You see it most painfully among the unhoused living on the streets, where fentanyl is an escape, a trap and far too often a death sentence. Fentanyl has become an inescapable presence across homeless encampments, shelter systems and public spaces. We need to rethink how we deal with this devastating crisis, particularly among people who are living on the edge of existence.
We spend billions of dollars on the fallout from fentanyl but almost nothing on understanding the long-term impact of the drug on users’ bodies and minds and the toll on the communities where they live. In my city, San Francisco, more people have died of fentanyl overdoses than from COVID-19. And while we launched Operation Warp Speed and other efforts to rapidly create a vaccine for COVID-19, the scientific and research community has not given the same urgency to the devastating impacts of fentanyl. Without this understanding, we have a limited view of what’s “real” about fentanyl, dictating the success of policy, law and public budgets.
There are treatment protocols, including the use of methadone and buprenorphine, to keep addiction under control and save lives. However, both of those drugs are also opioids. This replacement of one opioid with a less lethal version gives users some semblance of a “normal” life. But the truth is, we don’t know if people are able to truly quit fentanyl without creating a gateway to a new substance.
As the founder of a nonprofit deploying community-based safety and supportive services in some of the grittiest corners of San Francisco; Los Angeles; Portland, Ore.; and Austin, Texas, I have seen firsthand that we have not met the challenge of the fentanyl crisis. But there is a clear path before us that doesn’t require additional funding or new bureaucracies, but only a realignment of existing resources. We should bring together homeless housing, drug treatment and research under one roof to meet affected people where they are.
Relocating treatment services to shelters where at least half of residents are struggling with addiction ensures that people experiencing homelessness have direct, on-site access to care without the bureaucratic hurdles that often prevent them from getting help. But we must move away from the outdated “three hots and a cot sprinkled with a little case management” model of shelter support to truly overcome the entanglement of fentanyl addiction. Meeting people’s basic needs is foundational but not the change mechanism.
Service providers can work with research departments in psychology and psychiatry as well as medical schools to create randomized control studies that test a wide variety of treatments, ranging from drugs like buprenorphine to alternatives like clinical psychology and even massage. Studies could also compare treatment in shelters to other settings like hospital-based clinics.
All services should be voluntary, not required for living in a shelter — consensual and transparent to avoid any perceived conflicts of interest for conducting research at residential facilities.
To make this research work, we need academics and universities willing to be partners. In Portland, where my organization, Urban Alchemy, manages hundreds of beds across five shelters, we’ve partnered with the city to provide embedded services a couple times a week — services including medical care, therapy, psychiatry, housing navigation and job training. We’re now in discussion with university students to bring in-house counselors to help address mental health issues.
We have an opportunity and a responsibility to rethink how we approach addiction and homelessness in the fentanyl era. By utilizing existing resources to integrate medical and social services directly into these environments, we can bridge the gap between survival and recovery. This is the kind of realignment of resources that can drive meaningful change without the need for massive new investments.
We can use research to shape evidence-based best practices, ensuring that those seeking recovery have access to care that truly works while tackling the root causes of chronic homelessness. We can mandate that providers who receive public funds utilize evidence-based practices (as identified by study outcomes) and transform their practices to ensure improved outcomes, and we can introduce performance-based contracting tied to client outcomes.
The fentanyl crisis demands a response that is as aggressive as the drug itself. If we fail to act, we will continue pouring billions into a system that does little more than contain the crisis. But if we seize this moment, we can redefine what’s possible, not just for those struggling with addiction but for the health and safety of entire communities.
Lena Miller is the CEO and co-founder of Urban Alchemy, a nonprofit providing trauma-informed social services to provide clean, housed and safe communities while building career pathways for the formerly incarcerated and homeless. Urban Alchemy was founded in San Francisco and provides services across California, Oregon, Texas and Alabama.
Governing’s opinion columns reflect the views of their authors and not necessarily those of Governing’s editors or management.
Related Articles
