“doing damage control as best we can… but we’re out of ideas”

December 18, 2022
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This article from the San Francisco Chronicle caught my attention this week. It illustrates the challenges big cities are facing with the combination of the behavioral health crisis, the aftermath of the pandemic’s disruption, noncarceral responses to drugs, the lack of affordable housing, social responses that frame addiction as secondary to other problems, and the absence of systems of care that deliver addiction care of adequate quality, intensity, duration, and scope.

The article focuses on overdose deaths and the reality that, in recent years, more than 40% of OD deaths in the Tenderloin occurred in sites used to house homeless people, and more than 16% of the city’s OD deaths occurred in single room occupancy setting that are part of the city’s housing program.

“We take people off the streets and put them in this environment they’re not ready for — due to mental illness, or trauma or substance abuse — and sometimes they get worse,” he said.

Even if people like Jackie want to live in supportive housing units where drugs are not tolerated — a model sometimes referred to as recovery housing — there are no permanent, publicly funded options for them in San Francisco. Currently, a formerly homeless person seeking a sober living environment would need to enter a temporary rehabilitative program rather than long-term housing.

So… they don’t have recovery-safe housing and the alternative is treatment. What happens when they complete treatment? Where do they live then?

Cohen said that the agency has heard from some tenants who would “prefer to be in a sober environment and have more choices within” permanent supportive housing. But, Cohen said, HSH’s stance is that abstinence-based programs are “not an evidence-based best practice” and therefore the department has no plans to pursue the model.

This is just not true. There’s considerable evidence supporting recovery housing. It’s not just a few studies and it’s not a recent development.

Sober living environments raise difficult legal and ethical questions, according to some drug policy experts. Critics say residents may hide their drug use at the worst possible time: when their tolerance has worn off and they’re most at risk of overdosing. The model could create a revolving door back to the streets as tenants are kicked out for using.

These concerns represent real challenges to the model, but they are not unsolvable. Systems of care and providers ought to be held responsible for developing and using processes to maintain engagement, restabilize relapsed residents, adjust treatment plans accordingly, and provide a pathway to maintaining or re-entering housing. There also ought to be safety net services for residents who cannot be restabilized and re-engaged. When residents know these processes exist they are more likely to report their relapse or the relapse of a housemate and the addiction can be interrupted–preventing overdoses.

Residents and patients also ought to participate in meaningful informed consent at multiple intervals throughout their early treatment and recovery journey, and they ought to have easy access to the pathway of their choosing with continuous recovery support.

Still, a growing coalition of advocates, including San Francisco Supervisors Ahsha Safaí, Catherine Stefani and Matt Dorsey say the city should explore more types of housing programs that would allow people to live in a drug-free environment.

“We should do more to make sure that people who have substance use disorder have more options than just being in an SRO in the Tenderloin where drugs are surrounding them,” Stefani said in an interview. “It is ridiculous to think that anyone can recover in those circumstances.”

What I appreciate from these advocates is their refusal to turn policy responses into false choices between protecting the lives of people who are using drugs, people choosing treatment/recovery pathways involving agonist medications, and people choosing agonist-free pathways.

One of the other important things I detect in Dorsey’s San Francisco Recovers model is the way they view people with addiction.

Years ago, I was involved in the development of an SUD program for young people in the criminal justice system. A partner in the development of that program said that “we can view these kids as perpetrators, victims, or resources.” Of course, one doesn’t have to cancel out the others, but it was a good reminder to check our mental models and approach those kids as resources.

I sense that same spirit in this model. These aren’t perpetrators to incarcerate or isolate. They aren’t victims to pity, infantilize, and expect nothing from. They are resources that need some help at the moment.

UPDATE: A friend just commented that this is a reminder of how easily compassionate and well-intentioned responses to addiction can devolve into something that resembles an addiction hospice. And, when we construct addiction hospices, we shouldn’t be surprised that people die.

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