The race for mayor has quickly become a rhetorical sprint away from The City’s official approach to the fentanyl epidemic that — at least on paper — favors gentle interventions over forced treatment of people with drug addictions.
Candidates Mark Farrell and Daniel Lurie both introduced proposals last month that would force drug users into treatment. Mayor London Breed, meanwhile, led a ballot measure to require welfare recipients to undergo screening for drug addiction and participate in treatment programs. She has also struck a more aggressive tone and distanced herself from her own administration’s policies, according to critics.
Last month, flanked by abstinence-based recovery leaders at a rally outside City Hall, Breed warned that The City’s “harm reduction” efforts are “making things worse.”
It’s a sharp turn from the Overdose Prevention Plan that Breed’s administration drafted in 2022. The plan features services such as safe injection sites — where people can use drugs under the supervision of a professional trained in overdose reversal — that have yet to come to fruition.
Political moderates angling for higher office are signaling to voters that they, too, are fed up with The City’s reputation for open-air drug use and a record-high number of overdose deaths.
One doesn’t have to be a seasoned political strategist to understand the candidates’ positioning. A GrowSF poll of San Franciscans last year found more than two-thirds of respondents support arresting and prosecuting people who use drugs in public.
But the tough-love approach, public health and addiction experts have warned, could have unintended consequences.
“We do have strong evidence-based approaches to treating substance use disorder in the medical field, and I don’t see any reason why we need to throw those out for political expediency,” said Dr. Matt Hickey, an assistant professor of medicine at UCSF. (Hickey stressed that his views do not necessarily represent those of his employer.)
What Farrell Wants to Do
Mark Farrell, who served as mayor following the death of Mayor Ed Lee in 2018, announced his campaign last month and promised to detain — and force into treatment — people who have overdoses and are revived with naloxone in at least two separate incidents.
“We need to shift and rebalance from a 100% harm-reduction approach to providing more recovery and abstinence-based options,” Farrell told The Examiner.
Breed’s camp openly questions whether Farrell’s approach is even legal. Still, Farrell believes it would be legal under California law that allows the state to involuntarily detain a person for up to 47 days and force them to receive treatment if they are unable to care for themselves.
Regardless of legal questions, Hickey expressed concern “that this approach will actually increase overdose risk.”
Someone who has just experienced an overdose is vulnerable and remains at high risk of death even after the reversal, he said, insisting that medical treatment is the priority post-overdose. Hickey also expressed concerned that knowing a person could be forced into treatment could dissuade people from seeking help in the event of an overdose.
But Farrell said he believes compelled treatment has proven effective. He points to Laura’s Law, which he sponsored in 2014. The law allowed The City to compel some mental health patients into treatment, and Farrell believes it was a success. He also believes it’s self-evident that The City’s current policies aren’t working.
“If anyone has a question about the efficacy of that plan, please take a walk in the Tenderloin and see for yourself,” Farrell said.
Roberto Evangelista, who leads the San Francisco Public Defender’s Office Mental Health Unit, said in a statement that “incarcerating people suffering from substance use disorder actually increases the likelihood of overdose.”
Evangelista also argued that Farrell’s policy “is an overbroad and likely incorrect interpretation of what these laws allow.”
“It’s also important to emphasize that our current mental health treatment system is already strained and under-resourced for the number of individuals who currently need treatment,” he wrote.
Lurie’s Plan
Lurie introduced a multifaceted plan in February that centers on a “treatment or arrest” option for people experiencing addiction on the street.
“We’ve been too lax, we’ve been too laissez-faire,” Lurie told The Examiner. “There are families, there are kids walking down these streets every day seeing people openly use — and, frankly, die.”
He said he wants to establish new teams, staffed with mental-health professionals and specialized police units, that would offer people committing low-level offenses — such as public drug use — a choice between being arrested or taken to a “Drop-Off Crisis Center.”
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Such a center, which would be open 24/7, would be staffed with professionals to assess a person’s needs and provide case management. A person could detox on-site and be directed toward more substantive treatment elsewhere.
Currently, Lurie argued, “police are left with the choice of taking people to jail or the emergency room, neither of which is what any of us are hoping for.”
Lurie — who co-founded anti-poverty nonprofit Tipping Point — also promises to demand more from the city departments and city-funded nonprofits leading the response to the drug crisis. He would create a new position in the administration that would coordinate The City’s drug crisis response across the departments that play a role.
“Once we win, we will be sitting down with each department head, and they are going to need to justify being the roles that they’re in to continue on in a new administration,” Lurie said.
Is it possible?
Lurie and Farrell are introducing these visions at a time when The City faces a budget deficit projected to exceed $1 billion toward the tail end of the decade.
Lurie argues his plan doesn’t have to cost The City more than it’s already spending because it will free up resources elsewhere. For example, he said, police will be less burdened with responding to drug and mental health-related crises, potentially reducing the mountainous amount of money The City spends on police overtime.
Likewise, Farrell said he does not see a cost issue, noting that The City’s spending on health and welfare initiatives has expanded by more than $2 billion in less than six years.
“We literally have nothing to show for it,” Farrell said.
Compelling people into treatment requires that treatment be available. Lurie’s plan calls for the addition of mental-health professionals at a time when they’re in high demand across the country.
“We have to recruit, and we have to pay people well, but we do pay people well,” Lurie said.
Supervised-consumption sites
What Lurie and Farrell won’t back are overdose-prevention centers that would allow drug users to safely consume.
Lurie said flatly that he would not support one, arguing that fentanyl is a strong enough opioid to have “changed the game” and is too potent to justify “safe consumption.”
Under Breed’s watch, The City opened and operated the Tenderloin Center, which quickly evolved into a de facto supervised-consumption site in 2022. Data collected during the Tenderloin Center’s first and only year in operation found that the center had little success connecting people to treatment — but a spotless record when it came to reversing overdoses.
Breed has since bluntly said that the Tenderloin Center didn’t work, and The City has not proposed a specific site for a new supervised-consumption site — but she hasn’t walked away from it in concept, according to campaign spokesperson Maggie Muir.
“The reality is that fentanyl is so much more powerful that we need to expand solutions to focus more on compelling more people into treatment and offering paths to recovery,” Muir said.
“The focus needs to be getting people into treatment before it reaches that point of needing an overdose prevention site,” she said.
Only one prominent candidate, Supervisor Ahsha Safai, has continued to back overdose-prevention sites, although only as part of a network of services that would include abstinence-based recovery.
He argues that the concept has become “sensationalized,” particularly after the Tenderloin Center’s operation, of which he has been critical and described as being like an “opium den.”
It was, he said, “a fenced-in area, drug dealers surrounded the place and were literally seen throwing drugs over the fence to people, and you didn’t really have a stated goal and being there and engaging people.”
Both Lurie and Farrell argue that Breed has not done enough to stem the wave of overdose deaths plaguing San Francisco, while Breed has already argued that things are getting better.
But Breed points to recent efforts such as the establishment of a coordinated effort between federal, state, and local law enforcement officials to crack down on open-air drug use and fentanyl dealing. Breed has also noted that The City offers treatment to people arrested upon their release from jail.
