BROKEN FIX

In A Radical Approach, San Francisco Is Making Addiction A Health Issue
Rather Than A Law Enforcement Imperative. So Far, Though, Treatment On
Demand Has Been A Costly Pipe Dream.

He asks me for $10, though he hasn't told me his name. We're in the
emergency room at San Francisco General Hospital. It's early one Friday
evening, and the room is already packed with a motley array of bandaged
heads and seeping sores. This guy's shuffling from person to person,
asking, "You got a 10? I really need it," as if each were an old friend he
had borrowed from before.

"Why?" somebody asks.

"My sister needs it," he says. "She's having a baby."

He sits down in the chair next to me and plunges his attention into a
tattered People magazine. He's white, a young man, not yet 30 years old,
with a big red 49ers jacket and white Adidas. He wears a gold ring on his
right ring finger, two little hands clasping a heart. He could be any
middle-class Irishman from the Outer Sunset, except his socks are filthy,
drooping around his ankles, and he faintly stinks. Under the white neon
lights, tiny beads of sweat shine on his forehead as he flips through the
pages of the magazine. Then suddenly he gags, leaning over the arm of the
chair toward the wall. Once he recovers, he turns to me.

"Can you help me with $10?"

"I might if you'll let me ask you a few questions," I tell him. "Are you
jonesing?"

He nods.

"How long has it been?"

"This morning," he says.

"You ever try treatment?" I ask him.

He gives me a funny look. "Do I look like I got AIDS or something?"

"I'm just wondering," I say.

"Yeah, I tried it," he says. "It didn't work."

"Why not?"

"I wasn't clean," he says. "They told me I had to be clean. So then I came
back a few hours later, and they told me I'd have to come back tomorrow, so
I said fuck it. Can I have my $10 now?"

I give him a $10 bill, and he's out the door.

Like any number of heroin addicts, this man has sought help and, for one
reason or another, failed to get into the system. But considering that he
is young, it's likely he will try to kick his habit again, and when he
makes that decision, the San Francisco Health Department hopes to be there
to catch him.

The city's substance abuse program has gone through a major overhaul in the
last four years, expanding its budget by 88 percent, from $27 million to
$51 million, largely in an ambitious attempt to provide what health care
professionals call "treatment on demand": the ability to promptly place
addicts in a recovery program when they ask for it. In a sharp departure
from federal drug policies, the city is taking a radical approach to the
war on drugs, making addiction a health issue rather than a law enforcement
issue.

Mayor Willie Brown has made a strong commitment to the plan, earmarking
almost $14 million a year specifically for treatment on demand services.
The only other city in the country to even try something like this is
Baltimore, which began a parallel program of its own in 1997, the same year
as San Francisco. The two cities are gambling on the idea that pouring vast
amounts of money into treatment services will dry up the local drug
markets. It is a humanitarian approach with especially long odds, given the
fact that only one in five substance users are clean a year after treatment.

Despite the low success rate, however, drug policy experts -- liberal and
conservative -- tend to agree that attacking the drug epidemic from the
treatment side is the most effective approach to the problem. Incarcerating
nonviolent drug users has helped very few people, except for those who work
in the prison industry; on the other hand, studies estimate that every
dollar spent on treatment yields a $7 return. Even a report commissioned by
former prison-happy Gov. Pete Wilson showed that the $209 million the state
was spending on drug treatment services in 1992 was reaping a $1.5 billion
savings, mostly in law enforcement costs.

But if experts evince clear agreement that treatment is a good idea, it is
entirely unclear that San Francisco is implementing that idea well. Since
the program's inception in 1997, $13.9 million has been added to the
treatment on demand budget, and although it is still early to have a
complete picture of the program's effectiveness, San Francisco is showing
very few signs of progress on the drug abuse front. The city has opened
just 1,248 new treatment slots, a surprisingly small, 22 percent increase
over the number that already existed, considering the amount of money added
to the program. Waiting lists for residential drug treatment still hover
around 1,000 people long, and the waits can vary from four weeks up to six
months. It is true that far fewer people have been sent from San Francisco
to prison for drug-related offenses since the program began, which saves
the state Corrections Department money. But that doesn't mean treatment on
demand has cut into San Francisco's drug-related crime problem; there were
more drug-related arrests in 1998 than any year in the 1990s. Similarly,
the city's program has yet to make an apparent dent in the abuse of
dangerous drugs: Drug-related visits to San Francisco General Hospital's
emergency room are now more frequent than when the program began.

