blacks are significantly less likely to rely on professionalized services compared to whites. they were significantly more likely to receive non-professional services that includes 12-step programming, church-related support. and studies have found that blacks are more likely to use outpatient program. i asked the public safety and the neighborhood services committee of the city and county of photographer board of supervisors to hear and include action-based, faith-based treatment, and the creation of black treatment programs in san francisco. this cultural need must be, and we expect to handle the black problem san francisco has. thank you. >> chairwoman: thank you, geoffrea morris. tom wolf, i'd like to invite you to speak.

>> good morning, everyone. chair morris, supervisor haney, supervisor mandelman, thank you forgiving us the opportunity to speak with you today. my name is tom wolf, i'm a recovery advocate in san francisco, i'm a native san franciscan. and three years ago today i was -- only three years ago today i was sleeping on a piece of cardboard in the doorway of golden gate and hyde in the tenderloin, severely addicted to heroin. i chose heroin and fentanyl over my wife and two kids, and that led me to the street, where for the next six months i engaged in various forms of activity to support my activity, which included holding drugs for the drug dealers, which eventually got me incarcerated. i was arrested six times, and five of the six time i was released back into homelessness. the sixth time i had an opportunity to go to a six-month in-patient

treatment program. and the only reason i could go to that treatment program is because it was completely free. i was housed, clothed, fed, given 12-step, faith-based counseling, 100% for free, and whether you agree with that or not, the bottom line is that treatment program ended my homelessness. so when we talk about addiction and homelessness being connected, there is a direct correlation in san francisco. and i am living proof there is a direct correlation between homelessness and stubs substanceuse in the city. san francisco has made a choice to narrow their view of what types of treatment modalities will be. we are here to ask all of you to start a conversation with the recovery people here in san francisco on how we can expand treatment in san francisco to reach a variety of different demographics. no one modality of

treatment is the only way to go. there is room for all types of treatment, from harm reduction, all the way to 12-step, abstinence-based programs. unfortunately, those programs are now funded by private organizations, that raise money on their own, and they don't get a dime from the city unless hay offer harm reduction, which is fine. but there are empty beds. the home i went to in san francisco has 50 open beds for men and 25 open beds for women for a six-month in-patient program that is absolutely free. and we are not doing our duty to serve the city and county of san francisco and its thousands of citizens that are struggling with addiction by not working to incentivize filling those beds and san francisco. so i'm with everybody else here, and we want to start a conversation in the community about promoting

drug treatment. we need high and low technology enforcement of drug programs in street. we need to get out into the street, talk to feeble to peoplein the streets, and tel them what programs are available. and where someone can go directly from the street into a detox bed within hours, not days. thank you safe for listening to us, and i look forward to working with all of you in the future. >> chairwoman: thank you. richard beal, i would like to call you to the floor. >> good morning, supervisors, colleagues, friends, my name is richard beal. and i am really, really excited about this opportunity to speak to you about the different needs of our recovery working group. i want to applaud cedric akbar and my good friend

cregg johnson for being on the battlefield for many years. i started working in this field in 1996. in 1996, i got hired at a center for 3.35 an hour. i worked there for five years, a detox center. for five years we brought people into the program, and it didn't matter where they came from. they laid down in front of the door, some of them, and they were able to come in and get residential resources. this was the social model detox back in 1996. we had a number of programs we could refer people to, long-term programs that worked. they had faith-based programs, 12-step programs. and these programs do not exist in san francisco today. western district recovery house, men's program, 12-step residential program, tom smith, located in the san francisco central, and lone star program, and the

population was h.i.v.-positive african-american women. liberation house, mentioned geoffrea morris earlier. and shiloh men's house, and that is a faith-based program. san francisco used to be the gold standard when it came to addiction treatment. if you wanted to go to a an outpatient program, you could go there. if you wanted to go to a faith-based program, you could go there. we had people dr. daryl smith writing books. it was great for a long time. but then, guess what? they started putting those barriers to treatment with the drug medicare requirement. the next thing you know, the harm reduction thing came, and those programs were no longer funded and could no longer exist. could no longer exist. like i said, i went into

treatment july 20th, 1995, been clean ever since. i laid down in the front of the door. i have 53 detox episodes. they sent me to programs eight times, eight different treatment programs. i went to my first one in '83, and i didn't get clean until 1995, 12 years, of going to different modalities. i ended up working there for five years. my brother brought me to that program. in 2011, my brother relapsed. he went into a program, and he a heart attack in the program. he tried to get back into detox and get into other program, and he couldn't because they wouldn't let him in. there wasn't a bed. my brother died of a heart attack, and i have his ashes in my house right now. three years ago, i sent

him out here to san francisco to get into a program. he relapsed and couldn't get into a program. he immediately came to live with me. he drank alcohol and ended up having a diabetic seizure. march 1st, i found my brother dead because he couldn't get into a program. his ashes are on the other side of my chimney at my house. and i was saying, it is personal for me. i've been doing this for 25 years with cedric and cregg. we need change. it is resistance to change that makes change hard. i don't want to see another person die because they couldn't get in a program. i don't want to see another person die, lie my brothers die, where they couldn't get into a program where they could identify. we need to change. you talk about harm reduction -- harm reduction, meeting people where they are. we do a disservice when we just leave them here. it has to have a goal.

and that goal can be abstinence. that goal needs to be somewhere you can go to a place where your life will improve for the better. and it works best for african-americans and abstinence-based programs or faith-based programs cannot just be limited to harm reduction. we need to fund these other programs. because we didn't fund these programs, they ended and people died. we can change and go back to being the gold standard. we've got a great opportunity. like i said, change is not hard. we have opportunity. i want to thank steve. i want to thank everybody who continues to work so hard. if we come to these groups after hours, we don't get paid. i don't get paid to come to these working groups. we do it because we care. i've been working in this community in san francisco for over 25 years, working with cedric, working with cregg, working with people that have been on his battlefield for years

watching people die. so y'all, we're asking for some help. we need some help. we need the change. and that change needs to come by expanding treatment options, removing those barriers. and we could start with an abstinence-based program, but it is not there. we need it in the tenderloin as well, where matt haney is at. we need it in other areas, but it could start right there in bay view, but it cannot end there. a lot of times with start things and then that is it. we need to continue it and it needs to grow. i want to thank you all. i want to end it like this: god, grant me the serenity to accept the things i cannot change, the courage to change the things i can, and the wisdom to know the difference. thank you all for listening. >> chairwoman: thank you, richard. jabari jackson, i invite you to speak.

>> good morning, board. my name is jabari jackson, and i come to you and i represent the crowd of people that we're talking about who need the help. i represent the addicted and criminally-adjusted population, and i also represent the recovery community. i am a product of addictive families, community, and environment. and today i'm coming to you, someone proud in the recovery community, trying to make a change. i'm asking you guys to meet us where we are at. that has been said so many times. but meet us where we're at, and give us the opportunity for options of recovery. you know, recovery covers so many things. and i'm not here, and we're not here, to talk down on harm reduction. we applaud the effort that has been made to start this battle against addiction.

but understand addiction and recovery are two different things. when we're dealing with addictions, we're dealing with treatment. we need the options of treatment to find our niche, to find out when we need to go, 12 steps, abstinence, faith-based, all of those different types of things. because i'm here today to tell you and represent the crowd of people that harm reduction didn't work for. but before i go into that, i want to talk to you guys and ask about the stays in the drug treatment programs. honestly, ladies and gentlemen, 90 days, i'm just starting to detox. and i speak for the real-life drug addicts here in san francisco, who have lived half of their lives addicted to one kind of drug or another. many of us, or our parents or kids, have been sent away to school for four years to learn how to live, to learn how to do

their career in life. we need more than 90 days to learn how to live our days. 90 days doesn't do anything for them. people need more than 90 days to learn how to live their life. let me talk about harm reduction, and how it didn't work for me. i represent every graph that has been showed to you guys today. you guys are telling me how to reduce my drug intake to try to work on my life. it may work for some, but it may not work for others. and the statistics have shown it doesn't work for everybody. it is a proven fact that harm reduction may be a treatment, but it is not recovery. it's treatment. it's a band-aid on a gun-shot wound. and harm reduction has helped a few, but the statistics show it has

destroyed me. and so we want to start focusing on the many. we need help. and i say "we" because i'm a part of that generation. i'm proud to sit on here and talk to you guys and be on this panel with this people. for maritime, harm reduction just didn't work. i had to do many other avenues. i had to be 12-step. i had to do faith-based. i had to do all of though outlets, and through them outlets, had a second chance at life. through the grace of god i have achieved a lot of things, but this is not about me. this is about opening the door and holding it open for the next person. i am proud to say that men that spoke earlier, cedric and cregg, those are my mentors, and they have

showed me the way. once again, you guys, recovery is a lifetime treatment is just a process. and, please, let's open the door. let's be the trailblazers to get san francisco back to where we were on helping the people who need that help. and there is nothing better than being trailblazers and starting a treatment center or treatment location in the bay view. people are dying out there. i sit to you talking to you guys today with a heavy heart right now because i continue to have people die who has been in this battle with me. i continue to tell you how i sat in facilities that promoted and advocated for harm reduction, and they're sitting and dying through my time through treatment. i could sit here and tell you how being in the trenches, where i come from, where i've been born and a bred, when i've participated in addiction

and i've overcome the addiction with the strong people that led my foundation for my recovery, how important it is for me to be sitting amongst my own to help me overcome this problem. the baby was dying off due to addiction and overdoses, just like in many other neighborhoods. but i'm asking to support a black-led abstinence program in the bay view. let's be the trailblazers. let's start this. there are great people who have helped so many in this city alone. i'm fully asking for you guys to support this, and let's open the doors, kick the doors down, and let's give people a second chance, which you have done for me,and i would like to help do for others. thank you for your time, and god bless you. >> thank you. good morning, supervisors, my name is victoria

