When Vitka Eisen entered a residential substance use Treatment program at San Francisco’s Walden House in the 1980s to seek help for heroin use, it wasn’t for a short, 90-day visit. She stayed for two years. Eisen had tried numerous times to kick her habit. But it just didn’t click, until she found a supportive, long-term program that gave her time to get her back on her feet.
“I was at Walden House until I had a job, until I had an income and some savings, and friends,” she said. “You didn’t leave treatment until you could fully support yourself.”
For Eisen, that model of wrap-around, long-term support worked. She’s now CEO of HealthRIGHT 360 — the nonprofit health care provider that runs Walden House. But in the 30 years since she was in rehab, things have changed dramatically.
“Nobody finds that anymore,” Eisen said of her two-year treatment.
That’s because, for those most in need without private insurance, 90 days is the maximum period Medi-Cal, the state’s insurance program, pays for — and it only does so 30 days at a time.
“Every 20 days, you’re stating your case as to why (you need) another month,” Eisen said.
And as insufficient as 90-day substance use treatment can be for creating lasting recovery, those who receive it are in some ways the lucky ones. San Francisco has a severe shortage of treatment beds. In 2021, the city had 11,691 people with substance use disorder enrolled in its health care plan. While not all need extensive treatment, thousands do, especially those who live on the streets; the Department of Public Health identified 8,758 homeless people with either substance use disorder or mental illness in San Francisco last year. More than 3,000 had dual diagnoses and struggle with both issues at once. Yet the city has only 2,550 Mental Health and substance use treatment beds combined.
The department did not answer the Editorial Board’s question about how many beds are needed to fully address the demand for treatment, but Mayor London Breed has set the goal of adding 400 beds to the current supply. Even as officials scramble to open more, however, it’s a constant fight against attrition, as longtime substance-use facilities are closing due to the high costs of operating in the city.
As of Thursday, there were only eight slots available for people needing detox support and 13 in residential treatment programs. For those looking for long-term residential step-down programs, such as those who’ve exited a 90-day program, there were just five beds open.
This shortage makes mental health and substance use recovery particularly difficult for people experiencing homelessness, the population everyone in San Francisco agrees most needs urgent help. Studies have shown that those without homes struggle to maintain even low-barrier addiction treatment options, like taking buprenorphine or methadone to stave off cravings and help with withdrawal.
Yet despite a glaring lack of infrastructure to meet demand, there’s a growing movement in San Francisco and beyond to force more people who use drugs into treatment, largely in response to the number of people experiencing homelessness in California, which grew 31% from 2010 to 2020. Now, the state of California wants to step in.
A red herring
A new bill, SB43, authored by state Sen. Susan Talamantes Eggman, D-Stockton, seeks to expand the power of California’s conservatorship law, the Lanterman-Petris-Short Act of 1967. It would do so in part by amending California’s definition of a “gravely disabled” person eligible for conservatorship to include those with substance use disorder. If the bill becomes law, drug users could be looped into the state’s conservatorship system and may be forced to receive care involuntarily. Gov. Gavin Newsom’s CARE Court bill, enacted last year, similarly seeks to compel people who use drugs into treatment through court-ordered treatment plans.
Mayor Breed and the San Francisco Board of Supervisors support SB43. Breed has been particularly enthusiastic about any effort to be more aggressive in combating addiction. People who use drugs openly in San Francisco are now being arrested under the pretext that the criminal justice system will mandate treatment.
“Force is going to have to be a part of it, whether people like it or not,” Breed said during a Board of Supervisors meeting last month. “Compassion is killing people.”
The idea is a familiar one: Civil liberties are holding back commonsense solutions, prioritizing human rights over the seemingly more urgent approach of force.
Sparks flew again on this topic Tuesday during a Board of Supervisors meeting when, in response to Supervisor Dean Preston’s questions about the efficacy of arresting users to force them into care, Breed said: “Here we go, another white man who’s talking about Black and brown people as if you’re the savior of those people and you speak for them.”
But arguments around who is allowed to have opinions on the city’s response to its drug crisis, and whether compassion or toughness should play the leading role, are red herrings — a distraction from the woeful state of our treatment infrastructure. The truth is that neither San Francisco nor the state has the treatment capacity to meaningfully force people into care — via conservatorships or any other means — even if they wanted to.
If our politicians don’t already know this, they should.