As is so often the case in San Francisco, it appears city government has
allowed the ants to make off with the picnic. Rather than developing a
solid planning process for the allocation of $13.9 million a year (and
rising) in treatment-on demand funds, the Health Department has assigned
the task to a "council" of competing interest groups, all vying for a
helping from this big pot of money. The Health Department's description of
the program as "grass roots" is an understatement, critics say. In reality,
they say, the city has virtually handed the program to a loose confederacy
of nonprofits dependent on public funds for their survival.

Until last month, there had been no money designated toward planning for
the treatment on demand program, and there still has been no money
allocated toward evaluating which treatment services work, and which do
not. As a result, some of the most effective modalities, such as methadone
maintenance, have received just a trickle of funding, while other, less
effective services, such as "education" programs aimed at preventing drug
use, have gotten more money than they probably deserved.

San Francisco's treatment on demand program has the opportunity to be
"lauded as a national model," as Supervisor Gavin Newsom has suggested, but
it also runs the risk of being used as an example of how good ideas can go
horribly wrong.

"My fear about San Francisco," says Herbert Kleber, director of the
substance abuse division at Columbia University, "is that it's going to
throw away all this money, and discourage other cities that might want to
try this."

More important than the example San Francisco sets for other cities,
however, is the grave need S.F. has for these services. Earlier this year,
Public Health Director Mitchell Katz declared that San Francisco leads the
nation in emergency room visits for heroin, speed, and LSD. Drug-related
injuries lead all other categories in admissions to General Hospital. There
are now an estimated 14,000 heroin users in San Francisco, and the city's
heroin-related death rate is three times higher than the state average.
Experts say the flow of heroin into the city has yet to reach its peak, and
without the proper services in place, the death toll is likely to rise.

It's just after Thanksgiving, and the Treatment on Demand Planning Council
is meeting in a conference room within the offices of the city's Community
Substance Abuse Services. Outside the room, a buffet has been laid out with
a spread of Aram sandwiches, pale vegetables with ranch dip, and a few
random dishes such as yams and pecan pie, no doubt left over from the
holiday. The conference room is small, and seems smaller with the
40-some-odd people crowded inside around a long wooden table.

The planning council is in charge of allocating the large sums of money
flowing into the treatment on demand program. Comprising the city's drug
treatment world, it bears the loose resemblance of a United Nations
meeting. You've got the two jail-treatment guys, both African-American, one
sharply dressed, the other enormous and wearing a fedora. You've got a
representative for the homeless, and a few ambassadors for the gay,
lesbian, bisexual, and transgender communities. A variety of white people
are in attendance with earnest expressions of understanding, as well as a
few down-and-out members of the public who have come to ask where in the
hell they can find treatment in this town.

The council has gathered to discuss the priorities for the next budget
cycle. Item by item, the group goes down a list of 19 services, chosen as
priorities from the last meeting. Tonight each member will rate each of the
proposed treatments from most important to least important, and from this
grading process, a final tally will decide what programs get funded next
year. These recommendations will go straight to the mayor, virtually
unchanged, in the planning council's budget proposal. The mayor often
revises the proposal, sending it back to the council, which can either
accept it or lobby for more money. Throughout the process, however, it is
the council and the mayor negotiating the treatment on demand budget, with
program staff acting only as intermediaries in the dialogue.

Second from the top of the preliminary council priority list is a program
called "Culturally competent treatment services for Samoans," with an
estimated cost of $100,000. A thin Asian man with long, flowing hair asks
the difference between treatment services for Samoans and treatment
services for Asian women, the last item on the list.

