In San Francisco, the impact of homelessness and long-term substance abuse is starkly visible in Bruce and Lisa, both participants in the city's contentious Managed Alcohol Program. Lisa's tooth loss and hoarse voice and Bruce's bloodshot eyes speak volumes about their struggles.

Bruce once resorted to drinking spilled gin off the floor with a straw, demonstrating the depths of his desperation. Meanwhile, Lisa's recent hospitalization with a mysterious broken arm after seeking additional alcohol highlights the risks she faces.

Despite their hardships, Bruce and Lisa acknowledge one undeniable truth: Were it not for this pioneering city initiative, they would likely not be alive today.

Within the framework of the Managed Alcohol Program (MAP), as it's commonly referred to, a maximum of 20 homeless individuals grappling with severe alcohol use disorder find shelter in a converted hotel. Here, they receive regulated doses of alcohol at scheduled intervals.

It's a far cry from the convivial atmosphere of a neighborhood bar during happy hour. Instead, nurses administer these beverages as a medicinal intervention. The aim is twofold: to prevent clients from reaching dangerous levels of intoxication and to stave off the potentially life-threatening consequences of withdrawal, such as seizures, which are particularly perilous for those heavily reliant on alcohol.

The necessity extends far beyond the borders of San Francisco. According to the Centers for Disease Control and Prevention, approximately 178,000 Americans succumb annually to the consequences of excessive alcohol consumption.

MAP targets a specific fraction of the homeless demographic: those grappling with the most severe forms of alcoholism. This subset places a disproportionate strain on the city's emergency services. Despite its intentions, the program has faced criticism from detractors who argue that San Francisco's investment amounts to millions of dollars being funneled into sustaining addiction.


Bruce and Lisa present a different perspective.


"Before joining MAP, my entire day revolved around drinking. It was breakfast, lunch, and dinner for me. I couldn't even walk properly. I was a complete wreck," shared Bruce, aged 65. Both Bruce and Lisa requested anonymity due to safety concerns. "MAP has been instrumental in ensuring I take my medications regularly, and attend my appointments. Without this program, I wouldn't be engaging in these essential activities. They truly saved my life."

Echoing Bruce's sentiments, Lisa, 62, expressed, "I was self-destructing. Without a doubt, I would have perished if they hadn't taken me under their wing.

The scientific evidence strongly supports the benefits.

The idea of a renowned liberal city offering complimentary drinks to individuals struggling with alcohol addiction has become a target in conservative circles. Headlines have often highlighted the concept of "taxpayer-funded" alcohol. Representatives from the San Francisco Department of Public Health report instances of harassment directed towards clients and staff, both online and in person, by individuals affiliated with right-wing media outlets. These incidents have included unauthorized approaches during outings and photographing through the closed building's windows.

Dr. Paul Linde, an expert in substance abuse and a long-standing resident of the city, acknowledges that "at first glance, this might appear unconventional to the average person."

However, Linde, a professor emeritus at the University of California, San Francisco, with 24 years of experience providing psychiatric emergency services at S.F. General Hospital, asserts that there is sound scientific reasoning behind the approach to mitigate the harm caused by addiction.

The Managed Alcohol Program (MAP) operates on the principles of harm reduction, a model focused on minimizing the adverse effects of substance use without mandating total abstinence. Linde underscores that harm reduction is commonly associated with intravenous drug use, which can lead to the spread of diseases like AIDS and hepatitis C. He believes this framework is equally relevant to alcohol abuse, which poses risks such as liver, heart, and brain damage, along with an elevated cancer risk.

Linde emphasizes, "The scientific evidence strongly supports the physical health, mental well-being, and overall quality of life improvements achieved through reduction rather than cessation of substance use." He notes that patients undergoing harm reduction typically reduce their substance intake by 50% to 75%. Linde concludes, "From a public health perspective, this program is highly rational. It's not just about providing alcohol; it's about fostering social support and engagement, with the option for conventional treatment readily available for those who seek it.


Conventional approaches to treatment, as advocated by organizations like Alcoholics Anonymous and the Salvation Army, center around complete abstinence. Linde observes that this emphasis occasionally fosters a rigid mindset among individuals who have experienced positive outcomes through total sobriety. They may perceive abstinence as the sole path to addressing alcohol use disorder (AUD).

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) asserts that recovery can be achieved without requiring complete abstinence.

Two years ago, the National Institute on Alcohol Abuse and Alcoholism revised its definition of recovery, no longer mandating abstinence. According to the institute's website, an individual can be deemed "recovered" if they achieve and sustain remission from Alcohol Use Disorder (AUD) alongside a reduction in heavy drinking over time. They define "cessation" as consuming no more than 14 drinks per week for men and seven for women, with limitations on daily intake.

Dr. Linde, currently serving as a medical director for the telehealthcare provider Ria Health, notes that some of his patients have flourished through participation in Alcoholics Anonymous (AA) programs, while others have struggled.

"For some individuals, AA proves to be highly effective. It has undeniably saved numerous lives," Linde acknowledges. "It's a remarkable model, but its success hinges on its compatibility with the individual. It's not the sole path to recovery from alcohol use disorder; it's one of many.

San Francisco's adoption of harm reduction has faced skepticism from various quarters, including the city's mayor, London Breed. In February, Breed expressed doubts about the effectiveness of this approach, stating that it was exacerbating the city's escalating fentanyl-related deaths.

Despite her reservations, Breed has maintained the annual budget of $5 million for the Managed Alcohol Program (MAP). Jeff Cretan, her spokesperson, explained via email that the program serves to remove some of the city's most challenging individuals from the streets, providing them with shelter and attempting to link them with additional support services.



