San Francisco County Jail.
Photo of a San Francisco county jail from court filings.

Supervisor Matt Dorsey sparked controversy this month after he asked the mayor for a major budget reallocation: Moving the entire $18.9 million budget slated for a drop-in opioid treatment center to fund health services in jail instead.

“I think we should shift those dollars to where they can be used to improve outcomes for those most at risk,” Dorsey explained to Mission Local. 

But, while several doctors agreed that funding treatment behind bars is scientifically proven to improve patient health and reduce overdose risk upon release, the Department of Public Health already runs an in-jail treatment program — and has done so for decades. 

Officials at the existing Jail Health Services program say it is highly unlikely that adding $18.9 million to their budget would significantly alter the program or benefit patients. Instead, they say, the need is for more services once a resident is released. 

“We are able to provide medications to all patients that are clinically indicated for medications and are ready to take them,” said Tyler Mains, the chief medical officer of Jail Health Services, which operates out of three county jails in San Francisco. “So I don’t think more money or more staffing would increase the percentage of patients, for example, that are on medications.”

In the past year, a monthly average of about 149 of 716 incarcerated people were addicted to opioids (21 percent), according to health-department data. All were referred to treatment, and 60 percent are accepting medication, most preferring buprenorphine, a synthetic opiate used to treat addiction, health department officials said. 

Additional funds were not top of mind, Jail Health Services officials said. Instead, they are facing a problem endemic to public agencies from the police department to the school district: Too few people are interested in taking already-funded positions.

The staffing challenges for Jail Health Services, in particular, are part of a national trend for public-health workers. 

“We could have all the money in the world; it doesn’t increase the challenge we face with a very limited workforce,” said Tanya Mera, the director of Jail Behavioral Health and Reentry Services at Jail Health Services. “It is very, very difficult to find people to fill vacancies. And that’s not just us.”

Particularly, Jail Health Services is struggling to fill positions in the behavioral health program and the reentry program, both key tools for an incarcerated person who is experiencing substance use disorder. 

SF addiction medication scarce on the streets

Dorsey’s proposal imagined moving $18.9 million allocated for a drop-in center (or “Wellness Hub”) to the jails, but the health department said the service shortage is most acute outside of the jails. 

Health experts agree that ensuring a smooth transition from jail to the outside world is paramount for supporting a patient’s health, especially if they need access to medicines like buprenorphine or methadone, both opiates used to treat withdrawal symptoms from shorter-acting drugs like fentanyl and heroin. 

In interviews with more than two dozen people, all frequent drug users recently cited or arrested by San Francisco police, most said they did not see services materialize once they were on the streets. They said being provided services outside jail was more effective than within it, when the overriding concern is leaving one’s cell.

“For jails and prisons, the critical part is the linkage to care when people get out,” said Dr. Josiah “Jody” Rich, a professor of medicine at Brown University who has shaped Rhode Island’s jail addiction medicine program since the HIV epidemic. 

Developing a strong, individualized reentry or discharge plan while a person is in jail is “a core component” of success, added Dr. Justin Berk, the former medical director for the Rhode Island Department of Corrections. 

“When is this person going to get out? Where are they going to get their medications when they follow up? How can we support them in this transition, and get them connected to other community resources?” Berk said. 

Numerous doctors noted that methadone, though highly effective, can be difficult for some people to get, once released. Partly for that reason, many patients prefer buprenorphine. In San Francisco jails, buprenorphine is most commonly prescribed, Mains said. 

SF jail reentry plans and services

Beyond access to medication, patients reentering society may need referrals to housing, employment and mental-health counseling.

“The reasons people use substances are widely varied, and a lot of times have to do with underlying factors,” Mains said. Substance use disorder is a complex disease that can be exacerbated by a patient’s external circumstances, such as homelessness or unemployment, that “one day in jail is not going to change.”

“If someone’s losing an arm, you wouldn’t put a bandaid on it. They need surgery,” Mains said. “And we cannot, as jail health alone, fix all those problems.”

Definitely, there’s a need for follow-up. Throughout a 10-month period from 2022-23, the health department measured how many incarcerated people on medication in jail later accessed medication at least once within the first 30 days upon release. At the highest point, in March 2023, 32 percent did so; at its lowest, in Dec. 2022, only 9 percent. 

Still, San Francisco’s Jail Health Services, which started decades ago after Dr. David Smith founded the Haight Ashbury Clinic in 1976, meets many essential marks of a “gold standard” program, according to multiple jail health doctors. Patients have their choice at a menu of medication, and psychosocial and behavioral services are offered. 

Smith said starting treatment in jail is essential — but only if there is serious follow-up outside jail to prevent relapse and “frequent flier syndrome.” He compared treating addiction to treating patients with acute diabetes. We can’t, he said, have a system that says, “I’ll stabilize you for the acute crisis, and then put you right back into the sugar factory, and you eat it, and have all these crises.”

Executive editor Lydia Chávez contributed to this report. 

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REPORTER. Annika Hom is our inequality reporter through our partnership with Report for America. Annika was born and raised in the Bay Area. She previously interned at SF Weekly and the Boston Globe where she focused on local news and immigration. She is a proud Chinese and Filipina American. She has a twin brother that (contrary to soap opera tropes) is not evil.

Follow her on Twitter at @AnnikaHom.

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  1. We finally have the blessing of buprenorphine’s absolutely stupid limitation of being so heavily regulated that even OxyContin is easier to get, leading to the health department finally able to have the chance to get a grip, to Dorsey is squandering the opportunity for the best chance we have to get people consistently on it.

    The “what’s next” after jail is almost always an afterthought.

    Tell me something new.

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    1. Agreed !!! It’s nearly impossible to get suboxone and many folks in jail so get it and then are cut when the leave jail. It’s not the jails fault but there does needs to be very specific follow up from jail to the suboxone clinic. Additionally- I don’t think people realize how hard it is to get once you’re out of jail – a very limited number of prescribers can offer it – even within treatment programs.

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  2. We need to open treatment places. San Francisco is wasting money on stuff that don’t work ! I was able to help for myself for free ! Does anybody in San Francisco know how to talk to each other with out hating on people 💔 We are wasting time. I’m black and straight and old. We can better for black people in San Francisco.

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  3. The jail has to let them off lock down first. They are continously keeping them on lock down. The C.Os need rehab themselves.

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  4. What if, and stay with me here it gets complicated, they used the money to hire more people!?!

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    1. Please consider reading the article.

      They already have positions open that they have funding for. They’re finding there’s a shortage of people who can fill those positions.

      And then on top of that, the program’s own chief medical officer says that neither more people nor some other use of more money is what they need as much as they need for the services outside jail to be better resourced. How often do you hear an organization’s leadership say it *doesn’t* need more budget and the money should go somewhere else instead? So that really says something.

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