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How to Get a City off Drugs

The ABCs of fighting San Francisco’s injection drug crisis.

Civic Center Plaza is filled with users and dealers. 

 

This story is part of our special report on the private tragedies and public toll of our injection drug epidemic. Read more of One City, Under the Syringe here.

 

WHAT DRUGS ARE INVOLVED?
There are two main types: stimulants and opioids. Stimulants include methamphetamine (speed) and cocaine. Opioids include heroin and morphine, as well as hydrocodone, oxycodone, and the like. Because of the ways they affect users’ brains, both types are highly addictive.

HOW DO YOU TREAT PEOPLE WHO ARE ADDICTED TO THESE DRUGS?
For decades, only one chemical treatment was available for opioid addiction: methadone. Methadone is highly effective, but it has certain drawbacks. It is itself a powerful opioid: Between 2010 and 2012, 45.9 percent of the 331 opioid overdose deaths in San Francisco were caused by methadone, although most if not all of these fatalities occurred as the result of improper use. It can only be administered by a federally regulated narcotic treatment program, which requires patients to come into a methadone clinic every day (until they have demonstrated that they can be given take-home doses), pass regular urine tests, and attend counseling sessions. The demanding nature of the regimen and the drug’s potent effect make it less suitable for some patients.

Around 2000, an alternative to methadone was approved. The new drug, called buprenorphine, revolutionized the field of addiction medicine. Buprenorphine (also known by the brand name Suboxone) is not as potent an opioid as methadone, does not require daily visits to a clinic (though it is taken daily), and is less intensely regulated. From the user’s perspective, the main drawback of “bupe” is that you have to be almost fully withdrawn from heroin before you can start taking it, making the induction process agonizing for some. But it leaves users feeling less drugged, is easier to take, and is as effective as methadone at blocking the craving to use heroin. No effective medication exists to treat stimulant use disorders.

WHERE DO DRUG USERS GO TO GET TREATMENT?
San Francisco has an extensive network of organizations that offer treatment, ranging from city-run programs to nonprofits to for-profit companies. The city’s goal is to provide same-day or next-day treatment with methadone or buprenorphine. The city’s respected methadone program, the Opiate Treatment Outpatient Program, administered by UCSF at Zuckerberg S.F. General Hospital, serves 300 patients and also operates a methadone van that serves the Bayview. Another joint city-UCSF program, the Office-Based Buprenorphine Induction Clinic, helps patients get started on buprenorphine. Nonprofits like HealthRight 360 offer substance use disorder programs. There are several private companies that offer methadone or buprenorphine treatment, including BAART, Westside Community Services, and Fort Help; there are also residential treatment programs such as Positive Resource Center (Baker Places) and Delancey Street.

Finally, needle exchanges such as the 6th Street Harm Reduction Center , the S.F. Drug Users Union, and Glide provide clean needles and referrals for treatment. For stimulant users, city-run programs like the Stimulant Treatment Outpatient Program at Zuckerberg S.F. General offer counseling and support. Finally, the city has a program designed to help the highest-risk, most vulnerable injection drug users, almost all of whom are homeless. Dr. Barry Zevin and his team at Tom Waddell Urban Health Clinic Urgent Care, working closely with the city’s Homeless Outreach Team, go out on the streets regularly, bringing medical care and treatment to people who otherwise might not get help.

WHO PAYS FOR ALL THIS?
Even indigent patients can receive free medical care and treatment—and the city isn’t on the hook for nearly as much money for these programs as it used to be. Medicaid expansion under the Affordable Care Act made substance use treatment an “essential benefit” and guaranteed federal funding for treatment in state-run low-income programs like MediCal. Before the Obamacare expansion, the city had to fund most substance treatment programs out of its General Fund. Last year, of the $70 million spent on substance use by the S.F. Department of Public Health, less than half came from the city.

WHAT ARE THE SNAFUS?
A bureaucratic Catch-22 can disincentivize providers from giving treatment and patients from seeking it. To receive coverage, a MediCal patient must choose a provider to be his or her medical “home.” Patients who choose a provider that doesn’t offer, say, buprenorphine and subsequently want or need to get on a buprenorphine program will have to go to a different provider. But unless they make that new provider their medical home, their treatment will not be covered by MediCal—meaning the new provider will have to pay. Some providers will not accept patients under these terms, and some patients do not wish to leave their home provider, which means they can’t get necessary treatment. Providers are trying to resolve this problem.

 

Originally published in the October issue of San Francisco

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