made law in 2008 with the passage of Proposition T.
Supervisor Rafael Mandelman, who along with Supervisor Catherine Stefani called for a hearing on Treatment on Demand on Friday, said that “a walk on the streets of San Francisco suggests that Prop. T hasn’t been working that well.”
Overdose deaths spiked in 2018, and by the department’s own admission, 3,669 people who are in need of treatment aren’t receiving it, including 370 people who are actively seeking services.
But city leaders who sought answers on what has kept the program from being successful were told by Department of Public health officials Friday that the demand — measured by those seeking services — is largely being met.
The department oversees and funds 45 community service providers providing services like residential treatment programs and reports an intake of about 11 to 12 people each day to residential treatment programs. Utilization across its portfolio of residential beds is at 86 percent capacity, with a stated goal of 90 percent.
According to a two-page report on access the City’s substance abuse services, San Francisco’s “treatment system is large enough that there are treatment openings every day.”
Clients seeking access to residential treatment programs wait 5.9 days on average and “the median is four days, which is a huge difference from when Prop. T was written,” said Dr. Judith Martin, deputy medical director of DPH’s Behavioral Health Services. Ten years ago, the wait time for treatment averaged 60 days.
In 2018-19, the health department served 6,005 people seeking substance use treatment, of which 56 percent were homeless.
The department does not keep data on clients the department “loses” because they are waitlisted for services and give up. Martin said that the department is struggling with retaining staff, reducing capacity at treatment programs.
Martin said that the problem in reaching all individuals who need services, particularly homeless clients, is that many don’t like the services The City has to offer.
“Isn’t it our job to provide services that people like?” Supervisor Shamann Walton wanted to know.
Clients and service providers who testified at Friday’s hearing painted a picture of a system that does not yet serve all.
An attorney with The City’s Public Defender’s office pointed out that treatment is not immediately made available to San Franciscans who are incarcerated.
“There’s definitely a waitlist for residential treatment programs — my clients wait a minimum of a month in jail..and that’s really good,” the attorney said, adding that clients often plead guilty “to get out of jail instead of seeking treatment.”
Troy Adams, who has been addicted to drugs for 35 years in San Francisco, said that he has experienced delays in The City’s treatment system whenever he attempted to seek help.
“I was at a low point two years ago — I went to a rehab facility and they told me to wait an hour. Within that hour I went out, used drugs gain, fell into another deep hole and didn’t think about treatment for three years. It only takes one hour, or less,” said Adams.
Brian Edwards, an organizer with the Coalition on Homelessness, said that San Francisco’s system of care continues to fail homeless clients because treatment is not coupled with housing.
“Entering into treatment doesn’t mean anything if you don’t have a place to live,” said Edwards. “It’s housing. Whether that’s a co-op or stepdown [beds]. We need to include housing in Treatment on Demand, otherwise you walk in and get booted and are part of the churn.”
Supervisor Matt Haney, who sat in on the hearing, said that there was a “huge disconnect” between the department’s report and the reality experienced by people with substance use disorders and by frontline service providers.
“How can our analysis lead us to say we are meeting the demand when common sense tells us that we have so many people who are not accessing care,” said Haney. “If someone can’t access [a service] because of wait time or because it’s not the appropriate type of care…and you’re not counting that as part of the demand, of course we are going to measure that as if we are doing fine.”
While the department’s report states that clients waiting for intensive case management services generally wait one week, Haney said that he has been informed that this wait list has more than 150 names on it.
“We know that there’s a gross shortage of residential step down beds. This [report] says there is no wait,’ said Haney. He said that The City is “grossly out of compliance with Prop. T,” which required the health department to provide annual reports on the demand for substance abuse services and a plan to meet the demand.
“What is happening now is this fiction that the demand is completely met — so we don’t even have a plan for how to do things better,” he said.
Stefani said that waiting even a few days for access to treatment was too long and out of line with the spirit of Prop. T.
“What you said is that when a homeless person comes in for treatment and they can’t get it in that moment [because] we are not able to provide it and they have to wait a few days — I can’t live with that,” Stefani said.
Advocates called for the creation of a treatment on demand task force, which the supervisors said they would support. Haney, however, said that systemic changes were needed to ensure the program’s success.
“I support a task force, but I think we need significant system policy changes in terms of how we think about our responsibility to meet the need,’ he said.
Editors note: this story has been updated to reflect the correct spelling of Brian Edwards’ name.