A large woman turns to the man. "I don't know what your problem is," she
says loudly. "Do you got something against Samoans? Samoans don't get
anything in this town."

"Bam," one of the jail guys whispers to the other.

With every item on the list, there is at least some disagreement as to
validity. A methadone-in-jail treatment program costing an estimated
$270,000 comes under fire as somebody suggests that with so few methadone
slots available in the city, a person might be tempted to commit a crime to
get into the program. There is also some question of its cost.

"Every fiefdom, I mean organization, has a different way of adding these
things," the sharply dressed jail guy says.

"Looks like I'm going to have to do some more 'advocating,'" the big jail
guy says, putting quotation marks around the word by raising his arms and
scratching the air with two fingers of each hand.

Farther down the list is a program described as "Long term and permanent
housing with supportive treatment for homeless people." It is being pushed
by the Coalition on Homelessness. A representative from the gay, lesbian,
bisexual, and transgender community points out that at $1.3 million, this
homeless program is estimated to cost $26,000 per person per year, and
there is not even any mention of drug treatment in the proposal.

"You better put harm reduction in there somewhere," somebody says.

"Good idea," the woman from the coalition says. "Let's make it 'long term
housing and harm reduction for homeless people.'"

In addition to its duties deciding which services to fund every year, the
planning council is ultimately responsible for the treatment on demand
program's success. And make no mistake: With $13.9 million flowing into the
program this year, people are looking for signs of success.

Mayor Brown, for one, was quick to declare the program a triumph, boasting
that the city had achieved treatment on demand in his 1997 State of the
City speech, according to newspaper reports. He was promptly corrected,
however, by members of the planning council, who held a press conference to
say that the city still had a long way to go before it could accurately
make such a claim. Brown stubbornly clung to his statement.

"They are just wrong," Brown was quoted in both dailies as saying. "I
checked. There has not been one clinic or one treatment facility that has
turned anybody who walked in away."

Actually, Brown was just wrong. Health care experts knew the city was far
from achieving its goal two years ago, when it took months to get into a
residential treatment program. The situation isn't much different today.

"If we're still talking about 1,000 people on the waiting lists -- I'm
sorry, that's not even close to treatment on demand," says Patrick Murphy,
an adjunct professor of politics at the University of San Francisco. John
Newmeyer, an epidemiologist at the Haight Ashbury Free Clinic, is more
blunt in his criticism of the program's progress.

"We should expect to see results the first year after treatment on demand
begins," he says. "But we're as bad off as when we began. Only the most
persistent and healthy clients can get into one of these treatment slots."

Considering the amount of money going into treatment on demand services,
the city has made very little effort to measure the program's success. Jim
Stillwell, interim director of the city's Community Substance Abuse
Services, says San Francisco has received about $1 million in federal funds
to assess the program on a "macro" level, charting how the system is doing
as a whole in "performance measures," but these gauges don't reveal much.

For instance, one performance measure the Health Department includes in its
budget proposal is the percentage of successful treatment outcomes. In
fiscal year 1998, the success rate was 50 percent, in 1999 it went up to 55
percent, and in 2000, the Health Department expects the percentage of
successful treatment outcomes to be 60 percent. These numbers would
constitute great news, if they showed the percentage of people who were
clean after they entered treatment; in fact, they show only the percentage
of people who completed a program.

Another Health Department measure of "success" seems similarly off-point.
This method counts positive responses to the survey question, "Would you
recommend clinic to a relative or friend?" This type of indicator might be
helpful to, for instance, the marketing director of a hotel chain, but
doesn't quite meet scientific standards for proof of efficacy of a public
policy program.

The only way to truly gauge the success of a program, experts insist, is to
track a sample of the clients through the process, from before they enter
treatment to at least a year after they exit the system. The tracking can
be as simple as testing whether the client stays clean, or as sophisticated
as charting employment and income levels.

