For six long years, crack cocaine owned Sandra Stewart. Growing up in a home where drugs were commonplace, she began smoking crack when she was a young single mother. Overcome by her addiction, she soon quit her paralegal job and found herself on the streets, living in shelters and cheap hotels.
"I was using [crack] to numb the pain," she says. "I felt all alone. I was pregnant with twins and didn't know where to go. I was lost."
Later, when the state's Child Protective Services threatened to permanently take away her three small children, Ms. Stewart decided to seek help from San Francisco's drug-treatment programs. But what she found was an endless stretch of waiting lists, procedural problems, and poor services.
Despite the roadblocks, Stewart is now clean and sober. Yet she may be the exception: Many drug abusers still can't get treatment because the system is overcrowded.
In an unusual experiment, San Francisco is hoping to change all that. The city is creating the country's first "treatment on demand" program. Under the $20-million plan currently being drafted, the city will treat any drug user within 48 hours of asking for help.
Critics say the program is financially risky and smacks of big government. But supporters, including treatment providers and city health experts, argue that the societal and economic toll of drug abuse is too high to be ignored.
Thus the experiment may provide the nation's clearest test of whether expanded treatment can help eradicate the drug problem - and, in the long run, save money.
"I've never seen the leadership of any city embrace the notion of treatment on demand while recognizing the price tag of the plan," says David Mactas, director of the United States Department of Health and Human Services' Center for Substance Abuse Treatment.
"On social and public-health issues, San Francisco is right on target. It's an environment that encourages such vision...." Federal and city officials will be watching closely, he says. "We're all invested in the success of this program."
City's drug problem
Few would argue that San Francisco has a serious drug problem. It has the highest rate of heroin and methamphetamine-related emergency-room visits of any major city in the country. For cocaine, it ranks second. On any given day, the city turns away more than 1,300 drug users because programs are full.
Stewart found her patience taxed. "When you're an addict, you have moments of clarity when you really want to get it together, to get ... into treatment," she says. "But you never get in - you wait. You're usually in an environment that's still using, and then you get sucked back into it. They call you four to five months later, but the moment in time has passed."
She has since been reunited with her children and works for Family Rights and Dignity, a local political advocacy group.
Supporters of the new program say untreated substance abuse costs San Francisco an estimated $1.7 billion a year, including indirect expenses absorbed by the criminal justice system, social services, hospitals, and businesses.
The direct cost to the city is $370 million a year, officials estimate. But this cost could be drastically cut, they contend. According to a 1994 California study, every $1 spent on treatment saves $7 one year later.
Larry Meredith, director of San Francisco's Community Substance Abuse Services, has high hopes that the program will go beyond just treatment to provide assistance with job training, child care, and housing. The plan, he concedes, is ambitious.
"There is no simple response to the phenomenally complex and massive dilemma of drug abuse in the 1990s," Mr. Meredith says. "It's far worse, especially in San Francisco, than other decades. But I think this city is ready to question its approach and make some major and dramatic changes."
Clearly, economics will be a key determinant of whether the program works. It will take substantial money up front to pay for the expanded treatment, and San Francisco, like other American cities, has no surfeit of funds.
But supporters believe that, over time, the program will more than pay for itself by reducing the social costs associated with substance abuse. One reason the San Francisco Board of Supervisors - along with Mayor Willie Brown - approved the plan is the realization that the city will not be able to rely on federal assistance to deal with its drug problem in the future.
For now, Mayor Brown is promising to stick by his pledge to secure funding for the plan, which will be added to the $47 million the city already spends each year on drug treatment.
"[The mayor] knows that many of the city's problems, such as crime and homelessness, are exacerbated by substance abuse and the lack of services," says the mayor's spokesman, P.J. Johnston.
The potential payoff is high, according to a 1996 study by the US Department of Health and Human Services that tracked substance abusers one year after treatment. Drug sales and violent crime dropped by 78 percent; heroin, cocaine, and crack use was cut in half, the study found.
"Substance-abuse treatment works consistently, demonstrably, and graphically," says Mr. Mactas. "The last thing you want from a public-health, economic, or humanistic point of view is to turn away an addict that's ready for treatment."
Not the government's job
Some are skeptical and say that other projects are more deserving of long-term funding. "It's a noble idea but financially risky," says state Sen. Quentin Kopp (I), noting that treating substance abuse shouldn't be the government's responsibility. "The city doesn't possess $20 million for a new purpose."
Others caution that treatment on demand won't work unless the assistance is tailored to meet different needs.
Supporters like Mactas and Herbert Kleber, executive vice president of the National Center on Addiction and Substance Abuse at Columbia University in New York, want a scientific evaluation built into the program and the city to consult with federal agencies.
"Too often, substance-abuse treatment is an accident of what door you knock on," says Dr. Kleber. "San Francisco runs the risk of its much-needed money being spent on a revolving door of repeated, short-term detoxification or other interventions."
Sandra Stewart agrees. "Treatment on demand is a wonderful idea, but it will take a lot of work to get off the ground," she says. "They need to build the structure from the client up; listen to what former and current clients say they need. They're the consumer. I don't care how messed up addicts are - they know what they need best."