westbrook, and i'm the women's gender responsive coordinator, and i'm an addict living in recovery. this issue is such an important issue. it touches countless lives and san francisco and it personally touched mine. i spoked meth, and it culminated in in getting me an indictment. a federal magistrate gave me the opportunity to go to treatment. i didn't go to treatment to get clean. i went to treatment to get out of santa lorita. i didn't believe that my life could be different. the only time people in my circle stopped using was when they were arrested or when they died. at the time that i went to treatment, i had been using more years of my life than i hadn't. something happened while i was in treatment. i saw people in recovery getting their lives back. and there were people

there that had higher expectations for my life than i did at the time. and they believed that i could live a different life. i started to believe it, too. i attended six months of residential treatment and transferred into after-care prior to going to prison, and did another 12 months of treatment while in prison. this may sound unbelievable to many of you, but i remember sitting on my bunk, while incarcerated, thinking that my life was better in prison than it had ever been on the streets. my life had gotten so small from my addiction and the life i was living. i released from prison in september of 2016 and started working in our community to help people with similar backgrounds to me, so that they, too, could live a different life. i was hired by adult probation in july of 2019,

and i'm grateful and honored to work for a department that values lived experience. when i first stopped using, i would never have imagined what my life could be like. because my perspective was that we addicts never stopped using. but i'm here today to tell you that we can and do recover if given the opportunity, held accountable for our choices, and shown a different way to live. i ask you to take these recommendations seriously. although i embrace harm reduction practices, i know for myself i wouldn't have been able to get my life back using harm reduction. harm reduction will tell you that abstinence is part of harm reduction, and yet we don't fund abstinence-based programs. thank you for your time.

>> chairwoman: are there any questions? >> supervisor safai, we'll turn it back to you and the committee, if there are any questions, or anybody you would like to address or ask questions to? >> thank you, steve. i am just blown away. i'm just -- thank you, everybody, for sharing your stories with us. it is quite emotional. i can't thank you enough. i think what we'll do is go right into the presentation from the department of public health. but i just want to say i think you're all amazing, and i'm really, really grateful that you are here and we've heard from you, and i look forward to following up with questions and hearing from b.p. h., and, of course,

working together to achieve the goals you so incredibly laid out for us today. we can have dr. judith martin. >> doctor: good morning co-chairs safai and supervisors. my presentation has slides, and so someone else is going to show them -- o. i appreciate the opportunity to respond to the particular recommendations that this group made. and i especially, as a white woman in a position of leadership, i truly appreciate the input from people of color and also in particular black and african-american people on how their treatment should be done and what kind of

things are gaps in the community and in the bay view. i'm glad some of the recommendations referred specifically to that. i was also really moved by the presentation, and i agree that the -- that in particular the white supremacist war on drugs is really a war on black people and black families. so we're left with that. some of it still remains. and we should address it in our treatment programs. so my name is judy martin. i'm the medical director for substance abuse services. i worked in addiction treatments since 1986. before that, i worked in family practice. and i'm board certified in addiction medicine. and most of that time i spent working with people addicted to heroin and

their families in east brooklyn, and later in the tenderloin. and i was medical director of the turk street clinic between market and hyde. and then in 2012, i joined the county. so i was definitely involved in that r.f.p. that was mentioned in 2016. and that was related to the affordable care act that allowed many people who had never been able to obtain medicaid benefits and insurance, to have insurance. so next slide, please. so these are the recommendations. and during my talk, i'll refer to some of these. some of these things we have already started working on, and i totally share the urgency of the overdose response. we have, right now, 18 proposals that address

specifically the overdose response that we need. next slide, please. so as i go along, you'll notices that some of the things i put up here are in response to some of your recommendations. we use the samsa definition of recovery, the process of change in which individuals improve their health and wellness, and strive to reach their full potential. it includes health, overcoming or managing symptoms, making healthy choices, both physical and emotional. and it includes a home, a stable and safe place to live. and in san francisco, this is really a challenge for all of us. if somebody is not housed, it is very hard to have a recovery pathway. and definitely housing that supports people who are working on their

substance abuse problems. purpose, meaning meaningful activity, and creative endeavors, and developing one's resources, and relationships, from the community, social network, family, and friendships. this part about relationships is also especially important because when people have used drugs and been addicted for a very long time, their community often becomes related to that. even when people do have homes, it may not be a home that supports their own recovery pathway and may get in the way. so all of those things are important when we consider our treatment program. next slide, please. by the way, notice that in that definition, abstinence is not mentioned. and it is just a definition, but it is so holistic, it includes

everything about the person's life. that's one of the things i like about working in addiction services, is that it's so -- it's very holistic. it includes every part of people's lives. it includes a spiritual path, for example, or things that -- developing activities that people can be passionate about that makes time stand still for them. that they really are involved in, and that's the purposeful activities. and it involves changing behavior. it involves treatment for illnesses, including some addiction treatment medications. so -- this is the second part of what samhsa has put out about recovery. and some of you have mentioned these recovery pathways. recovery pathways are highly personalized. they may include professional clinical

treatment, as was mentioned, use of medications, and, of course, support from families, which is sometimes hard to have, too. faith-based approaches -- we do have some faith-based programs that we contract with. peer support -- always all of our staff in the programs are in some way or another peers. and other approaches. and it also recognizes that the growth can vary in its speed, and it can have, in some cases, setbacks. abstinence is generally the goal for a lot of people struggling with addiction. and all of our programs do support abstinence, and that is part of the harm reduction spectrum. so they are inclusive of people who are working on abstinence.

and we have even those who are working on 12-step abstinence. for example, in the methadone clinic on turk street, when i was there, we hosted methadone anonymous. people worked the 12 steps and had sponsors. so 12-step, obviously, is based on alcoholics anonymous, and it has been around since the '30s, and has saved many, many lives. and for a while, it was all we had. there was no other kind of treatment. a lot of people have done well with that. it is not a professional treatment. it is not even treatment. it's mutual and self-help. in treatment, what we do is what we call 12-step facilitation for those people who want to do it. we can talk to them about which step they're doing or ask them whether they have a sponsor, whether they volunteered at the meeting, do they have a home meeting, etc.

so the other thing that is really important to say here is recovery is supported by addressing trauma. and it is very important that in our treatment system, in our program, we don't end up having a structure that retraumatizes people. we are working all of the time on creating programs that are welcoming and that listen to the people who are coming in about what they want, what they need, and work with them. next slide, please. so abstinence, yeah, this was discussed today, and i want to be sure and explain that the definition we use, which is similar to what samhsa uses. it includes the appropriate use of addiction treatment and medication, such as methadone. we have thousands of people in methadone clinics, and many of those people are abstinent.

and the methadone treatment is what supports their abstinence, in addition to their recovery pathway and their counselors. dipanorphene is valuable in many different places. it allows more free access to that drug. and the other thing is that it is very protective against fentanyl, which is one of our big problems right now. so a person who as dipanorphene in their body is 95% protected against fentanyl. it is a key element of what we're working on. and opioids are the most common reason come in seeking treatment.

long-term treatment is indicated for most of those people. so all of our programs will likely include people who are taking methadone or dipanorphene as part of their recovery. next slide, please. individualized care is offered in the least restrictive, medically-indicated setting. so moving along, a continuum of services for more independence is one of our principles. and it is the level of care determined by an assessment-based element. having different options of recovery pathways and goals is key, and i think everybody in this room agrees. inclusivity in is

concluded. is included. some people cut out sugar and lose 10 pounds, and other people do that and take insulin and it is still not under control. some people need very intense care, such things as going to i.c.u. during withdrawal, to help them survive their withdrawal from alcohol. and others will strive with mutual and self-help approaches and not even have to go into treatment. and i think that that wide range of severity is a challenge sometimes when we design programs because we have a lot of peers, and a lot of the professionals, a lot of the counselors, and certainly peer navigators, too -- but a lot of the people who work in addiction treatment have been touched by addiction, sometimes by themselves.

if they see something that is successful for such a highly charged, difficult area, it is hard not to preach it. it is hard not to say, well, this worked for me, so why don't you do this? and so it is really important to remember everybody needs different things. so the harm reduction policy is key in all of our programs. it's a policy that has been in place since 2000. it includes abstinence, and it means -- it means that participants are not discharged because of relapsing, if they're not abstinent. so their needs have to be addressed, including perhaps even more intense care. using the diabetes example, you don't stop somebody's insulin if they eat a doughnut and their

sugar goes up. you work to help the person perhaps not eat doughnuts, but also to improve the treatment so that it can control the blood sugar again. so each treatment program has to have an overdose response plan. that is part of their contract, and it is part of harm reduction training that is required. and educate harm reduction site -- we have organizations that are not part of treatment and not within behavioral health services that specifically are set up to provide safe-use supply, such as syringe access, and also naloxone in the community. that has been in place since 2003, and it has been very, very useful, and saved many lives, as you know. each of those harm reduction locations offers

paths into treatment and options. we need to increase those. that is one of our approaches right now to the overdose response, is to offer very low-threshold treatment access and harm reduction sites. so people are going there who use drugs, and who don't perceive the need for treatment, but they're doing something healthy, right? they're going there to prevent harm from drugs and alcohol. and each -- so if we offered them, for example, dipanorphene at the site -- so somebody is basically saying to them, you came in for naloxone, and i know you're using some opioid, and what do you think instead of using fentanyl, we use dipanorphene. and some people say yes.

and this treatment was done by a illuminary in san francisco on a purchase to health care for homeless people, and he pioneered that at sixth street, and it was evaluated and judged to be successful, so we're spreading that as an urgent part of our response to overdoses. and then, as i said, the level of care is chosen by evaluation, and we work really hard to have transitions across levels of care. in particular, one of the things we work at is when somebody is in residential treatment, which is highly structured and protected, that they be supported in their transition to the real life outside, and that that be done carefully and smoothly. and that it include outpatient care. now, outpatient treatment is unlimited right now.

