These people try and try to solve their debilitating chronic pain problem (which they still have, and likely will always have) through increasingly-desperate and illegal measures; and go through many harrowing things due almost solely of the illegality of acquiring these same drugs outside of medical channels: the difficulties of finding a source and potential for arrest; the income-eating expense (no insurance to cover costs, plus 10x risk markup); the heightened spike-dose addictiveness of street forms of these drugs, that leads to a quick fiending withdrawal and need to redose, leading in turn to loss of employment due to spending all your time on the street hunting for the next dose; and of course, the unpredictable dosing and potential for adulteration, leading into high potential for OD.

Most of this particular problem can (and in some trials, has!) been solved just by prescribing these people the drugs they need again. When you go from unpredictably doing random shots of freebase heroin/fentanyl/etc with a dirty needle alone in an alley, back to predictably being able to get precisely-dosed extended-release pills from a pharmacy and take them on a set schedule, a lot of “addict behaviors” for these chronic-pain “addicts” just evaporate.

Sure, opioids are addictive, and you might find yourself in a situation where you're stuck on them for life and that's not great. And ultimately we have to ask "so what?" There are many conditions and medications that are lifelong and we don't treat the patients or their conditions the same way. Imagine telling a person taking SSRIs that they can't have a higher dosage because they're getting "tolerant" of the medication. Imagine telling a diabetes patient that you're not going to give them metformin or insulin because they might be on it for life. There are huge amounts of chronic conditions for which the ongoing treatments suck and have a lot of negative side effects, but living with the condition un-treated is worse than the negative side effects. Chronic pain (and the conditions causing that pain) seem to be the only category that we don't accept the possibility of long term negative consequences as the price of dealing with the chronic condition.

And the hell of it is, I agree with concerns about pill mills. My family that has had to deal with this has had to deal with pill mills too. And it's bad just having higher and higher doses thrown at you. I agree that treatment needs to include more than just escalating opioid doses. But those same family members that were stuck in a pill mill were there for years longer than they needed to be because finding a way out was nearly impossible. If you want to change pain management doctors, 99% of them will not prescribe you opioids on your first visit. But you likely have a contract with your current pain doctor that says you won't go to other doctors for pain medications, so you can't see a different doctor while getting pain management from your current doctor. Then even if you could get them to prescribe your medications, they almost all want to start you from zero again. Imagine you want to change heart doctors but before they will treat you they want you to stop all your heart medications for a few months so that they can "get a baseline" for your condition. That would be an insane thing to ask for any other chronic condition, and yet that's a common thing to be asked of pain patients all the time.

Overall as a society we're terrible at dealing with the concept of a chronic condition. We don't really grok the idea that some folks just won't ever "get better", and our entire system is set up to assume you will. The sad reality is some people are going to be in constant pain for their entire lives, and there's nothing we can do to stop that from being the case. Restricting these people from being able to safely access treatments to manage that pain because they might get addicted is misguided, cruel and missing the forest for the trees.

Where were you the last 30 years? This comment sounds like you fell into a time warp from 1988.

No latent “American Puritanism” stopped Purdue.

https://en.wikipedia.org/wiki/Purdue_Pharma

True the recent shift is itself reactionary and with its own problems, but this one isn’t because of Nancy Reagan.

American Puritanism would also not explain having the highest rates of opioid prescriptions of peer GDP/capita nations in the world.

> there really isn't anything other than opioids for pain management.

1. Not true. 2. There are plenty of cases where opioids are ineffective just the same as NSAIDs/Tylenol.

> We don't really grok the idea that some folks just won't ever "get better"

Yes, we do. If your oncologist doesn’t prescribe you appropriate analgesia or refer you to a palliative care practitioner then find a new one.

> and our entire system is set up to assume you will.

This is one of the more unusual and unhinged takes I’ve ever heard in this era of diabetes, A-fib and COPD medications advertised on TV and every street corner (none of which are curative).

The vast majority of non surgical medicine is about chronic disease management. Medical cures are the exception.

> The sad reality is some people are going to be in constant pain for their entire lives

The sad reality is that the medical industry was complicit in causing unnecessary suffering due to the legitimized medicalized misuse of opioids and this is the aftermath.

