San Francisco set a record for the most drug overdose deaths last year, as the powerful opioid fentanyl continues to wreak havoc.
Desperate to stem the deadly crisis, which claimed 752 lives through November, some advocates and officials are calling for more housing and treatment focused on sober living — which means stricter rules around the use of drugs and alcohol in city-operated housing.
The current model for people leaving the streets, called Housing First, holds that everyone should be unconditionally housed regardless of credit, income, criminal background, or sobriety. People with a roof over their heads, supporters say, are in better shape to get help, including healthcare and substance use treatment.
But sober-living advocates say there should be drug- and alcohol-free places where people in recovery are welcomed. Ideally, that housing would also be outside the Tenderloin and South of Market, where drug dealers congregate and the most overdoses happen, many in single-room occupancy hotels operated by city-backed nonprofits.
“If I had to choose between doing more permanent housing at this point or more step-down sober living facilities for people who have completed a treatment program, I would definitely do more step-down, shorter-term, sober living facilities,” says District 8 Sup. Rafael Mandelman.
The city in fact has plans for a sober-living permanent housing project, according to its Department of Homelessness and Supportive Housing, but obstacles remain to broader adoption.
State funding is a key element, yet California’s funding rules seem to exclude sober living. There’s also resistance in San Francisco to low-income housing outside the Tenderloin and SoMa. Perhaps the highest hurdle is a body of research that shows that Housing First, not sober living, is the best way to get people off the streets and keep them housed, and the approach is nationally recognized as a gold standard.
With finite funds to spend, pushing more money into sober-living (sometimes called abstinence-based) facilities and away from Housing First options is dangerous, says Tiana Moore, policy director at UCSF’s Benioff Homelessness and Housing Initiative, which conducts research and supports Housing First.
“The evidence really shows that Housing First works when it’s appropriately implemented,” says Moore. “When a housing option diverges from Housing First principles and terminates residency for someone for not meeting a sobriety requirement, that individual may be left with few options but to return to homelessness,” and going back to the streets greatly increases a person’s health risks across the board.
But much of the Housing First evidence was gathered before the wave of fentanyl swept across the country. According to San Francisco’s medical examiner, 68 percent of the people who died of overdose through November 2023, mostly involving fentanyl, had a fixed address. Many of these were in the city’s permanent supportive housing — subsidized units dedicated to formerly homeless residents that include healthcare and other services — and single-room occupancy buildings.
“Fentanyl has kind of changed the game here,” says Tom Wolf, a former addict who was homeless in the Tenderloin and is now a recovery advocate who consults with the Salvation Army and other organizations. “Don’t you think we sshould maybe pivot our approach a little bit to reflect that?”
Sober living rules
Here’s how the Salvation Army, one major provider, sets the rules. It has places for 106 formerly homeless people in its San Francisco sober-living residence. Those who break sobriety aren’t kicked back to the street. Instead, they are sent to the organization’s Harbor Light residential treatment program. If they keep using drugs or alcohol, they’re asked to meet with a case manager and decide if the program is right for them. (The Salvation Army also runs SF facilities with more than 600 beds that don’t require sobriety.)
Steve Adami, executive director of the Salvation Army’s recovery-focused homelessness initiative The Way Out, says, “The goal is to not perpetuate homelessness and cause more harm in people’s lives but to really address the underlying cause of what was driving the housing insecurity and addiction.” It’s unclear if other local providers, who did not respond to requests for comment, follow the same rules or have resources to provide a different option.
The sober living push comes amid other calls for new drug-related policies and growing frustration at the mounting death toll. Mayor London Breed is asking voters in March to approve requirements that people receiving city cash assistance take drug tests. Sup. Matt Dorsey, who is in recovery, has called for drug-free zones around treatment centers and other sobriety-focused sites.
Wolf agrees that drugs are too accessible: “Let’s say you complete a 90-day treatment program and you’re in recovery from addiction, and you go live at [an] SRO on 6th Street. How are you ever going to pursue your recovery when not only everyone around you is using drugs, but you walk out onto the street and there are drug dealers?”
A 2016 California bill requires agencies that fund housing programs to adopt Housing First and deploy a harm-reduction philosophy that ‘recognizes drug and alcohol use and addiction as part of tenants’ lives.’
To be clear, all sober-living advocates who spoke with The Frisc insist Housing First should remain an option. But with finite resources, their calls for more sober-living sites can be seen as taking funds away from a proven method. And funds are likely to shrink. SF’s Department of Homelessness and Supportive Housing is facing cuts to its $1.35 billion budget for the current two-year cycle — 59 percent of which is allocated to housing.
That said, HSH has been planning for at least one sober-living permanent housing site.