"It's a big added cost, but without a research approach to the evaluation
process, you have no yardstick to measure which dollars are well spent,"
says Peter Banys, a physician at the San Francisco Veterans Hospital who
participated in the first phase of a preliminary feasibility study of the
treatment on demand program. "All you get are testimonies saying, 'We do
great work.' Just throwing dollars at something is not enough; you've got
to see what's effective."

Stillwell says the best type of evaluations are too expensive to implement
at this stage of the game. But even without an evaluation process, San
Francisco officials could and should know, in general terms, which types of
programs are more or less effective than others. The planning council,
however, has made some decisions about funding that seem to fly in the face
of available research, namely those connected to the council's meager
funding of methadone programs. As of fiscal year 1998-99, the planning
council had spent only 3 percent of its money on methadone, one of the most
researched and effective methods for treating heroin addiction, even though
an estimated 38 percent of the city's substance abuse clients are heroin
users.

On the other hand, the planning council spent a whopping 12 percent of its
budget on prevention -- in essence, teaching young people not to use drugs
- -- which is on much more shaky ground in terms of proven effectiveness,
does not open any new treatment slots for addicts, and is limited to a
young population comprising only about 14 percent of the city's drug users.

Lee lingers outside the bleak facade of the clinic one cold Sunday morning,
until a man inside sticks his head out and tells him to "beat rocks." There
is no loitering allowed outside the Bay Area Addiction Research & Treatment
clinic. Lee smiles and ambles off, his pupils the size of pinpricks, high
on the legal drug he has chosen over heroin.

Every day he comes for his daily dose of methadone syrup, which costs him
$12 a cup. Lee says part of his General Assistance check is set aside to
pay for his methadone maintenance program; he says he has to hustle for the
rest, whether it's panhandling, or stealing if he has to. "But $12 ain't
nothing compared to $30 or $40 a day I needed for heroin."

Lee says he has been on and off methadone programs for five years or so.
His current stint has lasted six months. He says he decided to seek
treatment after a revelation. "I knew Jesus was coming ... and I didn't
want to die like that. I didn't want to die like that even if Jesus wasn't
coming."

He says treatment has helped him become better aware of himself, to know
when to bathe and to take notice if he stinks while standing next to
someone who doesn't. He says he has some ideas of how to make something of
himself. He has come up with a few inventions, such as a recording device
that would play the sounds of a mother's breath and heartbeat to help a
baby sleep. He says he got the idea after reading Walden II by B.F.
Skinner, the famed psychologist.

Lee is one of the lucky few in San Francisco to get into a maintenance
program that he could keep the rest of his life, if he wanted. Lee says he
knows people who have been on methadone maintenance for 15 years. He was
lucky because he got into the system before everyone else tried to get in.
Now the wait for maintenance at the clinic is at least two weeks, an
eternity for a junkie.

Only 1 percent of treatment on demand money was spent on methadone
maintenance as of the last fiscal year, even though, at $4,000 annually,
it's among the cheaper forms of treatment for heroin addiction, and one of
the modalities proven most effective in studies going back decades. (Two
percent of the city's treatment budget was spent on methadone detox, a
21-day weaning off heroin that most experts agree is ineffective.) Studies
show methadone users earn twice as much income and their death rate is
three times lower than heroin users, but of the estimated 14,000 heroin
users in San Francisco, only about 2,500 have access to maintenance.

The shortage of treatment slots has only become more severe as heroin use
has increased over the last few years. In 1999, nearly twice as many people
visited the emergency room at General Hospital for cellulitis, a skin
infection that can stem from heroin use, than two years ago, and
opiate-related arrests last year were higher than any other year in the
1990s. Some experts, such as John Newmeyer of the Haight Ashbury Free
Clinic, blame the shortage on the city's Community Substance Abuse
Services' lack of foresight, and the failure of local politicians to push
for more methadone clinics.