I would argue that a non-puritan society would look at concerning rates of recreational opioid use and abuse and try to solve the underlying problems that are driving people into that instead of treating them as criminals for their choice of dug to abuse and putting policies and laws in place that make legal medical access to opioids increasingly ridiculously convoluted and scaring doctors away from prescribing them. That puritan streak is what underlies the societal revulsion to "drug addicts" and reacts with an attitude of "cut them off". It's what makes society view addiction as a moral failing on the addicts part, and it contributes to a lack of resources and help for people looking to escape that addiction. Sure if you're extra wealthy you could check yourself into a hollywood rehab center, but for the rest of us lowly schmucks, your average local rehab centers are cold places that will do the bare minimum to make sure you don't die, and then throw you back out into the world with no more resources or support than you had before, to face the same problems that drove you to your addictions again.

Or one could also look at the media and public reaction to Perdue's support for the concept of "pseudo-addiction". While the media and public mock this as laughable at best and dangerous overpromotion of drugs at worst, there's nothing unreasonable about the concept at all. The idea is really simple, that perhaps some people who exhibit addiction behaviors like "taking more pain medications than prescribed", "focus on when they can take their next dose", "moaning or vocalizing in pain", "demanding specific medications", "seeking to keep a extra supply" might not be addicts but might actually be - you know - in pain (due to an inadequate treatment regimen). And that seems obvious right? Like if you had someone who was being given say, 200 mg of ibuprofen every 6 hours for a broken leg, you might expect them to do some or all of those things right? I know I certainly would. And yet, switch from ibuprofen to opioids and all of a sudden people think this is ridiculous.

> 1. Not true

Fair enough, I should have say there isn't "much", and the things there are can have plenty of their own bad side effects even if they aren't "addictive". Steroids would be an option. Long term use of which can among other things raise your blood sugar contributing to diabetes, increase your chances of getting infections, increase osteoporosis, increase bruising and slow healing in general. Anti-epileptics can help if your pain is specifically nerve pain, and anti-depressants can help in some cases too, though again with their own non-insubstantial risks.

> Yes, we do. If your oncologist doesn’t prescribe you appropriate analgesia or refer you to a palliative care practitioner then find a new one.

Anyone with a chronic and disabling medical condition could probably give you a book worth of experiences where doctors, co-workers, family and friends became increasingly exasperated or frustrated by the fact that they do not in fact get better and continue to require accommodations. I'd also point out there are other conditions that cause high levels of chronic pain that aren't cancer and aren't terminal. Getting palliative care (or even someone to understand that you need palliative care that isn't also end of life care) in those circumstances is an uphill battle to say the least.

> The vast majority of non surgical medicine is about chronic disease management. Medical cures are the exception.

And one need only participate in any discussion about modern medicine and care to see how much people are against the idea of lifetime medications and treatment. See also recent sturm und drang over Wegovy for treating obesity. Perhaps a better way of phrasing it would be "if you don't have a specific set of well recognized 'incurable' conditions, our society and medical system is set up to assume you will get better". It's especially bad if you have slow and largely "invisible" disabilities. My family member that had to deal with the pill mill doctor was in that situation because they were being passed from doctor to doctor to doctor all of them wanting something that some other could treat to "get better" first before they wanted to do anything. And the pill mill doctor was no different, kept throwing more pills at them until "your condition improves and then we can look at other options". It took us nearly 6 years to finally put together an actual team of doctors that were interested in coordinating and understood that this wasn't ever going to go away and that treatment was going to mean sometimes one thing or another would get worse while the other aspect was treated.

>The sad reality is that the medical industry was complicit in causing unnecessary suffering due to the legitimized medicalized misuse of opioids and this is the aftermath.

And how many thousands or millions of others will be put through more unnecessary suffering in our reactionary spasms of guilt in this aftermath? How many lives will we lose to suicide because the alternative is facing a life of poorly managed pain and being treated like a criminal for trying to get treatment? How many people will be drive to ever increasingly desperate measures to obtain illegal pain medications as their options for legal paths are closed or made more and more unworkable? How many people will we leave in pain because they "might get addicted" as if being addicted to a tolerated but effective medication is the worse then being in disabling levels of pain? How many innocent people will we allow to suffer, because we are unable or unwilling to punish only the guilty?

