On Thursday, July 13, Mayor London Breed wrote that, of 115 people cited or arrested for public drug use in the previous two weeks, none accepted services, and the overwhelming majority were not San Francisco residents.
It’s a common refrain. Mission Local decided to find out: What does that offer of “services” look like? More than 30 people surveyed, all of whom were frequent drug users who have been cited or arrested by San Francisco police in the last two years, had little to no idea.
“They cram it in really fast when they’re discharging you [from jail], right in with all the other things they say,” said a woman named Sylvana, who was staying on Minna Street and grew up in the Fillmore. “You basically miss it.”
Of those interviewed, five were born-and-raised San Franciscans, and two more were born here, then displaced. Six were originally from Oakland, and three came from farther out in the East Bay. Others named hometowns all across Northern California. Two came from Virginia.
So, 23 percent were originally from San Francisco and 9 percent were from the Bay Area with about 66 percent from beyond the Bay, in line with city data: The city’s newly formed drug coordination center said 75 percent of recent arrestees were from outside San Francisco.
Gearing up for a sunny July day out in the community providing snacks, food and medical care, Khusar, 29, a program manager at Code Tenderloin, said: “I haven’t met a single person who doesn’t want ‘services.’”
“If it’s not food, it’s harm reduction. If it’s not harm reduction, it’s housing. If it’s not housing, it’s clothes. There’s always something that they want. It’s never nothing.”
Moreover, even if that moment comes, services out of jail won’t immediately follow. Jail Health Services, which provides addiction treatment and mental health services to those in jail, noted this month a deficit of 17 staffers, and a long wait for those referred out to treatment.
Earlier this month, a young man named Kado sat on a ledge at Seventh and Mission streets. “I’m high every day,” said the 24-year-old as he searched for a lighter to smoke fentanyl off some tin foil, scratched-up glasses falling down his nose.
On May 24, shortly before the May 30 crackdown on public opioid users, arrest logs confirm that police nabbed Kado for allegedly selling fentanyl and crack, which he says were for personal use and not sale. In less than 24 hours, he was released “on OR,” or on his own recognizance, with a written promise to appear in court the following week.
When asked about the offer of support through programs connected to jail on his release, Kado only laughed, looking confused. “Most people just want to get out of there,” he said.
Fentanyl is a short-acting opioid, meaning that without medication, withdrawal symptoms develop — nausea, shortness of breath, depression — within eight hours after someone’s last dose. Symptoms can last for weeks, according to the American Addiction Centers.
Kado said that while waiting out the day in jail, the only thing on his mind was getting his next dose. Withdrawal was already setting in.
Kado was born and raised in the Tenderloin. He went to Harvey Milk Elementary School and then a series of continuation and public schools in the city. He started using hard drugs when he was 13. Since then, Kado said, he’s stayed high.
Living on the streets with no working phone, there’s slim chance he’d stay in touch with a case manager.
A couple of years ago, Kado says he detoxed at Walden House on Hayes Street, but was kicked out when it was discovered he had used fentanyl again.
The stronger the drug, the harder the withdrawal, providers said. Fentanyl is considered around 50 times as powerful as heroin, making detox extraordinarily difficult, according to Gary McCoy, vice president of policy for HealthRight 360, which offers addiction and other health services.
Kado said that, ideally, he would like to get clean at a medicated service.
The week after his release, Kado missed court. The consequence of missing a court date is the issuance of an arrest warrant. And the cycle continues.
For homeless people and drug users, missing court is common. Others surveyed by Mission Local had the same story: a warrant for a missed court date, an outstanding citation (one owed $500 for smoking fentanyl in public), and no contact with a case worker.
A 2021 study that analyzed court appearances through the city’s main diversion program found someone without stable housing was nearly 1.5 times as likely to miss a court hearing as someone with a home.
Turning down service a ‘false narrative’
The Drug Market Agency Coordination Center — a collaborative of city agencies that includes the Department of Emergency Management, Department of Public Health, Police Department and Sheriff’s Office — on Thursday, July 20, gave its total arrests for intoxication: 170 people since May 30, when the city announced a ramping up of arrests for violating several drug codes.
Of those, reported Kristin Hogan, a spokesperson for the coordination center, “75 percent are not San Francisco residents.” Hogan added that in the past year-to-date, there have been “463 arrests for drug sales in Tenderloin/SOMA,” with 566 in all of 2022.
Most recently, she wrote, SFPD doubled the number of arrests from June 26 to July 9, when compared to the previous two-week period.
David Mauroff, chief executive officer of the San Francisco Pretrial Diversion Project, said the belief that people are turning down services is a false narrative, and largely anecdotal.
The most important part of treating someone, said Mauroff, whether it’s mental illness or drug addiction, is “meeting them where they are.”
“Addiction is a disease,” he said. “When someone gets their first cancer diagnosis, they’re not jumping right into chemotherapy. At that moment when you are wrestling with addiction and mental health issues, you’re not in a place to make that decision.”