if somebody is in outpatient care, whether or not they're on medication, many of those people stay on for years. and so there is long-term treatment in san francisco, very long-term treatment, and some people benefit greatly from it. next slide, please. and i wanted to mention the co-occurring mental health and substance use. and we have -- this was fiscal year 1920 members. substance use enrolled people in formal treatment. and we had 1525 people who were co-enrolled, which means they were enrolled in two places. they had two sets of counselors, two treatment plans. so we work as much as possible to coordinate that.

and from the information that is gathered from people when we talk to them, about 35% of them do get into treatment and have co-occurring substance abuse and mental health disorder. and a lot of those need mental health medications. so we work hard. and in particular, paid treatment was mentioned. in our youth services, we offer a lot of those under mental health, they have a more robust program with children, youth, and families. so the staff that treat people that do wrap-around services, for example, have some substance abuse skill. and we make sure to co-train people and make sure that substance abuse is addressed there. next slide, please. so this is the

demographics. most of the people we treat are men. 99% of our clients are adults. and that kind of reflects a little bit how san francisco is right now. 47% are experiencing homelessness. and in residential treatment, it is closer to 95%. so this influences every feature of our addiction treatment system, the presence of people experiencing homelessness at such high rates. it definitely interferes with their recovery pathway if they're not housed. one of the things i should mention that we developed recently, in the last year, is when somebody comes into residential treatment who is experiencing homelessness, they're enrolled in the coordinated entry system for permanent housing. and they're not taken that roll until ever, hopefully

until they get housing. it doesn't count against them to be in residential treatment or residential stepdown. it could be up to almost two years of treatment that doesn't interfere with their ability to eventually be permanently housed. this slide also had ethnicity in it. and i wanted to show some things that differed from the census tract numbers. notice how low the asian population is. in san francisco, 35% asian, and look how small it is. we have around 2%. so it was a signal to us to see how low these numbers were. and so some of our staff are looking at that and making sure we have access to, in particular, cantonese language services. we do have services that are specifically

spanish-speaking, and hispanic and latin culturally-specific. including residential treatments in perinatal residential and outpatient. notice how many disproportionate african-american and black people -- we have almost 30%. so that's really -- compared to 6% disproportionate. it largely has to do with the unfair application of the war on drugs, and who gets in trouble for it, and who comes in for treatment. and we do have some agencies that we contract with who identify as specifically serving black and african-american people in particular, and being culturally sensitive that way. and when we did our r.s.p., we were thinking to include that, it is there. we do include agencies

that focus specifically on black and african-american clientele, and they're staffed by black people and even led by black people. and the majority of white, just like san francisco is. next slide, please. i said this earlier, but notice how preponderent opioids are, the substance of choice, the thing that people get addicted to. it used to be alcohol is second, but lately it has been methamphetamine. that has increased dramatically among the whole population. it is no longer contained within populations where men have sex with men, like it was back in the '80s. now it affects everybody, and every program has people who use methamphetamine. the people who use methamphetamine tend to have more police contact

because the behavior is loud and also sometimes even gets in the way of other people who are in the neighborhood and it disrupts. so they're more likely to end up being the involved group of stimulant users. whereas in the case of opioids, they become quiet, in the corner, fall asleep, and sometimes overdose. alcohol -- so the places that have pretty severe disparities in terms of outcomes, we have many more people, by rate -- you know, per population -- who overdose who are black and african-american, six times what the rest would be. so the next highest one is white. and the same is true for alcohol. outcomes from alcohol, deaths in particular for black men from alcohol,

and, really, white people drink more. but if black people drink, they're more likely to suffer harm from the alcohol. so alcohol is very important to address in our services. next slide, please. i wanted to mention this because a lot of the people who spoke today, this was their pathway for recovery was through justice involved services. this has been developed by or forensics department, and angelica may have contributed this information, so thank you. the goal is to engage adults with substance abuse with treatment, and it includes things like reducing recidivism, which is not particularly a focus if those people aren't in trouble. in terms of stays, which was mentioned earlier, the

population that need help, the approach that was taken is to have wrap-around services through specific organizations that knows about that, and also to provide specialty development of the substance abuse curriculum within and for the residential program, and outreach to kay population. services are there to support after treatment, the residential treatment. and it is a faith-based organization that does a lot of this detox and residential treatment, that has an abstinence model with harm reduction, and client interventions and responses. so i think that might be kind of a thing to think about in some of the suggestions and recommendations that were made today. and the beds have been expanded, and particularly now because of covid-19. next slide, please.

so i wanted to -- because a lot of the recommendations were specific to residential treatment, i wanted to comment about that. so, again, as i said earlier, almost all of the people admitted to residential substance abuse treatment are experiencing homelessness. the authorization for residential treatment is done centrally by the county. so the programs submit a summary of their assessment for level of care recommendation, and then the county reviews and approves it. it is done every month. if they're medicallied medical - medically needed, we approve it. we look at the treatment to ensure it is working and that people are paying

attention to this person. we do extend beyond 90 days, and it is not covered by medicaid -- very little is. medicaid pays drug medi-cal for the treatment section of residential care now, which is a huge step forward. but it doesn't pay for room and board. it breaks it up. it doesn't pay for room and board. and so most of the programmes that apply to that 2016 r.f.p., they have medicaid in their budget, but they often have general funds for situations like this. and they do encourage everybody to sign up for medicaid because we don't want to overuse the taxpayer money when it can be a federal benefit instead. in 2017, residential stepdown model was created. and this is essentially

transitional housing for this group of people who are coming out of residential care, and who don't have homes. so in authorization, one of the things we ask is: what about this person means they can't go to residential stepdown. residential stepdown housing is tied to extensive outpatient, outpatient, and recovery services, of course. we do have a website to look at. it sounds like some of you did use it when you gave numbers for beds. finetreatment.org. we have 197 beds for residential stepdown. we need 200 to 300 more, and the outpatient care to match, right? as i said, outpatient care can be long-term. we believe that people who engage in outpatient care

are learning how to access treatment outside of residential in the community. and they'll be able to keep that with them, even when they leave the transitional house and hopefully are permanently housed. next slide, please. you mentioned bay view, so i wanted to talk about what we have in the bay view. jalani family is a residential stepdown program, and it is tied, of course, to outpatient treatment. bay view hunter's point foundation, methadone maintenance program, has been there for many years. and another thing that they do, one service they provide, which is really good, the nurses deliver methadone to people who are incarcerated who are on methadone maintenance. and bay view hunter's point has an outpatient prom, and some of the people at jalani family

get their outpatient care there. african-american healing center is routine and outpatient services. it's the culture of the program where the leaders are african-american. a lot of the clients are not. not everyone in the bay view, of course, is black or african-american. and then, ward 93, which is the opioid treatment outpatient program offers easy access. i believe it is in the parking lot of one of the churches. next slide, please. [please stand by]

some of these are in response to the fentanyl epidemic. the overdose increase so dramatic from 2018 to 2019. and so it includes ways to reach people, as i said, who don't perceive the need for treatment. the national surveys that look at use in households and health. and it's a service. when people meet the criteria

for having abuse disorder. and they're not in treatment, they're asked why not. for people not in treatment, they should be in treatment. that's what that means or could benefit from treatment. 95% of them say they don't perceive the need for treatment. sometimes they don't receive it right now. sometimes they tried it and feel it didn't work. but essentially, they're not treatment-seeking. so this is one of the reasons why just building more treatment programs, is not necessarily the answer. so we've developed expansions that through continuing management, which is the most proven management for stimulant disorder and the most proven treatment for opioid disorder

asize from methadone which is longer proven. we're expanding hours of behavioral health pharmacy and opioid treatment programs and access center. this is part of the mental health san francisco legislation. which is very good. overdose prevention site, meaning supervised consumption is one of the things that was mentioned. and the drug sobering center, which is a place for people to go when they're intoxicated. both of those things are priorities of the mayor. and they were pretty much interrupted by covid. but they started back up again. next slide, please. so in summary, there's room for abstinence and various recovery paths in our programs. the ability for opioid abuse disorder treatment social security vital. because of the overdose epidemics it should be in any

program. our residential design is tailored to the needs of people experiencing homeless in san francisco including transitional housing, even though department of public health doesn't do housing. in this case, we were able to justify doing this as part -- thinking of it as part of reentry into society. and being able to comply with the continuum of care. so in -- areally appreciate the recommendations and opportunity to respond to them today. thank you very much. >> thank you, dr. martin. i think those are all the presentations we have. we can get into questions. i'd like to start. i know supervisor haney has his name on the roster. just a few questions, dr. martin. i'm going to start with you and move onto the other presentation and ask questions. you said d.p.h. is not a housing provider, which we understand. and nor are you understand for

disrupting the drug market feeding the crisis. that said, you have a rouge role to play when it comes to identifying the needs in providing treatment and services to those suffering from the disease of addiction. and you know, i feel i have to be honest i feel there's still a huge disconnect between the presentations. from the testimonials from those who are pleading with d.p.h. to understand what they're saying about abstinence-based recovery. and leads me to believe sometimes i feel addiction continues to be grossly misunderstood. and the idea that people just want to preach it. i think that was said. and you know, understanding what richard said, what victoria said, what cedric said, the idea is not preaching it; the idea is

keeping it away so you can keep it. many people in abstinence-based programs is living on the foundation to help another alcoholic and addict, they have to give it away to keep it. and you know, i know that d.p.h. has many programs. you know, you just went through them, through the presentation. but for me, you know, the work that you just described, i can't in -- i cannot deny the fact that what we are seeing in the streets and what we're seeing in san francisco, something is not working. something is not effective. we are seeing people use in the streets. we're seeing people overdosing in the streets. and no one is getting clean. and it leads me to believe, yes, i know that people do not get clean and sober until they want to. anyone who has grown-up with