Problem is all those addiction behaviors were swept away under the banner of "pseudo-addiction" but they are still also TRUE addiction behaviors. The messaging was all these behaviors that have been associated with addiction (because they are) are really just pseudo-addiction. Which is sometimes true, but it's completely unreliable and removes any responsibility in judicious use of opioids, which was sort of the (cynical) point. That's why Purdue was rightly called out for its opportunistic weaponization and as a ploy to underreport addiction.

And in that wall of text you conveniently ignore the most salient point raised, that of skyrocketing opioid prescription rates being higher compared to most of the rest of the industrialized non-puritan world especially from the late 80s to 2010s.

> That puritan streak is what underlies the societal revulsion to "drug addicts" and reacts with an attitude of "cut them off".

There is clearly a historical protestant societal moral aversion to drug addicts, though opinion on that continues to shift. But let's also be clear, drug addiction is a societal blight. It has objective direct (like premature death) and indirect (too numerous) negative effects for both the addicts, and those around them both by relation and proximity. I am pro harm-reduction, but I don't think it is so simple to implement as you make it sound as to identifying what exactly is harm-reducing vs harmful woo. And in this era of agenda and incentive driven reproducibility crisis BS, it's not like those that give a damn (I mean, most of the stuff that got us into this mess was published as legitimate "Science") actually have much to go by. Some things, like needle exchanges, MOUD are pretty clear cut. But just prescribe opioids whenever for any complaint of "chronic pain" when asked (as you are suggesting because being addicted is no big deal in your ignorance) is nuts.

> and it contributes to a lack of resources and help for people looking to escape that addiction.

Not once do you mention MOUD. You type out way too much on this subject for someone that is ignorant of this, even if you want to criticize it.

> Steroids would be an option. Long term use ...

Steroids don't have to be given systemically. You also miss indirect (comorbid) treatment and non-pharmaceutical (surgical or otherwise) alternatives.

> I'd also point out there are other conditions that cause high levels of chronic pain that aren't cancer and aren't terminal.

You completely miss the point. The risk/benefit calculus for terminal cancer pain in an 80 year old is much simpler than the 40 year old otherwise healthy (but possibly fat) dude that comes in with lower back pain.

> "might get addicted" as if being addicted to a tolerated but effective medication is the worse then being in disabling levels of pain

You're conveniently ignoring all the very real morbid negative side effects and risk of iatrogenic harm completely away. In practical use, opioids increase the risk of death and this is dose and duration dependent (and as prescribed use of NSAIDS is not even in the same ballpark). I just love it when one of my patients with untreated OSA dies in their sleep. Did your pill mill give you Narcan? If they didn't I believe they are being negligent, they should, and this should be a good indication in itself that these things are not the harmless wonder drugs you seem to be pushing them as.

> How many innocent people will we allow to suffer, because we are unable or unwilling to punish only the guilty?

Hopefully fewer than those killed by the rampant increase in unnecessary opioid prescriptions since the early 90s. Opioids are nowhere near as effective at managing chronic pain as you have been misled to believe.

Opioid prescription rates more in line with progressive industrialized nations rather than being 7 times higher in some cases might make this not sound like the most ridiculous string of rhetorical nonsense.

It reminds me of this https://www.sciencedirect.com/science/article/pii/S009130572...

which in addition to hawking a number of questionable co-opted concepts is literally stating the equivalent of “risk of death from automobile ejection is now super low these days therefore seatbelts must not be necessary”, which is ballsy to put out there (or not so much if you’re retired).

This and your wall also just completely ignores the diversion issue. Ibuprofen may have harms but no one is selling it for $20 a pill or more to people that end up dead.

They do if they are very harsh, see Singapore, Indonesia etc. America doesn't want to that.

What a great line.

The Point in Time count data indicate the vast majority of homeless people have issues with drug abuse. A substantial majority of those also have dual diagnoses.

Maybe you are trying to argue that drug abuse is not sufficient, or something, but you have not brought that nuance. The OP is more correct than you: drug abuse has a large role to play in the street homelessness of San Francisco.

(An alternative view: if rents were the primary causal factor, then why is the problem substantially worse than a decade ago when San Francisco rents peaked? Why did the problem get so much worse during COVID when nonpayment evictions were held for many years and low income renters got billions in cash transfers, increasing their aggregate income while rents dropped?)

