After record-breaking years of drug overdoses, fueled mostly by fentanyl, San Francisco lawmakers are trying something new to stop the wave of death.
Two bills aim to change the city’s rules around drug use, part of a broader attitude shift in San Francisco toward crime and drugs. Last year, Mayor London Breed vowed to arrest dealers and users to combat open-air drug markets. In March, voters easily approved two Breed-backed measures to give police more power and require drug screening for welfare recipients.
As Election Day nears, potential voters in the mayoral race have said crime and public safety is their top issue. Violent crime rates are the lowest in decades, but drug overdose deaths hit a record 810 in 2023, with this year just slightly off that pace so far.
One new bill working its way through City Hall, dubbed Cash Not Drugs, would pay welfare recipients up to $100 a week for negative drug test results. It recently won key support when Sup. Dean Preston, a Democratic Socialist and consistent critic of the police, signed on as a co-sponsor.
His enthusiasm comes despite Cash Not Drugs piggybacking on a successful March 2024 measure (Prop. F) that kicks people off welfare if they refuse a drug “screen” – a questionnaire about their substance use.
“There are different views on the propriety of the punishment side,” said Preston at an Oct. 10 hearing, citing his opposition to Prop. F. He hoped that the Cash Not Drugs incentive would be “common ground folks unite around. This is an evidence-based approach and will help folks in treatment.”
Update, 10/29/24: The Board of Supervisors has passed Cash Not Drugs unanimously. It requires a second vote next week before it goes to Mayor London Breed for her signature.
A second bill in the works, dubbed Recovery Housing First, hasn’t yet had a hearing, but it will likely draw more fire than Cash Not Drugs.
It would allow city funding for low-income “sober living” homes, which prohibit the use of drugs and alcohol on site.
Currently, SF cannot spend taxpayer money on sober homes because of its Housing First policy — that is, people coming off the streets need a roof over their heads before they have to deal with substance abuse and other problems. (The new bill’s name is an overt play on that policy.)
Sober homes in the city, such as the Salvation Army’s Harbor Light, are privately funded. If the new bill passes, SF could require that up to 25 percent of its permanent supportive housing is drug- and alcohol-free. (Permanent supportive housing, or PSH, is for formerly homeless residents who need services to get their lives back together.)
Both bills come from Sup. Matt Dorsey and his allies on the board. Dorsey is a recovering methamphetamine and alcohol user. Before joining the board he was a San Francisco Police Department spokesperson.
“I have a lot of confidence that I have voters in a spectacularly progressive democratic city behind me on this, who are passing things like Proposition F and rooting for recovery,” Dorsey tells The Frisc. Prop. F — drug screens for people on welfare — passed in March with 58 percent of the vote.
Test negative, earn cash
Cash Not Drugs is farther along and only needs full Board of Supervisors approval to reach Mayor Breed’s desk.
Preston’s name as co-sponsor could help mollify critics who note that the payments will become part of new tougher rules for SF’s 5,700 welfare recipients that went into effect with Prop. F, which Breed put on the ballot.
Under Prop. F, recipients who don’t submit to a screening will lose their benefits. The Human Services Agency, which runs SF’s welfare program, says 30 percent of recipients deal with substance abuse. If a screening flags someone as a user, they can volunteer for treatment and perhaps sign up for Cash Not Drugs. Once signed up, the program would pay up to $100 for passing a weekly drug test.
Dorsey said he’ll let experts craft the details, but he feels strongly about “starting small” with $25 payments that could increase with every negative test.
Cash Not Drugs is formally referred to as “contingency management,” an evidence-based method that positively reinforces good behavior and has shown strong results, according to Marc Dones, policy director of the UCSF Benioff Homelessness and Housing Initiative. Dones has qualms about Cash Not Drugs, however, because of its association with Prop. F.
At first, the program would focus on methamphetamine users, because SF’s Department of Public Health already runs small contingency management programs for this population.
Billy Lemon runs a recovery group called the Castro Country Club. At the Oct. 10 hearing, Lemon described how the method worked for him a decade ago: “There’s a certain dopamine release when you use methamphetamines. Contingency management accesses that same dopamine release. It’s positive reinforcement when you test negative.”
Running programs for fentanyl and other opioids is more complicated because methadone, used as medication, triggers a positive test.
Operating Cash Not Drugs annually for 50 people is expected to cost about $220,513 for a 12-week program and $411,075 for a year, according to the city’s budget and legislative analyst. To treat 150 people for a year, the price tag is just over $1 million. The budget analyst suggests tapping Medi-Cal as a potential funding source.
Sober debate
Like cash rewards for negative drug tests, Housing First has a body of evidence to back it. It has been SF’s main model for housing formerly homeless people for nearly two decades.