addiction in their lives, and addiction is a family disease, i'm quite familiar with it. i just -- for me, i just -- is there any comprehension as to what you might be doing -- what you could be doing better? and what you might be doing wrong? >> so thank you for the question. and also for hosting this summit. and recovery session. so we are -- we have a culture of continuous improvement. we aspire to that at least. we do look at places that we consider gaps, which is for example, the additional transitional housing during outpatient care. and we try to work on the intake

process, especially to residential care. and it's improved over the years. but in addition now, we're doing a lot of things that include linkages. so -- and this is part of response to overdoses, too. in order for people to engage and be retained in care, the linkage from acute care to residential treatment, for example, is being -- has been developed in the last year through nurse practitioner tap for example, that communicates directly with the hospital and the emergency room and p.e.s. in order for people to sort of provide a pre-authorization before the person arrived at the

program. so that they get into a bed and then have their assessment. as opposed to having the assessment first. and in other words, she does the assessment while the person is still in the hospital. and by talking to the addiction care team in the hospital. so i believe that one of the areas that we continue to work on is the bed flow, i would say. and it's hard to do that, of course, during covid, because of shelter-in-place. so people have been -- many people have been authorized to stay just because of shelter-in-place. so room and board is covered. and also, what is happening in the transitional houses in the residential step-down, the average stay went from seven months to two years. i mean, there's -- people are still staying there because they have nowhere else to go. so we do -- we -- we want the longer stays in residential step-down and better engagement

in outpatient care. and that's why i think we need more of those beds. so that's one of the areas that we identify as an under-utilization or a gap is the residential step-down programs. those are two that come to mind. and then, having -- contingency management is under utilized. which refers to tangible incentives for healthy behavior. and it's used often as part of linkage. so if somebody says starts in the hospital and continues it in their doctor's office or program, there's a linkage. a peer-navigator linkage person along with clinicians that back them up to incentivize the

person. they follow them for six months. this type of problem has approved the linkage. since it's been there. we want to expand it and double it as part of our response. >> supervisor stefani: i have questions like where does a person go for treatment who doesn't want to be in medical-assisted treatment. you know, i really want to give a voice to those that came here today that -- and i want to -- i'm trying -- i just want to ask steve and steve, if you wanted to have anybody else respond, that's fine, too. you've heard from dr. martin. and you've heard the presentations. and augmenting services and the things that were said. i'm wondering if you feel like there's been needs that's been identified. if you feel like what you have

said has been acknowledged in a way that you feel there's a path forward. just to really get your, i think, take on where we're at with this discussion. >> thank you, supervisor stefani. and thank you, dr. martin, for your presentation. i want to acknowledge the difficult task d.p.h. has to do. i would also like to acknowledge i feel there's a giant disconnect. and recoveries have been hijacked by academics, medical doctors, and professionals. i'm not sure i can get clean today given all that you laid out. there's an interesting dynamic here. the police did for me with a $50 set of handcuffs, which d.p.h. cannot do with a multimillion dollar budget. and it's like, i would never advocate for incarceration. i believe in treatment. but i've got to say, i'm so

grateful for the interventions that happened to me, because i'm afraid if i was in san francisco now addicted to drugs, that i might die. it's that alarming out there. so i'm going to turn it over to my peers that i know that i would like adrian, who is a licensed clinician, who was a heroin addict. adrian can share his story with you. adrian went to college based on where they had china white. i would like him to respond to the department of public health's response to the drug crisis in san francisco. >> well, thank you, steve. i should actually be on my way back to the jail. i'm going to do an educational group with our program just after i get done here. ive do want to thank supervisor stefani again. and i think the question that she posed prior to talking with steve, is an important one. and it probably should get

answered. and i hope i'll be brief enough that it does get answered. i think dr. martin's presentation is useful, but i think what he's done is reenforced the recommendations and the ask that the working group, the committee has made. there is a wide spectrum of harm reduction strategies. i was one of the first people to engage in harm reduction. this was in the '80s. there was fentanyl in the '80s. many diseases of parkinson's and overdoses is not a new problem. that reenforces on top of these strategies which are really medically-centered and really derived from the idea that the medical profession and experts have all the answers, i think just reenforces that a secondary option that is based on many,

many years of practice, therapeutic immunities were brought into being to deal with the seriously mentally ill. my program, a cooccurring program in the jail, we have -- cooccurring, mentally ill, they're doing exceptionally well in the community. when we use an illustration like diabetes as opposed to medication it's apples and oranges. it's true. i would not negate a person with diabetes for eating a doughnut. but a person with diabetes is not sticking a pistol in someone's face and taking their phone or computer. they're not getting in cars as happened in supervisor stefani's district who took two children because they're on a drug-fuelled rampage. they're not living in tents,

defecating on the streets and really impacting predominantly the poor and working-class community. so i think we have to be a little careful with some these -- they become productive. san mateo county has a lawsuit now against the distributors of oxycodone. the extreme opiates brought into being were a political exercise. doctors, big pharma exercise that resulted in the opioid disaster we now face. i must say to the great profit financially of many, many actors in that endeavor. and now are going to have the so-called or the proverbial fox of methadone and suboxone distributors regulate the pen house. there are economic drivers at

play. perceived interests, economic interests, power interests of the various agencies that are trying to manage populations. my final point, as far as culturally competent, i was in graduate school. it was the first year that culturally competent therapy was part of the curriculum mandated by the b.b.f. and my experience with it was a very reductive understanding by the dominant group in the field, predominantly white privileged group, using stereo types of what people of color need. as a person of color, who grew up in the working class, we have 400, 500 years of experience of repression on the north american continent. and one of our major cultural values is resistance. is challenge to oppression. and is resiliency. and by that i mean we're looking for autonomy and agency and

liberation from the shackles that bind us. i don't want to use marxist terms because i'm not a marxist, but those of some of our core cultural belief systems. we don't want to be managed or socially controlled by clinicians or case managers or agencies anymore than we do by c.d.c. officers or law enforcement personnel. we want the opportunity to create in our own communities programs that will allow us to leave the slavery of addiction, regain our own agency and autonomy. and be able to give back to your community and challenge the systemic oppressions that we see, is a bigger issue than just addiction. i never ask the addiction. it's not relevant to me when i work with my clients. i ask about the pain. and people are using because they're in pain. trauma is a significant driver of pain, especially for women.

the eight studies have shown over a long period of time, the correlations between adverse childhood experiences and addiction, mental health issues, physiological outcomes. we need to get rid of the behaviors that provide temporary relief but long-term exacerbate the problem. i think supervisor stefani has posed a great question. i think there's more than enough room to have black-led -- by that, i mean truly authentic black-led treatment facilities in black communities or latino communities or asian communities, in which the community has input. it's not just the face of an executive director. we have seen that in law enforcement. many of the police forces through this past summer that have significant problems, were black-led. clearly, the identity politics

approach is not sufficient. so i appreciate all the work public health does. i work with them constantly in san mateo county. it's a harm reduction county. but the reality is that there's a need to have an alternative or not an alternative, another approach that offers another option. and it supported -- not seen as competition, but as a parallel approach. and that also allows more autonomy and more agency for the people who are the most impacted by this crisis. and those are people of color, black, brown, asian, transgender population, lgbtq community. our communities are being devastated. you are not seeing people in tents in pacific heights, with all due respect to my friends in pacific heights, or in the marina. it's not happening.

the highest concentration of school-age children and working class people in the city. i had to stop. forgive me for my fidel castro-rant, but i'm very passionate about this. the goal is to offer the people the most useful options. and hopefully, we're supporting autonomy and agency and liberation. not unending dependance on the state and socially managed in a more acceptable way. the final thing i would say, i recommend people read the book "saving normal" and "ag pharma". thanks, have a great day. appreciate the time. >> thank you, adrian. i don't think that was a rant. that was good feedback. i see my colleagues' names on the roster. i want to be respectful of their time. we have supervisor haney and

mandelman. supervisor haney, would you like to ask questions now? >> supervisor haney: thank you, supervisor stefani. and thank you to the presenters for their work and canadour and your support of people struggling with addiction. i know we have many of our city's heros who have saved so many lives with us at this hearing. thank you for that. i want to ask about entry points. i know that there was a lot said about the need to promote treatment more. and make sure people are aware of opportunities. you know, increasing awareness. i have a couple of questions about this. one is of course, we think about it a lot of what is happening on the streets. and you know, i live on hyde street. i walk up and down hyde street every day, including this

morning. there are dozens and dozens of people there who are actively using. and maybe i'm missing it. but i don't often see anyone out there trying to connect them with help. i don't see any signs of how people can access treatment. i don't see a mobile, you know, van out there at all times. it seems that where people are using -- and i'm sure there's other examples of this, that we don't have this really intensive all hands on deck. particularly when we measure it against what is happening out there. i appreciate supervisor stefani's point about that, considering how much particularly the last few years the number of people who are dying in our city has just exploded. i just don't have the sense that we have any sort of set of solutions across the board that

are matching the problem that we're facing, especially -- and i can speak in my neighborhood in the tenderloin soma and here in district 6. what can we do to better promote and ensure access when it comes to entry points for people who -- i understand everybody is not ready at particular moments. i think everybody agrees we need to make the barriers as low as possible, as immediate as possible, especially where people are. i'm going to leave that question there. i want to ask more specific questions about navigation centers, support housing and shelter-in-place hotels as it becomes to access. but can maybe dr. martin and one other person provide some

perspective on how we can improve awareness and expand access so it's as easy as possible to the broader array of what is out there. can this live in one place with one number with one website with one flyer? what does that look like? >> yeah, so this is -- i'm going to respond a little bit according to what things we have planned. i'm sure there are other things we haven't thought of yet. but right now what we're doing is there are the harm reduction sites are always in neighborhoods. they have people who walk on the street. we have street medicine on the street, too. so we want every interaction to include some form of welcome into treatment, if possible. and people don't see the need for treatment necessarily. that doesn't mean you can't be welcoming, you know. and we do have some programs

that specialize in outreach. and then, doing -- even having groups and pre-covid, of course, having groups that are walk-in groups. you know, just walk in and you can start talking to somebody. and they have continuing management programs people can continue in. it's a feeling where you can walk in and they don't judge you regardless if you want to stop using or don't want to stop using. for people who do want to move forward, they have access to treatment, full treatment. so we -- that's one of the programs that we want to expand to all the high-risk housing locations. including permit supported housing, sid housing during covid and s.r.o.s.