Others, such as Philippe Bourgois, a professor of anthropology at the
University of California, San Francisco, blame the shortage of methadone
programs on the treatment culture in California. Bourgois, who has worked
with a group of heroin addicts in San Francisco as part of an
anthropological research project, says California, particularly San
Francisco, has always been hung up about methadone. "I'd say the
policy-makers in San Francisco are in the mid-to extreme range of being
anti-methadone," he says. "Everyone's on the abstinence thing here, and
methadone doesn't jive with that. In San Francisco, you've got the yogurt-
and sprout-eating crowd, while in New York, they don't care, they'll just
throw methadone at you. And, perhaps for that reason, they don't have the
heroin problem we do."

Stillwell, in defense of his department, says it's been difficult to find
new locations for methadone clinics. Nobody wants an influx of junkies
coming into the neighborhood, he says. He says he has also been working
with Supervisor Newsom on legislation that would allow physicians in the
city to prescribe methadone, opening hundreds of new methadone treatment
slots. But when the treatment on demand program began, there were other
needs to fill, and, Stillwell says, he has no regrets. "It would have been
nice to fund everything at the same time, but of course that's not
possible," he says. "We had so many priorities, we simply couldn't do it
all. Remember, if you always go for the quick fix, then you never force the
big change."

The three large men sitting around the table appear slightly sheepish as
they describe the police pilot program called Campaign Against Drug Abuse,
often known by the acronym CADA. "Sometimes I feel like the long-haired
stepchild of law enforcement," says Michael Ortiz, a burly officer with the
state Department of Justice.

George Nazzal and Bob Hernandez, officers with the San Francisco Police
Department, say they feel the same way. As part of the federally funded
CADA program, they try to divert hard-core drug users into treatment
programs, rather than send them to jail, and they say some of their
colleagues accuse them of being social workers.

It's not the name-calling that bothers them. They seem a bit embarrassed by
the fact that since the program began in April 1998, they have managed to
place only four users in treatment. It took about a year to get the program
up and running, they say, but once they were ready earlier this year, they
couldn't find any clinic that would agree to take people in. Finally they
forged a relationship with the McMillan Drop-In Center, which makes
referrals to various treatment programs, but even then, they say they were
told to bring people by only once or twice a month.

"When we started, we thought we'd be dropping them off by the truckload,"
says Ortiz, "and everything would be hunky-dory, but it wasn't like that.
The treatment centers were telling us that they didn't want to be inundated
with people. So now we're limited to going out once or twice a month."

CADA's problems underscore, once again, the city's failure to significantly
expand its treatment capacity, even when two officers are willing to be
called "social workers" to help the program along. The police have good
reason to hope the city's treatment on demand program succeeds: They have
no interest in arresting the same people over and over again. But some
officers say nothing much has changed since the program began.

"Ask [the Community Substance Abuse Services] where the money goes," says
one officer, who chose to withhold his name. "Money seems to fly into that
department and fly right back out."

Even though the city continues to have a severe shortage of treatment slots
that sabotages achieving true treatment on demand, the concept of favoring
drug treatment over drug prosecution has had a major impact on
incarceration rates. According to the California Department of Corrections,
in 1998 San Francisco drug offenders spent half as much time in prison as
they did in 1988, in terms of the number of convictions and the length of
time served, and only a third as much time as they served in 1993. This
drop in drug incarceration can be largely attributed to District Attorney
Terence Hallinan's public declaration that he prefers to send nonviolent
drug offenders to diversion programs rather than prison.

The numbers show that Hallinan has kept his word. Last year, his office
sent 228 drug offenders to prison to serve an average of 20 months,
according to the state prison system, a steep drop from the 691 San
Franciscans who served an average of 14.4 months in 1988, and an even
steeper drop from the 832 people who served an average of 17.2 months in 1993.

Thus, thanks to Hallinan's stance on drug offenders, San Francisco is
saving the state prison system money at a rate of $1,770 a month for every
prisoner not sent to the pen. This type of savings is one of the rationales
usually put forward for favoring treatment over prosecution. But at $2,060
per month per offender for residential treatment, the city is spending more
trying to rehabilitate drug users than it would cost to incarcerate them.
And judging from the city's arrest reports, the majority of San Francisco
drug offenders are not getting into prison or treatment. They are staying
on the street.

