Special Section: Emergency! A WAKE-UP CALL: CONFRONTING STREET ADDICTION

Haining Yu, MD and John Maa, MD

The near-fatal fentanyl overdose in November 2022 of an infant at a Marina playground led to significant media coverage and San Francisco leaders making “strong calls for change” due to this “wake up call” regarding the city’s opioid problem. Heather Knight from the SF Chronicle notes that this is far from a new problem as pills, pipes and syringes regularly litter Tenderloin playgrounds. Knight rightly states that children living in lower income neighborhoods such as the Tenderloin, Bayview and Mission have been affected by the city’s fentanyl crisis (along with chronic homelessness, mental health issues) on a daily basis for years now. Parents regularly make social media posts to share their difficulty to explain to their children why people are passed out on the ground outside of their home. A child in the Tenderloin was attacked on her way to school last year by an individual likely experiencing a combination of homelessness, substance abuse and mental illness. All children are deserving of safety and the freedom to enjoy childhood, and we should all be outraged by the fentanyl crisis’ disproportionate impact on children who live in neighborhoods most impacted by this long-brewing crisis.

Knight’s article also suggests that psychiatrists exacerbate the fentanyl problem on our city streets by not keeping at-risk patients on psychiatric holds. The truth is that after 72 hours a patient can contest their hold before a judge, who often overrules the psychiatrist as the court’s definition of "gravely disabled" is very narrow. When a psychiatrist declines to place a hold, it is often a reflection of past experiences where similar cases have been ruled against them in court. One gaunt patient who illustrates this challenge was found sitting in his own waste, with delusions and very limited motor activity, and a medical record that stretched back years with similar presentations. Many thought “if anyone meets criteria for grave disability, it’s this man.” But he verbalized to the judge that he wanted to leave the hospital and that he knew how to find food and shelter, and so the judge deemed him not “gravely disabled.” In court he was represented by an appointed public defender whose job was to ensure his rights were not infringed upon by an involuntary hold. After he was released from the hospital against medical advice, one wonders who will be looking out for his right to be safe and to have his basic needs met?

The California state law— the Lanterman-Petris-Short Act (LPS) —that regulates psychiatric holds specifically states that psychiatric holds cannot be used solely for drug addiction. It would be illegal to place someone on an LPS hold without evidence that they also have “a primary psychiatric disorder." Even if a patient meets criteria for an initial 72-hour 5150 hold, a serious shortage of psychiatric beds means that often these patients languish in the ED until they recover slightly, and then are released having nowhere else to go. The sad truth is that even if someone gets placed on an extended 5250 hold, which allows for 14 days of involuntary psychiatric hospitalization, that time is often insufficient to help someone with chronic mental illness and substance use recover sufficiently to function on their own, but the threshold for longer term involuntary treatment is even higher, and the threshold for conservatorship and involuntary medication yet higher still.

Even court ordered treatment is hard to obtain. The woman who attacked that child in the Tenderloin last year was arrested and soon released back onto the streets. The woman’s public defender blamed the “underfunding of our mental health system” for her ongoing presence in the community. Again the bed problem rears its ugly head, because these patients often need long term supportive housing to be able to transition successfully towards stable functioning in the community, and those beds are exceedingly rare.

This severe shortage of both acute and long term beds results from intentional political (regulatory and funding) decisions that have been made over decades, leading to a continued reduction in bed numbers. It started with deinstitutionalization, which was an appropriate move to end horrific practices taking place in mental institutions. But it also meant that many who could not care for themselves were released back into communities that did not have the necessary support systems in place to provide the care they needed. Stigma again likely plays a role as cutting psychiatric beds is often a politically expedient thing to do when budgets are tight. Stigma against mental health likely shaped the reimbursement system that continues to systematically underfund psychiatric services compared to other medical services, which has led many large hospital systems to continue to cut down on psychiatric beds. The RAND corpora- tion estimated in 2021 that the SF Bay Area has 40.5 psychiatric beds (acute, subacute and residential) per 100,000 people, far short of their recommendation of 72.8 beds per 100,000 people. That’s an absolute shortage of 1,832 beds. Even with the proposed increase of 400 new beds (completion date undetermined), our City will still be 1,432 beds short of RAND’s estimate of the needs for our population. Of note, the RAND recommendations for bed numbers is based on a state-wide average, and does not take into account the fact that SF has an oversized need compared to the state average (due to our significant issues with homelessness, mental illness and substance abuse).

The patient repeatedly found lying in his own waste was eventually diagnosed with Huntington’s Disease. His atypical presentation of having limited motor manifestations meant that this diagnosis was missed over and over again, and the fact that he was homeless and was thought to have schizophrenia probably didn’t help. He was eventually sent to Laguna Honda after a long wait for a bed there. One wonders how he is doing during the threatened shut down and forced transfer of patients there, and whether he is still alive.

Knight’s article also highlights Portugal’s success in addressing drug addiction, which combines decriminalizing users with providing increased support services such as mandated treatment (which promotes accountability) along with stepped up enforcement of drug dealers. The infant overdose story led Supervisor Ronen to state that San Francisco “should not be allowing open-air drug use.” However, Ronen continues to shy away from accountability for drug-dealers plaguing the streets of San Francisco, hoping instead that federal level actions against cartels will resolve San Francisco’s local drug problems. That logic is akin to supporting federal efforts to crack down on tobacco companies, while putting zero restrictions on the marketing and sales of tobacco products locally.

Getting people off the streets and to stop abusing substances is the ultimate test of behavior change. The recipe for behavioral change is both simple and exceedingly difficult to follow. Successful behavioral change involves motivation, support to enact the change (social support, emotional support, functional support, tools, skills), being in an environment that supports the change, and then accountability.

Accountability for users needs to involve someone monitoring that changes are happening, and providing reinforcement (both positive rewards and negative penalties). We support decriminalizing users—harsh punishments seldom work, but there is also a middle space between decriminalization and the absence of any consequences. In SF, there is insufficient accountability for both users and suppliers, and so we face these negative externalities of unfettered drug sales and use. When it comes to environmental factors, when someone is addicted to fentanyl, being in an environment where dealers are free to do their business is a recipe for guaranteed failure, no matter how motivated the individual. One can be offered drugs countless times when walking down the streets in San Francisco—how can we expect people to kick a highly addictive substance that is being pushed to them all the time? Most patients who successfully stay in recovery either had to leave San Francisco, or be in a locked facility long enough to stabilize, get into treatment, and change their daily patterns of their life. It’s sad to think about all the people for whom this is not possible due to a lack of support and resources. While street-level dealers are not the root cause of our drug problem, they are part of the problem, and again, not dealing with them is akin to allowing unregulated sales of tobacco products in our city. If we limit access to SF’s open air drug markets, it could help more people who want to get clean do that successfully while staying in our city. And hopefully in the long term, it will also lead to a reduction in the consequences of the ongoing scourge of homelessness/ drug addiction/severe mental illness that we all face, and better protect innocent children in our city.