In 2019, the California State Auditor released a report stating that current conservatorship guidelines are more than sufficient to capture those in need of involuntary treatment. That report specifically called out San Francisco, telling the city that instead of broadening the scope of who it should conserve, it should focus on increasing its treatment bed capacity.
More broadly, a 2021 study from the Rand Corp. think tank found that California doesn’t have nearly enough treatment beds at any level to support the existing demand for conservatorships. This lack of infrastructure has led to bottlenecks in the behavioral health system that trap some people whose condition has improved in high-security facilities where they no longer belong, while others with severe needs end up in lower-level settings or on the streets, where they can hurt themselves or others.
In an interview with the Editorial Board, Eggman conceded that California lacks the infrastructure to tackle the scale of our behavioral health crises. She suggested we have to try anyway. Breed has argued similarly in defending her plan to leverage the criminal justice system to get people into treatment.
But there are consequences to forcing more people into a system that is already overwhelmed.
The scarcity toll
When a person is admitted to an emergency room for a severe psychiatric issue, they are evaluated by medical staff. If they are considered at risk for harming themselves or someone else, they can be forced into a locked facility for up to 72 hours. During that period, the psychiatric staff makes a determination about a treatment plan.
This is just the first step of the conservatorship process, and San Francisco lacks the bed infrastructure to handle patients under the state’s existing rules.
Maria Raven, chief of emergency medicine at UCSF Medical Center, told the Editorial Board that due to overcrowding, patients were being held on gurneys in hallways or sitting in hospital beds for days or weeks waiting for a rehabilitation center spot or a placement in a psychiatric treatment facility. Too often this waiting game becomes untenable, as new patients arrive at the hospital who need space to be stabilized. And so those stuck in the bottleneck who aren’t in immediate health danger are simply released to the street.
This is something Rachel Berman, a social worker who tackled issues of mental health and addiction for years in San Francisco, experienced with her clients, too. She was a strong supporter of earlier state and local efforts to strengthen conservatorship laws. But Berman’s views have evolved based on what she sees as a clear infrastructural deficit. She told the Editorial Board that some days she’d make three or four referrals to the city for inpatient psychiatric beds, only to be told they were full.
“Changing (the law) to include more people for conservatorship, when we have nowhere to put the people who are gravely disabled on the streets right now — to me, it’s just all rhetoric,” she told the Editorial Board. “People who need care can’t get it, and there’s maybe 12 people vying for every individual bed that becomes available.”
Forcing someone into a system that isn’t capable of helping doesn’t just create distrust, it does lasting damage to the individual.
That’s what happened to John Vanover, legislative committee chair for the Depression and Bipolar Support Alliance of California, who has bipolar disorder. Despite having “all the sociological advantages anyone could possibly think of,” he said, during one of his most grave bipolar episodes he couldn’t access mental health care. He ended up being involuntarily held in a hospital, an experience that traumatized him.
“Because I was unable to access services in a timely manner that mania turned to psychosis,” he told the Editorial Board. “And because those services were so poor, I now have PTSD towards the very systems that I need to rely on to stay well. I find my PTSD to be way more debilitating to my daily life than my bipolar disorder.”
‘Too in need’
Meanwhile, those who voluntarily try to access care are struggling to find help — even when bed spaces are available. Take Shahada Hull, a San Francisco native who last year shared her story with KQED. Despite wanting to receive mental health and substance use treatment, Hull couldn’t find a program that was willing and able to treat her dual diagnoses. Even with a volunteer advocate at her side, she was rejected from one facility for needing too much care. For another, she had to fill out a long application, obtain a tuberculosis test and get a doctor’s referral — all while experiencing homelessness. Unsurprisingly, she relapsed into drug use.
Rejecting someone who is “too in need” — often because they have mental illness and substance abuse disorder, is something Ryan McBain, a policy researcher at the Rand Corp. routinely came across when researching the think tank’s 2021 study.
“We spoke with different county administrators, and they talked about these hot potato cases where a facility doesn’t really want people who are really hard to serve,” he said.
Part of the problem is how siloed mental health and substance use treatment programs are.
“The overlap between mental health conditions and substance use disorders is 40% or so,” McBain said. “It would make sense for systems to be integrated to every extent possible. But the reality is that in most states, including California, they really operate quite independently of one another. There’s a mental health system, and then there’s a substance use disorder system. The way that the infrastructure is set up.”