Drug-related arrests are on the rise, indicating that the criminal activity
associated with drugs is not going away. Last year, police made 11,080
drug-related arrests, 6,806 for opiates, up from a high in 1996 when police
made 9,977 drug-related arrests, 6,163 for opiates. Police blame the rise
on an increase in drug trafficking, which has lowered the price of heroin.
Nevertheless, the numbers do not reflect well on the city's efforts to
reduce crime through treatment on demand.

A young Latina rolls into the emergency room on a gurney, screaming, and
she won't stop. She screams, she takes a breath, then she screams again.
Her face is covered with acne. She continues wailing, putting the
ordinarily thick-skinned hospital staff on edge. The woman behind the front
desk covers her ears. Some of the patients lift their heads off their
pillows to see what's going on.

"Her brain is frying on crack," says David Fleming, the assistant nurse in
charge of the floor. "She was probably doing S'mores [a quick succession of
hits boosting the high]. Finally it just overloads the body."

Fleming says the staff will give her a dose of droperidol to knock her out;
they'll examine her when she wakes up in a few hours. The problem is, he
has no place to put her. All 40 beds are filled. He has two patients
plastered on alcohol and chained to their beds. One with a sailor's mouth
has peed on the floor. He has six patients in for abscesses, the result of
slamming heroin into the muscle after all the veins in a body have given
out. He has one patient who has overdosed on his girlfriend's morphine. Now
the screaming crack overdose makes 10 out of 40 patients whose primary
reason for admittance to the hospital is drug-or alcohol-related. And this
is at 6 p.m. on a Monday night.

In theory, treatment on demand is supposed to reduce the number of these
types of episodes, but since 1997, the number of drug and alcohol visits to
the San Francisco General emergency room has gone up, while the total
number of visits has remained level. Alcohol-related visits have increased
by almost a thousand, from 3,373 episodes in 1997 to 4,218 episodes in
1999. Visits for cellulitis have shot from 781 visits in 1997 to 1,436 this
year. The numbers have risen in every other substance-related category too,
from general opiate dependency to cocaine.

"Treatment on demand," Alan Gelb, chief of the emergency room, says
skeptically. "Will you define that for me? Because I see a lot of people
who want treatment and can't get it. If you want treatment on demand, then
you better be ready to demand real, real hard."

Gelb's opinion of the city's treatment services seems to be shared
throughout the emergency room. Of course, at General Hospital, the staff's
job is to catch the people who have fallen down, and the workers have not
felt any lightening of the load yet.

Two years into treatment on demand, it may be too early to expect to see
results from this potentially groundbreaking program. But with millions of
dollars a year, and a piece of the city's quality of life on the line, San
Francisco at least deserves a solid game plan and a decent evaluation
process from the city's Substance Abuse Services. After all, it doesn't
have to be this way.

Baltimore, for example, has taken a different tack. That city, struggling
with a drug epidemic as bad as San Francisco's, has chosen a more
centralized method of managing its program over our grass-roots approach.
San Francisco health officials criticize the Baltimore program for its
top-down style, but at least Baltimore is making an effort to be
accountable to its citizens.

Baltimore is spending $1 million a year on an extensive three-year
evaluation process it began the first year of its treatment on demand
program, according to the city's health commissioner, Peter Beilenson. The
results are expected to be available in the year 2001. In the meantime, the
system is managed by a central body of health officials that keeps close
tabs on every one of the program's components, he says, monitoring
retention rates and taking urine samples for every type of treatment.
Baltimore has spent even more money than San Francisco on its program,
hiking its budget from $16 million to $33 million. And as a result, the
number of treatment slots has jumped from 4,000 in 1997 to 7,000 today,
according to the commissioner. There are still long waits for residential
and methadone treatment, but at least the citizens of Baltimore will be
able to see the results of their tax dollars at work when the city's
treatment evaluation comes out.

What results can San Franciscans expect to see?

"That's a tough one," says Stillwell. "It'll be in the little things. Maybe
our parks will be a little cleaner, maybe the line at General Hospital
won't be quite as long ...."