SF Pretrial is a nonprofit funded in large part by the San Francisco Sheriff’s Office. They manage most of the programs for arrestees awaiting trial or in need of support.
In the past year, arrests have shot up, and jail populations are climbing. Anytime arrests are up, SF Pretrial’s client base increases. In early 2022, they averaged only around 500 cases at any given time. Right now, they’re down to 22 case managers, said Mauroff, spread thin across a growing list of 900 clients.
The biggest challenge, Mauroff said, has been connecting clients with treatment. “Agencies are telling us to stop sending people.” Depending on the program, most are full up.
The issue isn’t quite as simple as there being too few beds. As of today, Public Health’s online portal estimates 43 available beds of 563 designated for treatment. Many treatment options have qualifications based on gender, disability, sobriety, Medi-Cal enrollment or citizenship, however, and regardless of how many beds they have available, someone may not make the cut.
Staffing is a persistent issue at many of the city-contracted services. And, “if you can’t fully staff a program,” said McCoy of HealthRight360, “then a bed is just a bed — just a piece of furniture, nobody to fill it.”
Experts at programs across the spectrum of treatment, from abstinence-based to harm reduction, agree that the system of constant referrals, waitlists, appointments and follow-ups is extremely discouraging to someone suffering from depression related to drug addiction. And the cycle continues.
‘It’s about building trust’
Getting a clear answer on what exactly constitutes the “offer of services” to arrestees has been a challenge. Correspondence with the Police Department, Department of Public Health and Sheriff’s Office did not bring clarity about what services were offered.
Many providers in the city said they face the same issue from the city departments when asking for details about how treatment is offered in jail. They refer to it as a lack of transparency.
What remains in question is how people are evaluated for services, and if the right services for that person are even available. In any case, offering treatment straight from jail does not seem to work as well as a slower, more incremental approach, providers said.
On a recent weekend, UCSF nurses and Code Tenderloin volunteers conducted a walkabout through Downtown, administering Covid-19 vaccines to unhoused people in the area and lightly treating wounds.
The team’s first point of engaging someone to get vaccinated was offering an (underripe) banana.
“I have two warrants out, one for alleged battery,” said Nestor, cradling his fruit. He was sleeping off a fentanyl high in a doorway on Minna Street. After some coaxing, he was given a covid vaccine by a UCSF worker and a bag of snacks.
“I want to get clean,” said Nestor, his eyes closed and voice almost a whisper. “But I don’t think I’m ready.”
Nestor was recently cited by police for using drugs in public. Asked if he was planning to pay, he said no, that he doesn’t have the money and doesn’t want to go to his court date and risk jail time.
Sherri Borden, a nurse practitioner and roving clinic lead, said getting users into treatment requires building a relationship of trust — one that people don’t associate with a law enforcement setting.
“People want services,” she said. “But it’s how you talk to them. It’s about building trust. It’s about handing them a banana and a granola bar. If you say, ‘Hey, do you want services?’ people will just say ‘no,’” said Borden.
Then it’s an “OK, bye,’” she said, shaking her head. “You’ve missed the boat.”
‘I was born drunk’
“You have to understand the mind of an addict,” added Portery McFadden, 65, who was en route to the Tenderloin YMCA on a Tuesday in July. McFadden grew up in what was formerly called the Army Street Projects, now known as Bernal Dwellings, in the Mission. She lives in the Hotel Isabel, a single-room occupancy hotel at Mission and Seventh streets, where she says many of her neighbors use drugs.
“I was born drunk, myself,” she said. McFadden’s mother was a heavy drug user and alcoholic for much of her life. “A lot of these people, they were born drunk or high, and grew up like this.”
“Look around. The average person out here is depressed. Fentanyl’s a downer. You get out of jail, you’re sick. You don’t want help; you want to get high. You feel like you can’t get any lower.”
Seeking treatment, she said, is not one-size-fits-all.
“Everybody’s different. Some people, you have to walk them yourself to the corner and take them to the clinic; they can’t do it themselves. I walked two of my siblings to the clinic for treatment.”
At the Hotel Isabel a few years ago, McFadden remembered a social worker who, every week, made enough chicken soup for the whole building.
“She would put the soup in separate bowls. And she would knock on every door. But really, she did it to check in on people. That’s the way,” she said. “Nobody can turn down chicken soup, even if you don’t want anyone knocking.”
Just like McFadden described, another man buying fentanyl down the street said he spent much of his childhood on the streets in East Oakland, and started using early. He felt safer staying outside with his community, and didn’t feel the same about most residential programs.
Three women huddled together at the corner of Seventh and Natoma all agreed — they would be more inclined to get clean if they were given safe housing. “As long as I’m on the streets, I’m gonna stay high” said one woman, who grew up in Oakland.
She said she hadn’t heard anything about services, but that when police came up while she was smoking fentanyl, she was given a $500 citation. The officers then moved along.