The current budget “included a general fund investment in a new sober living permanent supportive housing site,” says HSH deputy director for communications and legislative affairs Emily Cohen via email. “We are still working on the program design for this and will have more information about the project in the coming months.”
State dollars off-limits
Even if the city wants to shift more funds into abstinence-based housing, state coffers — a much larger funding pool — seem off-limits for now.
A 2016 California bill, SB 1380, made Housing First state policy. A state agency that funds, implements or administers a housing-related program must adopt Housing First and deploy a harm-reduction philosophy that “recognizes drug and alcohol use and addiction as part of tenants’ lives.” (Harm reduction aims to reduce criminalization and the deadly risk of using drugs, with more availability of the overdose reversal drug Narcan, clean needles, and supervised consumption sites — a long-running political fight.)
There’s a lot of local confusion about SB 1380. Several people interviewed for this story weren’t sure if SF could use state funds for abstinence-only housing; some gave conflicting answers. A spokesperson for City Attorney David Chiu declined to comment.
HSH’s Cohen says state funds cannot be spent on abstinence-based housing — but local dollars can. Cohen declined to say how much the city is allocating to the project in progress, but she did say the goal is to ensure those who relapse will be transferred to another program rather than end up homeless, much like The Salvation Army’s model. The approach could even fit within a Housing First framework, says Cohen, but it’s unclear if this would allow such programs to tap into California funding. (The state legislator who authored SB 1380, now a Los Angeles city councilmember, also declined to comment on the bill’s implications.)
Meanwhile, the Salvation Army itself is pressing ahead with longstanding plans to turn its property at 850 Harrison Street in the SoMa neighborhood into an eight-story rehabilitation center. (The SF chapter, founded in 1883, was the first to use the now-ubiquitous collection kettle, according to the organization.)
Adami says Housing First may work for some people, but for others he calls it “skipping steps:” “We take people that are dysfunctional and we forget healing, teaching how to live, all those steps, just put them into their own unit, and then we wonder why they don’t do well.”
In transitional housing that requires drug treatment, Adami says, “You get a couple years to practice living, and then when you become financially independent, you move on to independent living, which could be permanent supportive housing.”
The housing shortage also affects nonprofit staff who help people rebuild their lives. ‘It’s a big reason why San Francisco’s Housing First program is not as successful as it should be.’
California YIMBY policy director Ned Resnikoff
To unlock state funds, Wolf would like to see SB 1380 updated. He’s working with the Bay Area Council on amended legislation to take to Sacramento this year and find support from a state legislator. “All we’re trying to do is add language to amend the bill, not remove the harm reduction language,” Wolf says. (Sup. Mandelman, who has eyes on a run for state office, had not heard of the effort before speaking with The Frisc but said he supports it.)
But UCSF’s Moore says funding non-Housing First options could lead to more homelessness. The tension underscores how housing scarcity pits one option against another and points to another solution: Build more housing of all kinds.
Build housing first
One thing is clear: When a person wants to get their life back together, either in a sober or less regulated environment, they need a roof over their head. And there aren’t enough roofs to go around. That scarcity also affects the staff who work in these homes and help people rebuild their lives. The housing shortage is “a big reason why San Francisco’s Housing First program is not as successful as it should be,” says California YIMBY policy director Ned Resnikoff.
Resnikoff’s 2022 report compared SF’s Housing First effort with Houston, a sprawling city often lauded for its work getting people off the streets and into homes. (Houston also has more than 10 times the area of SF and few zoning restrictions.)
Low salaries mean that frontline homelessness workers living in the average one bedroom SF apartment “are themselves severely rent burdened, which ironically puts them at high risk of homelessness,” says Resnikoff.
HSH says it’s investing $47 million in the current budget cycle to boost wages, hire more staff, and lower the number of clients per case manager.
Concentration of poverty in a few San Francisco neighborhoods also makes Housing First harder to pull off, and it stems from decades of limits that prevent construction of lower-income housing in many places around the Bay Area. “The refusal to build anything in those places is directly helping to fuel the regional homelessness crisis,” says Resnikoff.
With that crisis comes more health problems, more substance use as a coping mechanism, and a heavier burden on social services. The overdose epidemic is not simply a homelessness problem; as SF’s latest data show — as well as high overdose rates in places with no housing shortage — a roof over one’s head is no panacea. But building more of those roofs in more areas of the city can start changing the concentration of poverty, give people a choice of environments, and make it easier to hire and retain essential staff who do the difficult work.
In San Francisco, more housing is coming. The city must plan for 82,000 new homes, more than half of them affordable — no easy feat. Where those units are built, and whether some provide more options for people trying to stay sober, could help the city not only address the housing crisis but the overdose epidemic too.