we have programs already in those places that serve as sort of models. so the things that are working, we're pushing to extend it. it's part of our overdose response plan. >> so dr. martin, this is cedrid akbarn. i presented earlier. in my presentation, for me, to have open and honest communication. and the first thing is, this is the part for me personcally, which is insulting is that they send you instead of sending the director in the first place. and then, the information you have given us is information we can find on the website. that we can find in every meeting. and in reality of what you are talking about, is it's one agency that basically has all those programs in bayview. that's walden house or health right 360 as you call it.

the healing center, which to me is if it's a healing center, should be out in the streets covering these families, is a white woman, who has no connection to this community. i'm in these streets every day. i haven't seen her one time out here with us or coming to integrate with us or talking about how to make the change. the other thing is, the same things you're talking about is the issue about why we're asking for more treatment, residential treatment. you talked about methadone and people being sober on methadone. we have methadone clinics. most of the people on methadone, guess what they're taking? benzodiazepan. the u.a.s, 90% of that. they are actively using. i got what you say about the

city and what sam you're using. but what we're talking about is the people that in the program that want total abstinence, they need to have a place to go also. and then, you want to talk about what the clients want and what they deserve. and most of us look at it like that. but if i'm out of my mind, like if i have mental health issues and i need -- i have schizophrenia and i need medication to talk to me, if i talk to you while i'm out of my mind, i'm not making too much sense. and sometimes as a family approach and as a collective approach, we have to step in and help one another. so it's like i'm doing my best to be respectful to you. because what you basically did was insulted us on everything that we just talked about. and i don't want to put you in that position, because that's really shouldn't have been your role. it should have been the director of the department of public health here.

and i appreciate you for acknowledging it. and saying things. but what we're talking about is meetings. because what you just did is you shut us down and said you're already providing all of these things. so the door has to be open. a table has to be open where we sit down. we're saying to you this is what we see on a day-to-day basis. and don't just acknowledge me and say it. but let's sit down and talk about this. because what you just did is shut us down, acknowledged what we said. told us basically what i took it is be quiet. this is what we're doing. and this is what it's going to be. so all i'm saying is is we extending a branch out to talk about this, let's talk about it frankly and what it really is. and not talk about some hypothetical thing you think is going on. because that's not what is happening out here at all. >> miss martin, before you

respond, i want to thank mr. akbar for the follow-up points and questions. and really, to all of the members of the recovery summit working group for your powerful presentations. and but i think before this gets even further into a back and forth between the working group and miss martin and d.b.h., i wanted to emphasize that this is a hearing of the public safety and neighborhood services committee, so i want to recognize speakers before they speak. and i know some of my colleagues or committee members, you know, had questions and remarks to make. and i think we have some folks waiting in public comment as well. so, miss martin, can you respond? >> yes, i would welcome some kind of future conversation. i think this is a good way to open a conversation to be clear.

>> chair mar: great. supervisor haney, were you finished with your questions? >> supervisor haney: no. if i could make one more point and ask one more question. i feel and appreciate that response, dr. martin. i do feel that a number of things that you talked about were things that we are planning to do or may do. you know, last year, we saw just a horrific, as you know, you work on this every day, number of people who died. just this week on one day we lost three people in the tenderloin. i mean it seems like we're far beyond a point where we are -- should be saying what we may do or what might happen. particularly when we have models in the neighborhoods and in the communities that we can draw from. it really feels this needs to be a stream lined, simplified

process to get people easily access immediately. i would out there and everyone has an experience like this trying to get somebody into treatment on a sunday. and it was impossible. from where i was. and i know there are places who would have taken this young man, but i didn't even know how to access that. you know, we know what it looks like at this point to respond to an epidemic. we're doing that when it comes to covid. if a restaurant that was not supposed to be open because we were in shelter-in-place opened their doors for five minutes, they would have been shut like that. yet, there are hundreds of people out there who need help, and i just don't see that level of urgency or scale to create the solutions right now that i think can save lives. i do want to ask, though, because in terms of the access. you know, we've had shelter-in-place hotels open now

since march of last year. it's my understanding that we've only exited based on the numbers i've seen two people of the many thousands who have been in these shelter-in-place hotels into any sort of residential treatment. it seems to me that when we have folks who are inside who have shelter, whether it's a shelter-in-place hotel, i know it's happening a different way through jail house services. what are we doing to assess these folks? and provide the array of options that may be available to them for residential or other forms of treatment? i know there's some challenges when people are on the streets for a variety of reasons. but if someone is in a shelter-in-place hotel, is every person there be assessed? if it's appropriate for them. do we have connections with a broad array of treatment

options? and providing them information about how to access those as next steps. you speak to what we do in in each of those spaces and sort of a different thing. but you know, supportive housing is where i see people going in supportive housing and not actually having ongoing treatment that is effective. for people in shelters, shelter in place hotels, navigation centers, how are we connecting them with the options that are available effectively? >> uh-huh. so each one is slightly different. right now, we're really concerned about overdose, as you point out. so in the s.i.p. hotels, the people that had low threshold access to the medication, weren't showing up to pick up their descriptions once they moved to s.i.p..

so the pharmacy developed a delivery system, as you know, using the medication for people on fentanyl is more complicated and might require what is called microdosing, special doses. and that takes the pharmacist to explain it. and they have bubble packs that they use. and they've -- the pharmacists have been going out to s.i.p. hotels to help people take their medicines. the s.i.p. hotels do have psycho social providers that cruise them and make sure that people who need them, that they have help. so there is some, what you would call, supportive services. the other things that occur in the s.i.p. after a lot of hard work by the dope project, san francisco aids foundation and population health division is there's naloxone on every floor. it's kind of velcroed onto the wall. anybody can take it. we know that don't use alone is one of the major advice that we

can give somebody. and so when you're isolated because of covid, it makes you more at risk. and so people looking out for each other, it gets harder. training all the staff that staff the hotels and making sure there's safety supplies and disposal of needles and so on is front and center in the front. and the packages that have the safe use supplies have flyers how to access treatment. so there are a variety of things have that have been tried and seemed to be working. and still i agree with you there are still overdoses. the ones that happen in this particular cluster started in the bayview. and our programs -- kind of like what miss woodson was

describing, the people that had information and knowledge about naloxone and how to prevent overdoses was the ones we contacted and said yes, i'm going out there and doing this and that. even those people were using cocaine and they were not tolerant to opiates to the overdoses happened with contaminated cocaine. so test strips became important for that group. so they're talking to people they offered to open their doors and talk to anybody who comes there. and one of those programs is a program that specifically serves black and african american people. >> supervisor haney: can i get your perspective?

i mean, exiting two people from all of the shelter-in-place hotels, which have had thousands of people in them, what is happening there? does that seem low to you, right to you? is there a process where we are working with people who are inside environments like shelters or navigation centers or shelter-in-place hotels and helping them identify more long-term placements like we heard from today like with the city? it seems to me there's a lot of disconnects here. one of the disconnects is the way we assess and enter people and streamline that process into the appropriate, you know, treatment opportunity for them. two people out of many thousands -- there are 2,000 people in shelter-in-place hotels now. but there are many hundred that have exited. >> so the housing part of it,

like where they go after shelter-in-place, where they live, i'm not sure about. that's part of housing. but i am more familiar with the supportive services that are offered by nonprofits. and access to treatment through telephone and televideo is one of the things that has been offered. not many takers. not many people are looking for treatment. so keeping them safe ends up being very important. and the assessment, when somebody comes in for treatment, the assessment i mentioned, is a series of questions about what do you need in terms of withdrawal? do you have to be in a residential withdrawal program? and depending on the drugs you use, that might influence whether you need medication or not? and then, on the medical side, do you have medical needs that are urgent, like an infection or something that needs to be treated right away.