Even if the state and San Francisco did build out enough beds to meet the demand for mental health treatment, substance use treatment and dual diagnoses, there would still be gaps in the system that would make enhanced conservatorships impossible. Most urgently, there is an extreme shortage of behavioral health workers. A 2018 study from UCSF estimated that by 2028, California would be short 50% of the psychiatrists it needs and 28% short on psychologists.
The COVID pandemic almost certainly did not improve those estimates.
HealthRIGHT 360’s Eisen said that because of the shortages, sometimes her treatment facilities can’t operate at full capacity, even if they have empty beds. Money is the primary issue. HealthRIGHT 360 cobbles together payment for its staff through private donors, a state-funded internship program and Medi-Cal reimbursements for services provided. But reimbursement rates are too low for the challenging nature of the services provided, making it hard to pay staff members well enough to keep them aboard, particularly in a market where they’re high in demand.
Other challenges include the inability of many facilities to accommodate those with physical disabilities. According to city social workers interviewed by the Editorial Board, patients with mobility issues often wait for weeks in hospitals for a substance use treatment bed to open because there is a shortage of facilities with elevators. There is not a single dual diagnosis treatment center in San Francisco with one installed.
San Francisco also has few facilities capable of accepting monolingual Spanish speakers. And this isn’t just true for those who voluntarily seek treatment. According to Assistant Public Defender Crystal Carpino, monolingual Spanish speakers who are arrested and accept treatment as part of a diversion program or a plea deal must wait for weeks in jail for beds to open in places that can accommodate them.
It’s also nearly impossible to find a treatment facility that will accept anyone who is a registered sex offender, a definition that often includes unhoused people who were convicted of indecent exposure for peeing outside.
Other barriers are simpler to solve. And yet they haven’t been. Social workers told the Editorial Board about homeless clients who sought voluntary treatment but who couldn’t access services because they weren’t allowed to bring their dogs.
Last year, San Francisco’s Tenderloin Linkage Center came under fire for not getting more of its clients, many of whom used drugs, into treatment. But faced with such barriers, it’s not surprising the center’s referral numbers were modest. To be effective, San Francisco needs a broader network of options at all levels of care, as does the state.
This isn’t a new insight. In 2009, the United Nations Office on Drugs and Crime reviewed 48 medical studies conducted over decades and came to the conclusion that “the availability of effective, affordable and humane treatment and care that meets the varied medical and social needs of people with drug use disorders in the community will facilitate the voluntary uptake of treatment and prevent drug-related crime.”
Forcing people into care using the criminal justice system, meanwhile, is largely an empty talking point. Even if treatment infrastructure were widely available, a 2020 study from the Center for Court Innovation found that after the passage of California’s Proposition 47 in 2014, which reduced criminal penalties for low-level drug crimes, “defendants … have little incentive to enter a drug court,” the criminal justice system’s primary tool for leveraging users into treatment. Referrals to those courts have plummeted statewide as a consequence.
To its credit, the Newsom administration recently announced a plan to amend the Mental Health Services Act to free up $1 billion for substance use and mental health treatment. But if the state wants to urgently address the crisis of people using drugs on our streets, it could do many other things it has dragged its feet on. Clearing treatment bottlenecks and ensuring greater bed capacity is essential.
Beyond that, the state could authorize supervised consumption sites so people can use drugs indoors and away from public view, a scientifically proven method for saving lives and connecting people to medical and mental health care. It could meaningfully increase Medi-Cal reimbursement rates for substance use and mental health treatment, making it more feasible for providers to pay for staff well enough to live and work in expensive regions like San Francisco. It could find ways to pay for prolonged substance abuse treatment as needed, not capped by an arbitrary 90-day window. It could invest more heavily in wrap-around services, like step-down residential programs, ensuring that those who enter recovery have the long-term support they need to not relapse. And it could provide funding or pass legislation to eliminate structural and programmatic impediments for those seeking voluntary care, from language barriers to a lack of elevators to hurdles faced by those whose only crime was going to the bathroom outside.
Trying to force people into a system that cannot accommodate them, however, will not solve the crisis in San Francisco or anywhere else in the state. Pretending otherwise is politics, not policy.
Reach The Chronicle Editorial Board with a letter to the editor at SFChronicle.com/letters.
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