Mayor London Breed and three moderate supervisors said on Tuesday that a proposal to drug test San Francisco welfare recipients would keep individuals “accountable” and help shepherd those struggling with addiction into treatment.
But more than half a dozen addiction experts and political figures told Mission Local that, if the goal of the measure is to address people’s addictions, the plan is likely to backfire.
Tell welfare recipients to undergo drug testing or risk their cash, and “they’re going to say — pardon my French — ‘Eff you, I’ll find something else,’” said Dr. William Andereck, a doctor of internal medicine who runs the ethics committee at Sutter Health/California Pacific Medical Center.
Andereck said that, because addiction is a serious disease that changes brain function, most drug users will probably want to use, and decline treatment and forgo the cash.
Even if they accept, there do not appear to be sufficient treatment options for the potentially hundreds or thousands of additional patients the measure would create.
The proposal, announced by Breed on Tuesday, would require drug testing for some 5,200 people who receive cash through the County Adult Assistance Program, a city-run program that disburses between $100 and $700 a month to low-income San Franciscans.
The city’s Human Services Agency, which administers the program, said that some 20 percent of those receiving cash assistance during 2018 to 2020 had reported substance-use disorder. Twenty percent of today’s program enrollees is 1,040.
Presently, there are almost no slots available for drug treatment, according to Vitka Eisen, the CEO of nonprofit HealthRight 360, which provides addiction services across the city.
There are just 2,600 overnight beds in the city for various drug and mental health purposes, according to the Department of Public Health; another 50 are in the pipeline.
The majority of these beds, however, are currently occupied, said Eisen.
“If everybody decided today to go, and they get urine tested … there’s definitely not enough capacity for that,” Eisen said.
Drug users and experts said that, in reality, the proposal would likely lead users to other means, like crime, to fund their addiction. Cutting off cash could even worsen health outcomes by limiting access to basic needs, like food or housing, they said.
Many experts said there is little evidence that coercive proposals help people sober up. Even doctors who believe in forced treatment for severe addiction said restricting cash assistance did not make sense.
“I don’t see how [this proposal] accomplishes what they want,” said Dr. Daniel Ciccarone, a professor on family addiction medicine at the University of California, San Francisco. “This is another piece of proof that the war on drugs is a war on people.”
Is cash enough to compel people into treatment?
Andereck, the internal medicine doctor, said that he generally supports Breed’s efforts to address the “frustrating” drug epidemic.
When he first heard Tuesday’s proposal, he was supportive, he said. “But then, you start thinking about it — it’s harsh,” he said. “The only consequence is creating more crime.”
Of the choice to revoke cash assistance or get help, he said: “I basically see it as a bribe.”
Several medical experts said the compulsory proposal runs counter to best practices in harm reduction and public health. The approach “aligns, in people’s minds, a coercive public response that can be unhelpful,” said Harold Pollack, the co-director of the Health Lab, a public health division at the University of Chicago.
Pollack compared the situation to a doctor whose diabetes patient comes in for an appointment while slurping down a Pepsi.
“You want to say: ‘Let’s work on that, because that’s going to hurt you, given your health,’” Pollack said. “We’re not going to say: ‘We’re not going to give you any medical care for your diabetes right now, and we’re not going to give you food stamps.’”
Janet Coffman, head of the Master of Science and Health Policy and Law Program at UCSF, added that the most successful outcomes are when individuals voluntarily participate in programs.
In reality, cutting people off from cash may actually worsen people’s health by depriving them of basic needs, like food or housing, experts said.
Supervisor Catherine Stefani said she supports the measure, and she suggested that some individuals are using welfare cash to buy drugs off the street. Dr. David Smith, an addiction expert, said this was true in some cases, and that drug markets should be disrupted. However, he estimated that just 10 to 15 percent of patients he has studied who were experiencing addiction use cash for drugs.
“Which implies that 80 to 90 percent, if they get [cash], use part of it for the intended purpose,” Smith said.
Capacity unlikely to meet demand
Withholding cash may incentivize some to accept help, experts agreed. But in a time when nursing shortages abound and bed availability is scanty, many wondered if those who accepted the preconditions would receive adequate treatment.
“The big question for the mayor is: Do we have the resources to provide treatment to everybody who … will accept?” said Coffman, adding that there are also not adequate withdrawal medications for methamphetamines on the same scale as for opioids.
Smith, who opened the Haight-Ashbury Free Clinics and is the former president of the California and American Societies of Addiction Medicine, agrees with Breed and Andereck that the status quo is “not working.”
Smith is open to forced treatment in certain instances, but proposals like Breed’s should only focus on the heaviest users — not all welfare recipients.
“The extension of drug testing for everybody seems to be a little beyond,” Smith said, saying he would like to see programs targeted to those cycling in and out of emergency rooms, or “frequent flyers,” instead.
And, he said, he has asked the city to study how similar programs have fared elsewhere before implementation. “I would like to see more clinical evaluations,” he said.
Why go after the poor? It’s politics.
Meanwhile, political consultants and progressive supervisors accused Breed of using the proposal to play politics. Breed’s announcement came the same day that Daniel Lurie, the Levi Strauss heir and Breed’s most well-heeled opponent, announced his candidacy for mayor.
“There are no coincidences in politics,” said political consultant Eric Jaye, who helmed then-Supervisor Gavin Newsom’s Care Not Cash measure and subsequent mayoral campaign.“If she loses the billionaires, who does she have?”
Board President Aaron Peskin swiftly denounced Breed’s proposal on Tuesday. He questioned how the mayor could test thousands of welfare recipients if she could not even act against hundreds of drug dealers.
“She can’t, and she won’t, and this would simply be silly politics if the issues we face as a city were not so serious,” Peskin said.
The proposal is unlikely to pass the Board of Supervisors, which is controlled by a progressive faction, though Breed could take the measure to voters directly as a ballot initiative.
For his part, Jaye said he was tempted to introduce a ballot measure of his own: Mandating drug-testing for elected officials and their aides.
“I’ve known many people who are on welfare and I’ve known many people at City Hall,” said Jaye, “and there are many more people at City Hall who are high on drugs.”