and the third demention is mental health. so if somebody is out right psychotic, that determines a lot about where they end up. the fourth one is called readiness. which means preferences basically about what the person would want right now. and whether they would stay, you know, in treatment if we introduce it. and then, the fifth someone relapse. the danger of relapse. for example, one of the main dangers of relapse as i think was pointed out today, is for somebody to be discharged to a community, where there's high levels of dealing and drug use. and where someone might target them. and then, finally, the home environment is the sixth dimension. and that one has to do with life or death danger at home, like say abuse at home or a danger not living at home. and actually being in danger of

being attacked. so all of those things are taken into account to decide what level of care the person should have. >> supervisor haney: thank you. i appreciate that. i do think that, you know -- and i've visited many of the shelter-in-place hotels and navigation centers and shelters, and i think that when we're bringing people inside, and hopefully we're bringing people inside, as often and as much and as many as we can, that we do have to take that opportunity to provide treatment in all forms. and even next steps in terms of some of the options that have been discussed here today as well as others in addition to of course the harm reduction piece of it to, you know, protect the immediate situation a person may be in. so i'll look forward to further conversation about this and i'll pass it back to supervisor

stefani. >> supervisor stefani: thank you, supervisor haney for all of your good work. supervisor mandelman, are you still here? >> i'm still here. thank you, vice chair stefani. and thank you for holding this hearing. and thank you to the recovery summit working group for all of your work for this hearing today and the work you do every day and thank you to dr. miller and the work that you do at d.p.h. i have a few questions or comments or thoughts. and i have this frustration or sinking feeling or feeling of badness that occurs every time we try to talk about drugs at this board. because there appears to be such a massive disconnect between the

presentation of the city we inhabit and the public health response as perceived by the department of public health. and the experience of substance use as perceived by the communities all of us represent in different ways, different parts of the city experiencing it in different ways. but it feels like we're not having the same conversation in some important way. when supervisor haney had the hearing on overdose deaths, i think it was almost 700 last year. and i would note listen to go a npr story about contra costa county very concerned their overdose deaths approached 700. d.p.h. is responding to the

forefront of substance abuse disorder. yet by the measures that most regular folks look at, we're failing miserably. i asked in the overdose hearing, is what you're telling is that if we just did more of what we're doing now, we would have different or better outcomes? and i still have that question. because the response -- your response today, seems a little bit -- i mean, you were getting a fundamental basic critique of d.p.h.'s approach and harm reduction approach. folks are saying, fine. continue doing harm reduction, but we need to be doing other things. greater consideration of abstinence-only programming would actually help, would move us in a different direction. that if we -- that there are ways we could be approaching this massive drug problem the city has differently, that would be getting us to different

places or to a different place. and that is -- you know, that has some -- it's at least something that is a policy maker like myself has to think about or listen to. because what we seem to be doing now doesn't seem to be working. and there are 700 dead people last year. and it looks like who knows how many more dead people will be coming in the coming year. but go to the neighborhoods i represent, the neighbors supervisor haney and walton represents, it's playing out in different ways in different parts of the city. but there's a lot of folks using a lot of substances and it doesn't feel like d.p.h. has an effective response to it. and i know that's a huge and unfair question. i have some more maybe specific questions. but do you have any thoughts? i mean, it's really a question for hillary when she arrives.

>> so we do have -- we are doing things differently because of the epidemic. i mentioned some of them. and so the people who are dying are not the ones in treatment. in fact, some of those people are working next to you you don't even though they're in treatment they're doing so well. and so i'm in a privileged position to know who they are and see that they do benefit from treatment. and treatment protects people from dying against overdose. the ones that i don't think do such a good job of are the ones in treatment. those are the most visible ones. that's why we have and proposed and started to work on where we offer treatment. making it like on the street treatment, you know. like street-level treatment

basically. and -- >> i don't know if this is right. but i think the argument is something like san francisco does innovative things around treatment. we also enable and allow and are very creative in our interaction with the drug-using population that makes san francisco a good place to use drugs. that may make it easier for folks to continue using drugs. i don't know if this is right. i mean, this is sort of a data and analysis, and we need someone to figure this out i think. unless you have the answer. even in the discussion of overdoses, you talked about the relative sophistication of our drug-using population. >> yeah. >> and that notwithstanding the flood of narcan we're sending out into the world, that people adapt our behavior. and then, are able to use

substances maybe people in other places would be scared of using, because they might die. and that the whole threshold goes up. and again, i'm not saying this is happening, because i'm not an expert. -- but this is the conversation that i think is happening in the community. and a real questioning of some of the harm reduction assumptions. i think it would be good for d.p.h. to figure out how to respond to it or address that if you think that that analysis is wrong. i think -- i mean, tom wolf said san francisco is a place where it's too hard to get clean and too easy to access drugs, or something like that. that we have both of those things going on. >> well, there's no question that san francisco is different from other places in some ways. one of them is how welcoming and accepting the community is through various kinds of people from various countries and who have different behaviors. and the other part is there's so

many people who are homeless, who really don't have anywhere to live. which may not be true in other places. the income disparity is huge, with you makes it harder, for example, to do the rehabilitation part, getting people good jobs and competing with other jobs. and so i think all of those things are part of what plays. there's no question that harm reduction saves lives. that's been proven over and over again, and it's a good intervention. and our san francisco people who use drugs have reversed 4,000 overdoses last year in 2020. so that's -- i map, something -- i mean, something there is working that we don't have more deaths. >> it's a weird metric if the deaths we're having -- we have more people being saved and way

more people dying, too. we're just like at an order of magnitude different on both levels for other places. >> yeah. i think the equitable distribution of naloxone should keep up with the overdoses. in other words, if overdoses are happening more often, we need more naloxone as i would say it. more easier access to it and safe use supplies. i think that the challenge to us who offer treatment is to make it easier and more welcoming. and make it attractive. >> do we need to nudge people more into treatment? do we need to be pushing more? >> so we're in a way that's what is happening at harm reduction locations that offer

access. it's a nudge. here, try this. kind of approach. and also, having somebody come in like the san francisco aids foundation program, and say here have something to eat and drink and talk to us for awhile, and come back. that kind of approach is a sort of attraction into treatment. i think a lot of community organizations do that. drop-in centers, et cetera. >> there's a lot of talk about the portugal model, which i think is an interesting model to look at. and you know, pretty close to complete decriminalization of substance use. but you do if you are in possession and arrested, you have a conversation with a set of people who want you to stop using and you talk about, you know, what you're doing and how to stop. which seems like more of a nudge than we do in san francisco.

>> yeah, they have -- >> so i don't want to -- i want to ask a few more sort of kind of specific questions. but i mean, this is slightly more specific. how do we -- when you say -- when you make a statement like we know harm reduction works and we know we're saving lives, how do we measure our outcomes on substance use? because one measure -- do we have anyway of measuring how many folks in san francisco are addicted? and how that relates to, you know, how that percentage relates to other places? and if that number is going down or up? or looking at it on the level of the individual where we've identified someone with an addiction and how successful are we at getting that person to stop using? how does d.p.h. think about measuring success? >> there have been several attempts to identify the -- to

use metrics. so what we're looking at is the rates of increase in overdoses, and trying to stop that a little bit as much as we can. we're looking at the number of naloxone doses distributed, making sure it keeps up can demand, the need. we're looking at the unique individuals enrolled in treatment which we can get through the national drug prescription monitoring program. and we have goals to increase that dramatically. we want 90% of people who are -- have opiate use disorder to be on opiate addiction medications. we're approaching it as the aids epidemic was approached with a cascade model. they wanted 90% of people who were identified as having hiv or hiv-positive to be on anti retro

virals in the similar way we're using the addiction treatment medications. and san francisco has a high percentage already. it's just not anywhere near 90%. but it's much higher than most places. and then, of those, we want 90% of them to be in treatment at least six months. and to be retaped in treatment as long as we need it. and so those are the metrics we're looking at. we're also looking at racial disparity in overdoses. making sure that's coming down and disappearing hopefully. so all of those things are things that are goals. i would say are metric goals. and then, we have the countermeasures to make those things happen, are the ones i've been discussing. we have several -- 18 proposals on that. >> two more specific questions and comment and i'll get out of the way. i noticed on the staff -- i understand because of fentanyl

and heroin and the risk of overdose, why we are trying to have, you know, interventions to treat those addictions. but i notice the interventions for alcohol or meth are -- seem like it's less -- each individually is less than half of that. even though i know if you look at -- i think when that work was done on the 4,000 folks on the streets who have some kind of substance abuse disorder, alcohol was 95%, like overwhelming alcohol addiction. a lot of people dying of fentanyl overdoses still have meth in their system. and i know there's not an easy -- there isn't a medical intervention to -- at least prescription intervention with meth, at least not anywhere near as effective. but it was striking to me how much less we do in trying to

treat alcohol and meth than opioids, even though it's all kind of often part of a swirling set of, you know, challenges. >> uh-huh. yeah. >> have you given thought to that? >> yeah. so there's no specific f.d.a.-approved medication for stimulant use disorder, however there's good treatments including contingency management that was mentioned today. that's the one that's shown the best output. and cognitive behavioral treatment. and cognitive behavioral treatment shares qualities with 12-step programs, especially don't catastrophize part of it. changing how you think of your life and getting continue. contingency management is something that is easy to understand for people who are cloudy in their thinking

perhaps, intoxicated, whatever. and the most severe kinds of stimulant use disorder appear in psych emergency in psychotic states, so they do need medication to bring them down. >> i guess i'm trying to think about those interventions versus 12-step programs. because i mean, what is the efficacy of, say, contingency management versus 12-step programs and is that murder? >> 12-step programs are not a treatment. 12-step programs are community anonymous, right? >> it's so hard to measure. but whether we call it a treatment or not, if we're looking for what works, isn't it interesting -- [simultaneous speaking.] >> yeah. >> how that relates to going to a meeting. >> 12-step programs have been

studied. you just can't do a double line control study. but you can study the people who get there and do it. what can predict how they're going to do. if you look at the people who come in today to 12-step meetings, there have been people who followed them overtime and see what gives you a sense of who is going to do well and who doesn't? and the answer is really the people that get most involved. and you know most tied to their program. and so there a relationship part of it that is key. i mean, it's obviously key. and mutual support. so most programs do have an element of that. they would never discourage somebody for going to 12-step. and they would encourage and even sometimes take them there. and offer 12-step facilitation.