Are there more effective ways to allocate these funds?

Krystyl Wright, a licensed clinical social worker and psychotherapist at Diamond Recovery Group in Los Angeles, suggests redirecting the funds allocated to the Managed Alcohol Program (MAP) towards treatment for a broader spectrum of individuals, particularly the most vulnerable who lack health insurance or stable housing.

"While I don't completely oppose the concept of harm reduction," Wright explains, "I am concerned because alcoholism is an addiction. I view MAP as enabling, and if there are plans to implement it in Los Angeles, I hope it remains a pilot program. I don't believe it offers a comprehensive solution.

Lisa and Bruce recount their struggles with attempts to quit drinking, which have proved unsuccessful in the past. They both acknowledge histories of drug use: crack and crystal meth for Lisa, and methamphetamine and intravenous drugs for Bruce. Despite Bruce's past drug use, he hasn't injected drugs in over a decade.

"For me, quitting drugs was easier than alcohol. Alcohol, that's the toughest battle of them all," Bruce reflects. Having grappled with alcoholism for 45 years, he aspires to achieve sobriety. "MAP has assisted me in confronting that formidable adversary. With some of the medications I'm prescribed, I don't experience the same cravings as before."

Health officials note that while variations of the Managed Alcohol Program (MAP) were implemented elsewhere during the COVID-19 pandemic for isolation and quarantine purposes, San Francisco stands as the first city to permanently adopt this model. Fifty-five clients have participated in the treatment, expected to last at least a year. Alongside the provision of alcoholic beverages, which may include beer, wine, or vodka, clients receive medication and therapy as part of the comprehensive program.



Lisa became involved with MAP during its early stages amid the onset of the COVID-19 pandemic in 2020. As city officials endeavored to ensure the safety of San Francisco's substantial homeless population by accommodating them in hotels and motels, individuals struggling with alcohol addiction were provided with liquor to alleviate cravings and prevent withdrawal symptoms. The unexpected success of this initiative laid the groundwork for the program's current implementation.

During this period, Lisa recalls consuming more than a fifth of gin daily. Presently, she has reduced her intake to four standard drinks per day.

"I used to drink myself into seizures, often requiring ambulance assistance," she reveals. "Even waking up in the morning, without a drink, I'd risk having a seizure. Since joining MAP, I haven't experienced any seizures.

Significant decrease in the utilization of emergency services.

Dara Papo, who heads the health department's Whole Person Integrated Care, is responsible for overseeing MAP. The program originated as a pilot initiative inspired by similar endeavors in Canada and Europe.

Papo acknowledges that MAP's $5 million budget and unconventional methodology attract criticism. However, she highlights the findings of a 2022 internal analysis, which revealed that over six months, the city saved $1.7 million due to a significant decrease in emergency room visits (73%), emergency medical system activations (65%), and hospitalizations (45%) among frequent service users who enrolled in MAP.

Papo underscores the profound human connections fostered by MAP, emphasizing how participants have regained a sense of dignity they previously lacked while often found in distressing conditions on the streets.

She shares a recent anecdote involving a man who transitioned to an abstinence-based program. When he returned to provide updates on his progress, he shared the heartwarming news of reconciling with his adult children and meeting a grandchild he had not known existed. Additionally, Papo highlights moments like Bruce and other clients joining staff members to celebrate Lisa's birthday in May.

Papo identifies three pillars of MAP's success: providing compassionate care to clients, reducing reliance on emergency services, and benefiting the community by increasing availability of emergency medical services and reducing interactions with distressed individuals struggling with addiction.

"The ultimate goal is stabilization and improved health and wellness," Papo asserts. "While some individuals have chosen the path of recovery, others have significantly reduced their alcohol intake from 18 drinks a day to just two. They may not be completely sober, but they've achieved a level of functionality.

Accessing a drink isn't as simple as walking in off the street.

Papo addressed some misunderstandings about the program, clarifying that only staff and clients have access to the facility—there's no open-door policy for anyone seeking a free drink. She explained that clients are referred to MAP and undergo a screening process upon admission, after which they receive a personalized care plan.

According to Papo, while the health department offers other rehabilitation services aimed at achieving abstinence, MAP has proven most successful in stabilizing individuals with chronic, severe alcoholism. Many of these clients significantly reduce their alcohol consumption, even if they do not completely abstain. Additionally, department officials clarify that none of the alcohol provided in the program is purchased using taxpayer dollars.

The San Francisco Fire Department has voiced support for MAP, stating in a release that its members are familiar with the frequent need for emergency services among chronic alcoholics, some of whom require assistance on a daily basis. They describe the initiative as "an incredibly impactful intervention" in reducing unnecessary emergency calls.

"Since the inception of MAP in 2020, our Department has witnessed a notable decline in EMS utilization from this small yet highly vulnerable population," the statement reads.



Vitka Eisen, CEO of HealthRIGHT 360, a San Francisco nonprofit advocating for the treatment of substance use disorder, highlights that some alcoholics may resort to ingesting hand sanitizer or mouthwash to prevent withdrawal symptoms if they cannot access liquor.

Gary McCoy, the organization's vice president, shares his personal experience, explaining that his use of heroin, methamphetamine, and alcohol led to a cycle of homelessness and incarceration until he found sobriety— and maintained it— through a harm reduction program over 14 years ago. He views this approach as a valuable tool for guiding addicts toward recovery and, eventually, abstinence, although he acknowledges the criticism it may provoke.

"This is the challenge with stigma," McCoy remarked. "When personal morals cloud judgment, it's easy to overlook the broader context and the wealth of data and research backing programs like this."