But after the city broke its record for overdose deaths in 2023 — many occurring in the city’s PSH buildings — the city’s top homelessness official acknowledged the need for more sober spaces.
Shireen McSpadden, executive director of SF’s Department of Homelessness and Supportive Housing, wrote recently in a letter to Dorsey that “HSH agrees with the notion that San Francisco should have more sober living options for people coming out of treatment programs or who are in recovery.”
Assemblymember Matt Haney, a former SF supervisor, tried to change California’s rules to allocate 10 percent of state housing funds to sober living facilities. The bill died in committee this spring, but it set the stage for Dorsey’s local bill.
Dorsey’s bill goes farther. It would force SF to fund sober recovery homes until 25 percent of PSH units are in drug-and-alcohol free buildings. Only then could funding flow to Housing First-based places, which McSpadden’s letter criticized.
With state funds unavailable, Dorsey says he could tap the Our City Our Home fund, created by the 2018 passage of Prop. C, and state bonds for housing veterans and the formerly homeless created with the passage of Prop. 1 this March.
An HSH spokesperson said via email that the department is seeking more sober sites. But PSH advocates worry that the push will take money away from care and counseling programs associated with Housing First.
UCSF’s Dones called it “robbing Peter to pay Paul” and said behavioral health services in PSH need more funding to make Housing First succeed. In recent years, that funding has been “winnowed down or restricted,” said Dones, “and as a result, folks who have significant behavioral health or substance use issues are not able to access the supports PSH is supposed to provide them.”
Two thirds of HSH’s 2023-24 budget of $713 million was allocated to housing. Its five-year plan calls for 3,250 more units by 2028.
But as The Frisc has reported, staff shortages and an increase in high-need residents have strained the PSH system, leaving some officials to think about another level of housing and services.
Lauren Hall, co-founding director of DISH, a SF-based PSH provider, recently told the Homelessness Oversight Commission that there aren’t enough case workers. “We are in dire need of sophisticated case management programs that understand the complexity of the folks that we’re serving,” Hall said.
Fentanyl in the equation
The evidence that Housing First leads to better outcomes for formerly homeless people doesn’t take fentanyl into account, says recovery advocate Tom Wolf, who does consulting work for the Salvation Army: “Fentanyl has kind of changed the game here. Don’t you think we should pivot our approach a little bit to reflect that?”
HSH objects to using Housing First funds to pay for sober living, and it has criticized Dorsey’s plan for a lack of evidence and research. McSpadden’s recent letter said “there is no data behind the 25 percent mandate set forth in the legislation” and “no research conducted to determine demand, need and interest.”
In an interview with The Frisc, Dorsey agreed with HSH’s need for more data, stating that he’s flexible on the percentage and would work with HSH to survey residents and determine the right figure. But he emphasized that the lack of data should not be grounds to stall the bill.
It is not necessarily progressive to follow a party line based on ideology, nor allow the addiction and overdose deaths and the deterioration of public space that has happened in San Francisco.
sup. rafael mandelman, co-sponsor of the recovery housing first bill
“To the people who say ‘we haven’t seen any studies,’ I would challenge them to show me the study that [says] we have to have 100 percent drug-tolerant housing,” Dorsey said. “There is no disagreement that there is a number, substantially more than zero, of people who want drug-free options, and we don’t have any.”
When pressed for evidence, Dorsey said he would send a survey from SF affordable housing developer Tenderloin Housing Clinic (THC). By press time, he did not. But THC director Randy Shaw said at a February press conference that a majority of THC residents surveyed would like sober options.
The safety dance
Sup. Rafael Mandelman, a co-sponsor of Dorsey’s Recovery Housing bill, says efforts to change policies like this one shouldn’t be viewed through SF’s typical political lens.
“It is not necessarily progressive to follow a particular party line based on ideology, nor is it progressive to allow the level of addiction and overdose deaths and the deterioration of public space in the way that has happened in San Francisco,” Mandelman says.
However one might label SF voters, they are saying they want alternatives to programs that don’t seem to be working, says San Francisco State University political science professor Jason McDaniel — even if the failure is due to lack of funding.
Three mayoral candidates – Breed, Mark Farrell, and Daniel Lurie – are trying to appeal to voters who feel SF has become too permissive. (Breed also says things are getting better on her watch.) Sups. Ahsha Safai and Aaron Peskin also acknowledge voters want to feel safer, with Peskin taking pains to frame safety as a “progressive value.”
The latest polls say it’s a tight race, and ranked choice voting means first-place voters aren’t necessarily the determining factor. It’s unlikely the outcome will be a clear referendum on San Francisco’s drug policies. But whoever is the next mayor will have a big hand shaping those policies – including bills like Dorsey’s.