>> my last question is there were some specific critiques about the 2016 r.f.p. it sounds like -- and i understand on the 90-day, there's room in the city's programming to go beyond 90 days. i'm wondering if there's room in the city's programming to contract with a provider that is an abstinence only provider, and if not, why not? when we say there's an array, there would be people who might presumably for whom abstinence might be something worth trying. why would we not contract with them as well? >> by far, most people that go into treatment are looking for abstinence. and we support that totally. >> why would we require the -- why would we require all the providers in the universe that

we deal with be people be providers who are willing to not have an abstinence model? >> it's not that they not have an abstinence model. it's that being inclusive of people relapsing. >> but given people can go to different programs and if the one -- if the abstinence only program is just you can't -- that didn't work for me. folks are going to try different programs probably. what is the harm in having abstinence only programs in the array of options? >> so abstinence programs definitely have worked over the years for people who fit in and can stay there. we're concerned that the people who don't, not be dropped. and that's what we mean when we say that there has to be harm reduction approaches. and also, in the middle of this epidemic, there has to be a response to overdose, if it

happens, inside the program. regardless of whether a person was abstinent yesterday, they may relapse. >> why is that on the program rather than -- i mean, why -- a person tried the abstinence program. it's not working. we can move people between programs, right? if program a wasn't working, wouldn't we try program b? >> yeah. but we have to know it didn't work. if they just leave, it may take us a long time to find them. we want the help to be immediate. like the intensity of treatment to be increased in response to that. the one program that sees itself as abstinence-based does that. they put people who relapsed into their management program, detox program. >> what is that program? >> the salvation army program. >> is that a program that we are able to contract with? in >> so they -- they didn't meet

the 2016 r.f.p. for various reasons. but they do contract through forensics. so several forensics grants. so prefer that sometimes people who go through being incarcerated and are coursed into treatment, sometimes the people who are in treatment say this has to be abstinence based. >> do we measure the success of those programs against the success of the non-abstinence-based programs? >> every program is successful if people can stay, usually. so we don't have a good way to measure it. it's not intent to treat measure. you don't take 50 people and send half one way and half another. most of the people in forensics are coerced into treatment. and don't have much --

[simultaneous speaking.] >> i think it would be interesting to try to get a handle on which programs work for whom. how do we compare them? what are the right assessment measures? rather than kind of -- and maybe these decisions in the 2016 r.f.p. were based on actual data and the kind of assessment i'm thinking we should be doing. but i'm not totally confident from your responses today we're doing those assessments and comparisons of different programs and how well they work and who they do or don't work for. >> i'm sorry. we have a regular measurement. it's called outcome measure that we do for every program. it's part of being licensed. you have to do that. and one of the things we look at and it's part of our contract as a performance measure is reduction in use or abstinence. and we measure that every year. and we have a 70% rate of that.

and so we look at that every year. and we have, you know, reflective data discussion about any program that doesn't meet that. and why not. anybody in in treatment for at least 60 days we expect them to reduce use and/or become abstinent. residential programs, most of them have institutional abstinence you might say. so it's a little bit not fair to use that measure and compare it to outpatient in the real world, where people are more likely to relapse. >> all right. thank you, dr. martin. this is, you know, clearly a conversation the city is going to be continuing. and thank you for your work. i'm reminded -- this hearing has reminded me we are well overdue for another treatment on treatment on demand. the last one was september of

2019. vice chair stefani and i called for that at the time. i think everyone, including supervisor haney was shocked by the city's assertion we were meeting treatment on demand goals. i think some of the questions supervisor haney asked about, are we trying to get customers? you may meet your treatment on demand goals if you're not not seeking to boost demand. but i think it is well past time for us. i hope there was a 2020 report. i don't know if there was because of covid. but we ought to have another treatment on demand hearing. i'm imagining vice chair stefani might be interested in doing that and supervisor haney and others. thank you, everybody. thank you, vice chair stefani. >> thank you. i know chair mar has questions. i'm quite baffled that you said 12-step programs are not treatment. i don't understand why

psychologists, psychiatrists recommend people go to a.a. or n.a. for treatment for alcoholism. i don't understand how that can be said. and also, this discussion around maybe programs dropping people of 12-step programs and maybe a particular program might have those rules in place, but anyone in recovery knows that relapse is a part of recovery. and in 12-step programs, you're never shunned away for relapsing. everyone knows that that is something that happens with alcoholism, addiction. if you relapse and you're in one of the 12-step programs, you will be welcomed back. you will be welcomed back with open arms. there's no dropping anybody. and i just want to make that very clear. and i also want to make very clear that there's a lot of recent studies out on 12-step programs. in the "new york times" in march of 2020, basically saying it's the closest thing in public health we have to a free lunch.

i'm not going to read the quote, because i know a lot of people want to speak in public comment. and chair mar wants to ask some questions. and i want to give a chance to some of the people in the recovery working group that also have additional questions. so chair mar, with that, do you have any questions? >> chair mar: yeah. thanks, vice chair stefani for calling this incredibly important hearing and for this really really important discussion we're having today. i want to thank all of the presenters, community advocates and leaders for sharing your powerful personal stories. and really also your recommendations for what ready needs to happen based on your lived experience. and really struggling with these important issues for years or decades. i do want to really acknowledge that. i hear and support your call for the urgent need to expand access

to treatment and recovery programs. our city alongside our harm reduction programs. and also, i really hear and support your call for community-led, peer-based and really black-led solutions and programs. my colleagues have already sort of touched on a lot of the questions that i had for dr. martin. but i did have one question more around services and supports for young people and transitional-age youth. as a parent of a teenager i was struck by but not surprised by the information presented that i think it was 61% of the survey respondents began struggling with drug and alcohol at the age of 18 or younger. and 17% at the age of 13 or

younger. you know, i believe one of the presenters, rico hamilton pointed out our city currently has very few or maybe zero treatment programs specifically for young people. so dr. martin i wanted to see if you could respond to this, the need for really targeted programs for young people, transitional age young adults. >> yeah d.p.h. has a division for behavioral health. there are programs that are specific to adolescents. the way they approach substance abuse disorders, knowing that that's a time when people start using, is to do sort of

wrap-around services in case management and also address emotion and mental health issues. usually there's a lot of trauma. and one of the features about that early phase of people starting to use drugs, is that the diagnose, the formal diagnose is -- can vary a lot from day-to-day. so it's important to keep addressing it. but they may not need the high levels of formal treatment until -- they might need it for a short time, is what i'm saying. so there's more chance of getting over it, the sooner you address it. the other thing we know about youth services is that the earlier the age of beginning to be exposed to drugs, and the

higher and more frequent the exposure, that the more of trouble they'll have later. they won't do as well in, for example, in school, training, and jobs and so on. and the outcomes are much harder. so we have prevention programs for youth. and in particular to reduce binge drinking. we have a strengthening families program. which is essentially a primary prevention program training adults to talk to teen-agers about drug use and teaching teen-agers to talk about adults about drug use. and modelling it over a family meal. and having it, you know, monitored and for fidelity and supported. and that's an evidence-based program that eye effects people

20, 30 years later they're still doing better than the people who didn't do that program. so i am glad to have evidence-based primary prevention programs in the city. i think that the co-training of people of the providers like the social workers and counselors and therapists who work with adolescents includes not only mental health but substance abuse disorders and should continue to do that. it's not that we don't have programs. it's that they don't show up on the substance abuse side even though they're cooccurring. probably the place in substance abuse treatment is the pregnancy programs. because it's a younger crowd usually that gets pregnant. and also, of course, we see the

people who are on probation, the young people. and homeless youth substance abuse treatment is offered there by medicine folks. >> chair mar: thank you, dr. martin. i know the working group members have their hands up for questions, so i believe we have people waiting to speak in public comment. but vice chair stefani, did you want to take -- do you have further remarks or do you want to lead the... >> supervisor stefani: thank you, chair mar. i don't have further remarks at this time. i feel we turn it to public comment now and, steve, we come back to you and go to those that have their hands up. i see victoria and tom want to weigh in in. does that sound good to you, steve? chair mar, can we open it up for

public comment. >> chair mar: great. mr. clerk. >> clerk: thank you, mr. chair. operations will check to see if we have callers in the queue who are ready. for those who have connected via phone, press star followed by 3 to be added to the queue if you wish to speak for the agenda item one. for those on hold in the queue, continue to wait until you're prompted to begin. you will hear a prompt that informs you your line has been unmuted. that will be your opportunity to speak. those watching on san francisco cable 26 or streaming link or www.sfgov.org, please call in now following the instructions on your screen. you'll dial 415-655-0001. enter the meeting i.d. for today's meeting. the meeting i.d. is 1877819333.

following that, press the pound symbol twice and then press star followed by 3 to enter the queue to speak. can you connect us to our first caller. hello. is there a caller on the line? if your line has been unmuted, it's your opportunity to speak. is there a caller here? we hear you. >> my name is james daggs. i've been listening to the presentation. and you know, my family came to san francisco from a segregated

south to have a better opportunity in san francisco. and we never thought that a generations and generations would be living with drug addiction. however, listening to this meeting, we've seen that the department of public health -- you know a lot of policies make a lot of sense in theory. however, in working and practice, some of the work that steve are doing in the community is true -- it's policies that truly work. we need to have more options and different treatment for individuals in san francisco can get the treatment that they need. and i definitely know that the work that they are doing, it works. you know, me as a young person that experiences substance abuse and in the criminal justice system, i've seen how a

community-centric program helped me. the supervisor and everyone made great points. hopefully you're taking it into consideration so we can have a program that truly helps the community that helps the african american community. that understands the need of the community. and not people who have -- don't really understand the community, is not giving the community what they need. we need more options. and more opportunities to serve our community. programs that are led by african americans and led by the african american community that has a deep interesting in helping the community so that we can continue to move forward. you know, a lot of people are dying from these drug addictions are our family, our kids, our loved ones. and it's truly hurting them. you really won't understand the experience... [beep] >> clerk: thank you for participating. can you bring us the next

caller, please. is there a caller on the line? a reminder once again, if you hear from the system your line is unmuted it's your opportunity to have your two minutes. caller, begin. >> hi. good afternoon. my name is rebecca jackson. i'm with the center on juvenile and criminal justice. and i run a program in the city that is called cameo house, we're an alternative sentencing program for homeless women with children here in the city. 90% of the women who are in our program are women of color that come from the neighborhoods of the tenderloin, the bayview, the mission.