Millionaire rock stars go in and out of rehab repeatedly and don't end up homeless. There is no direct cause-and-effect relationship between drug abuse and homelessness. We only make that connection after the fact. I know of zero credible sources predicting homelessness based on "He's an addict! So it's inevitable!"

There are lots of problems with the stats we keep on homeless people and such people are by their very nature tough to track. There are political agendas driving how the questions get asked and the data gets framed, all of which contradicts my firsthand experience with homelessness and what I have heard for years from actual homeless people.

In a nutshell:

California has about 12 percent of the US population, 25 percent of the US homeless population and more than 50 percent of the nation's unsheltered homeless. I do not find it credible to claim these people are all "locals" and I firmly believe California is the dumping ground for the nation's homeless problem.

Your last "nutshell" paragraph: I have read similar from other sources. Deeper question: Why? My thoughts: The weather in California makes it possible to be homeless, full time (12 months a year), without shelter -- not great, but not death by freezing. What do you think? I wonder if Hawai'i and Florida also have very high proportion of homeless people for similar reasons.

Yes.

That being said, a resident of SF has many more other ways of avoiding the streets (and still be considered unhoused) vs that ex-con, so the numbers are going to be lopsided if we are just counting the visible homeless problem.

The place with the bunk cots is WeHOPE.

Must have a referral from a San Mateo County, or Santa Clara County Partner Organization to receive shelter.

> Nearly 8 out of every 10 unhoused people in Oakland were living in Alameda County when they lost their housing.

https://www.sfchronicle.com/projects/2021/homeless-project-o...

> Primary Cause of Homelessness (Top five responses, Fig. 19)

> Family or friends couldn't let me stay or argument with family/friend/roommate: 27%

> Eviction/Foreclosure/Rent increase: 25%

> Job loss: 22%

> Other money issues including medical bills, etc.: 13%

> Substance abuse: 13%

https://homelessness.acgov.org/homelessness-assets/docs/repo...

It's possible that many frequent flyers to emergency rooms have been dumped from other communities. But most homeless people are just that, people who have lost their homes in their community. And anyway, how could it really be any different?

> with their own wage income

Of course poverty is the number one reason they are becoming homeless. Why are you talking about wage income. They have too little income. Who the hell wants to live on the street!

> Nearly 8 out of every 10 unhoused people in Oakland were living in Alameda County when they lost their housing.

That's not what the Point in Time count asks or tries to measure. The statistic reported is the location of last known shelter. So, as an example, someone who moves to San Leandro from Fresno to crash on a friend's couch for two weeks and then is asked to find a different place to stay would count as "living in Alameda County" for the purposes of the statistic. Another example: a longtime homeless person who has cycled in and out of shelters in the region for decades counts as "living in Alameda County" even if they first lost their home in Kern County or out of state.

> Primary Cause of Homelessness (Top five responses, Fig. 19)

This is silly data to cite. Drug use is correlated with money issues, interpersonal relationship problems, eviction, foreclosure, inability to keep a job, and more. Maybe if the survey had a multiple response design, the distribution would be relevant.

> And anyway, how could it really be any different?

I can think of dozens.

It really is in the self interest of homeless oriented agencies and NGOs to present the problem as local as possible. If it isn’t local, then giving out housing will only make the local problem worse (people will start arriving for their free housing from other areas of the country), you can judge your success by how much worse the problem gets, which isn’t popular with local voters.

Without good information, at any rate, it isn’t weird that we are seeing the problem get worse for every billion we throw at it. Eventually the popular cities will just give up trying very hard because they never had the power to fix it in the first place.

When did I say that?

> How do you propose your magic mechanism to send people from SF away the moment they become homeless?

What does this have to do with anything? The vast majority of tenants evicted in San Francisco receive both legal representation and relocation fees starting at ~$7k per person and more if you claim disability, which most do.

There are ~80 nonpayment evictions in the city annually, and there were ~0 from 2020-2023.

> Someone who ends up homeless is going to stay in a place that is familiar to them.

Probably true of the average homeless person, but there are many more homeless people outside San Francisco than in it, so you only need to believe a small percentage of, say, California's homeless population ends up in the city for local homelessness to be dominated by folks who lost their last stable shelter outside the city.