We need to acknowledge that San Francisco has spent billions over decades on homelessness programs, yet the crisis persists, leaving us to ask: Is this truly the best we can do? Are we investing efficiently, or are we simply maintaining a broken system?
For meth, crack, etc there are effectively no pharmacological interventions available. And many (most?) of the street homeless have dual addictions to a stimulant and an opioid, so even if they did manage to switch from fentanyl to buprenorphine they would almost certainly be extremely unstable with their stimulant addiction.
Obviously there are psychological interventions and peer support groups, but these require quite a lot of stability to stick to and get to, which I think is extremely difficult for someone in a very chaotic addiction cycle.
To me, it seems some of the billions that cities spent on social services for homeless should be diverted (or in addition to) to pharmacological research. There is so little funding available for this - I read Prof David Nutt was doing an interesting PET study for kappa opioid response in addiction but ran out of funding. The funding requirements were low-medium hundreds of thousands of dollars and couldn't find it to continue the research.
The current status quo seems a bit like trying to treat TB without antibiotics. The treatment back then was basically similar to current 'rehab' programs - send them to a quiet place and give them care and help. Obviously not a bad thing to do; but once you had antibiotics the prognosis improved by many orders of magnitude almost overnight (and a lot less costly to provide).
Isn't that still treating a symptom, rather than the core problem? If homelessness is caused by drug addiction, what causes drug addiction? Underlying mental health? Lack of opportunity? Government welfare dependence?
My hunch (not as an expert) is that people who are very prone to addiction have a maladapted brain system of some kind. I think this system 'malfunction' can either be genetic and/or caused by trauma/environmental reasons in their life. I suspect this because nearly everyone I know that has had addiction problems has had a parent with similar. It's surprisingly rare to find someone with an addiction problem that isn't in the family. Strangely, not all siblings seem to have the same issue.
Problem is, we don't know which system(s) it is yet. The research on kappa opioid receptors is very interesting as the KOR regulates stress response, and we know that stress causes many relapses in previously addicted individuals in recovery.
I also think we may find there are multiple types of addiction, caused by different systems/reasons. These all present very similarly, but similar to the discovery years ago that some infections were caused by viruses and some bacteria, it could be similar for addiction.
So really I think it goes something like this:
People are predisposed to addiction -> they become addicted -> they become homeless and trapped in a chaotic loop which a tiny percent of people can recover from
When I believe the best response for people that are affected by addiction would be something like this
Addicted person (homeless or otherwise) -> some sort of diagnostic (genetic testing?) -> new tailored medication -> recovery
It may be also these maladaptations cause all the mental health problems themselves. But not everyone that has mental health problems becomes addicted, despite experimenting with substances.