75% of those mothers are -- 75 percent of them are mothers. and the population that we try to serve here are extremely complicated in that they are coming from points of extreme poverty. they've experienced homelessness. many of them have mental health challenges. mostly based on complex trauma they've experienced from life, years of domestic and street violence. substance use. justice involvement. a lot of times leading to active c.p.s. cases. adrian had spoken early on in this meeting that show that women are the fastest growing population that is suffering from these situations. and their situations are perpetuated. and they use substances for all of these different reasons.

and as a provider, we are long-term. and we are abstinence-based. it's our experience that abstinence-based programs is vital. and so is the length of stay. we think that it's a travesty, because where do these women go? where does a homeless woman of color in san francisco who is dealing with these challenges, with these barriers, where do they go? what options are available to them? [beep] >> clerk: thank you, rebecca jackson for participating in the discussion. can you bring us the next caller, please. >> hello, everyone. my name is malik washington, the editor of the san francisco bay view national black newspaper paper. i am a recovering addict. i'm a person released from federal prison.

i'm in the community. i stay at the tenderloin. i'm at the taylor center. i don't want to talk about that. i have litigation with that place. i do want to talk about this: what are we going to do about cameo house? it is a black woman, rebecca jackson, providing services for black and brown women, who have suffered from ptsd, mental health issues, substance abuse issues, sex trafficking! we do not have another program like this in the city. yet there are entities and individuals that are trying to defund cameo house. we need to look at it, people. my name is malik washington, the editor of san francisco bayview black newspaper. thank you for letting me share and have a blessed day. i want to thank all of you for the work you're doing. >> clerk: thank you, editor washington.

can we get the next caller, please. >> good afternoon. [indiscernible] i'm -- harm reduction strategy -- the stigma people with punishment and shame. through education, opportunity, supportive services and respect. people are punished for drug use. many people will continue to use drugs and engage in chaotic behaviors despite abstinence and conservatorship -- with respect to life of people who use drugs. our harm reduction services are vital to the cities most vulnerable communities to make our cities safer and healthier, including the risk of tran mission of hiv and hep --

hepatitis c. it's disappointing to hear the board of supervisors with self-acknowledged, unsubstantiated themes. [indiscernible] harm reduction steps fully support the individuals -- access treatment modalities -- while some people have used drugs -- [microphone interference] >> wide spectrum of services to support people every step of their journey. -- alongside people who use drugs. our network of providers have strong working relationships with the california department of public health. people understand the actions is the continuum of care. overdose and other public health consequences will continue so

long as we criminalize and put barriers to the most vulnerable. [indiscernible] [beep] >> clerk: thank you. could you bring us the next caller, please. >> the harm reduction policy with the san francisco aids foundation. i want to say a big thank you to supervisor stefani for your very clear acknowledgment about how harm reduction works and that you support it. i want to thank steve adami and his recovery work group ensuring these conversations include the voices of those most affected. but i feel there's a profound misunderstanding why some services no longer exist in san francisco. the harm reduction policy was --

in 2000. most of the services that used to exist were eliminated in the 2009 budget cut. there are hundreds of millions of dollars of valuable community-focused services. and we have not started to come back and rebuild those services. that's why we've lost so many of these. i want to echo the desire to have culturally focused to have black-led -- harm reduction, this ongoing pitting of harm reduction against abstinence treatment. so much of the city's funding goes to the residential treatment programs that by and large are serving people for whom abstinence or recovery is their goal. this idea that somehow we have

extensive support for harm reduction services doesn't ring true for those of us on the ground, understanding there's so much more needed to save lives -- abstinence treatment programs. i heard cedric's call to speak. and i'm ready and willing and happy to help figure out how we can expand... [beep] >> clerk: thank you, laura thomas for your comments. could you bring us the next caller, please. >> hello, i'm a provider serving as a health educator at the san francisco aids foundation. at today's hearing, it was mentioned there are open beds for treatment programs but those beds are not getting filled the rate they go. the question was posed how do we

raise awareness? how do we get treatment options in front of people who use drugs? the answer, we access people where they are at. harm reduction are for people to learn about treatment options. accessing services, people who use drugs are not giving access to lifesaving supply that help keep them alive -- examining

from using drugs to 100% abstinence takes multiple steps. some take all steps -- all 12 steps at once. others take one step at a time. harm reduction is -- thank you. >> clerk: thank you, caller, for sharing your comments. could you bring us the next caller, please. >> good afternoon.

i was part of the original team that implemented prop 36 in 2000 with bruce.

and there was a definite choice to put that program through the department of public health to treat the substance use as a public health issue. we -- you had to try really hard to not get a treatment slot. in prop 36. because we understood that relapse is part of the disease. unfortunately, it happens to be. we just found a program or another modality that worked for them. i've celebrated by 28th year of sobriety. when i heard the number of programs no longer in san francisco. i was appalled. half of those -- at least half of those gone were ones that we used for prop 36. we had good success rate. i also think there's a fallacy that people don't seek recovery

until they're ready. this is not true. every time i had an encounter with harm reduction program, i knew that there was another way. and it was slowly building upon itself as a previous caller said. i really hope that san francisco can find an answer to this. the fact that we've had more people die from overdosing than covid last year is appalling. [beep] >> clerk: thank you for sharing your comments. could you bring us the next caller, please. is there a caller on the line?

. are we able to pass over a caller and come back? or is this the last one? it's one of the better programs to participate in. it gives us the ability to see where we're going. the programs in san francisco has given me opportunity that has taken me out of my shyness and inability to feel comfortable. and allowed me to come outside of myself and not be ashamed of who i was but who i'm going to be. i'm grateful for that. i thank you forgiving me the opportunity to say that. >> clerk: thank you for sharing your comments. is there anyone further on the line to provide public comment? >> mr. chair, that completes the queue. >> chair mar: thank you, operations. public comment is now closed. i want to thank everyone that

called in during public comment to share your perspectives on these important issues. vice chair stefani, do you want to move to close out this hearing? >> supervisor stefani: yes. i want to make a few comments on public comment and make sure we have victoria and tom i think wanted to say something. but i do want -- i do want to thank those who called in for public comment. i think, you know, it's really unfortunate that it turns into a conversation of harm reduction versus abstinence or versus any other type of program. and to the first point, no one is talking about removing options off the table. no one is doing that. we're talking about adding things that this -- you know, this recovery group finds effective for themselves. i want to thank laura thomas for your comments. i want to continue the conversation with you, because i don't think we should be pitting

methods of treatment against one another. and you know, as we think about the emotion behind addiction, emotions -- the emotion behind recovery and trying to understand why it drums up a lot of these feelings of what -- we're against one another. it's not that. i think for addiction or anyone who is an alcoholic, an addict, sat through 1,000 alanon meetings because your family members are, and you know if your brother does one more of a certain drug, a drug of choice, it could be his last. when you know your sister takes one more -- could lead to her death, you know, when you feel that emotion, when you have that

pain in your life, when you know what addiction can do to people, and you know addiction is a disease and people do things under the influence of alcohol and drugs that they would never do sober, and then, they get in trouble for it, and its know -- they're not bad because they have a disease of addiction, what they might do from that, could be bad. could be criminal. the emotion behind addiction and the emotion behind recovery is real. and i think we need to acknowledge that for all the people here that have spoke, whose lives have been turned around. when victoria spoke, she finally got recovery. and that feeling of having recovery and knowing your life could be so much better than it was before when you were doing that drug, and you want other

people to know the same experience. it's not just that you think someone might need methadone or narcan -- we have to continue those methods of keeping people alive and meeting where they're at. but i think when people have profound experience with addiction, profound experience with a family disease of alcoholism and addiction and all of it, co-dependancy, all of it, when people grow up in that trauma, when people feel that trauma on a daily basis, they -- sometimes when they hear harm reduction, they feel -- they know that their siblings, they know that their parent can't take one more hit. they know their parents or their siblings or themselves can't take another sip of wine, because it will lead to destruction. i think that's where the emotion

is getting in the way of sometimes the conversation of pitting these different methods against one another. laura, i definitely want to continue the conversation with you. i admire your work. and we have to meet people where they're at. and sometimes where people are at and what this has shown me and what i hope has shown everyone through the recommendations, sometimes people are at a place where they cannot do their drug of choice for another minute. and we have to recognize that. we have to recognize, try to intervene in a way that is helpful. and leads people to paths of recovery. so that is what i intend to do in this hearing today. i think we've done a good job. and i appreciate all of the presenters. and i look forward to continuing to working with you, dr. martin.

i'm hoping we can facilitate another conversation with you in working group off-line. and continue to talk about this. because we cannot continue in san francisco as we are now. it is unacceptable. and we know there are programs out there that help people. so i want to turn it back over to steve to close it out. i know, steve, i really want victoria -- seems like she's had her happened up. i want everyone to feel like they've been heard. that's why i called this hearing. before we close this hearing out that those of you who have taken time to share your lives with us, your stories with us, have the chance to comment. and then, please know i'm going to ask to continue this hearing through a call of the chair, so we know this discussion is not over today, because it has to continue. steve. >> thank you, supervisor stefani. i want to make a couple of comments and i'll call on my peers to close out the meeting.

first, i also want to acknowledge laura thomas. we've had a long-standing relationship when she was with the drug policy alliance. we value her work. i don't know why i feel i have to continue to say over and over again. nobody is saying stop doing harm reduction. what we are saying is it appears our values are different. i'm no different than the guy at hyde and jones with a syringe in his arm. i'm now in a leadership role, overseeing staff and had somebody left me there, i wouldn't be sitting here. we believe people can change. because we changed. was it fun? no. but thank god somebody cared about me enough to tell me the truth about my life! the judge who sent me to prison last is a friend of mine. it's