SF Program Isn't Just 'Free Beer' for Unhoused. It's Backed Up by Research

Over the last few days, social media commenters and conservative news outlets have piled on after AI entrepreneur Adam Nathan asked his followers on X, formerly Twitter, “Did you know San Francisco spends $2 million a year on a ‘Managed Alcohol Program?’’’

Nathan, the founder of AI marketing company Blaze and chair of the Salvation Army San Francisco Metro Advisory Board, posted last Tuesday describing the program as “giving out free beer” to unhoused people with alcohol use disorder.

Tech executive Garry Tan, who has often criticized San Francisco’s harm reduction policies for drug use, replied to the thread, calling the program “harm acceleration.” A Fox News headline declared it “buys vodka shots for homeless alcoholics.”

But while providing alcohol to people with alcohol use disorder can seem counterintuitive, research shows that such harm reduction strategies can be helpful, according to Keanan Joyner, a professor and researcher in the Clinical Research on Externalizing and Addiction Mechanisms Lab at UC Berkeley.

“The science is very clear at this point that harm reduction as a general strategy for treating alcohol and other drug use disorders is very effective. It’s a very positive thing,” Joyner said.

San Francisco’s Managed Alcohol Program, or MAP, provides housing, three meals a day, nurse-administered alcohol — usually in the form of beer or vodka — dosed to keep clients at a “safe level of intoxication,” and enrichment activities. It started in 2020 as public health officials responded to the COVID-19 pandemic, and its goal isn’t to reduce patients’ alcohol use or lead to abstinence but to increase their safety and overall quality of life.

Nathan, who did not immediately respond to KQED’s attempts to reach out for comment, said in his thread on X that while some studies and explanations support MAP, the concept “just doesn’t feel right.”

Joyner said that feeling isn’t uncommon, making harm reduction strategies for alcohol and substance use disorders the “most difficult topic for academics who study this.”

However, harm reduction strategies can result in fewer missed work days, trips to the emergency room, ambulance rides, and other disruptions to daily life for those with alcohol use disorder.

“This program seems good,” Joyner said. “I think it’s very good at doing what it’s intending to do, which is to reduce drinking levels to a manageable level without inducing severe withdrawal.”

According to San Francisco’s Department of Public Health, an internal analysis of MAP found a fourfold reduction in the usage of emergency department services by clients in the six months after their intake compared to the six months prior. It also reported that clients called emergency medical systems and visited the hospital half as often.

The program is run out of a 20-bed facility on the grounds of a former hotel and bar in the Tenderloin, where clients live in a “closed campus” environment under the supervision of staff.

The site’s bar, which has taps that previously dispensed beer and cannot be removed due to the leasing agreement, is one element that opponents of the program have taken issue with. So is its funding.

“Why isn’t every public health dollar not going to prevention and treatment?” Nathan wrote in one of the posts in his X thread.

Funding programs like MAP, however, can actually have monetary benefits to the public, especially since not all people with alcohol use disorder are willing to go through abstinence-based treatment programs, Joyner said.

He explained that when someone uninsured goes to the emergency room for withdrawal, an injury or other medical emergency related to alcohol use, “the city quote-unquote ‘pays.’”

“When you’re trying to consider the cost of implementing programs [like MAP], you’re not doing it against zero,” Joyner said. “How many people are going to show up in our emergency departments and ambulances? How much money does that cost? You’re comparing that amount of money to the amount of money that you’re spending on funding towards this type of program.”

A 2022 analysis by the Department of Public Health estimated that in the six months it tracked MAP’s impact, the program saved approximately $1.7 million. MAP costs over $5 million annually, and the department said it is in the process of finding this funding through Medi-Cal reimbursement.

The program is not without its shortcomings. MAP has served just 55 clients in its four years of operation, and a presentation from last October showed that although clients used fewer emergency services while in the program, some who left the facility returned to relatively frequent utilization of these services.

Still, public health officials believe the program is effective.

“This is a program for a really small but highly vulnerable subsection of the population of people with alcohol use disorder — really severe and pretty end-stage alcohol use,” Dr. Joanna Eveland, the chief medical officer for SFDPH’s Whole Person Integrated Care Program, told KQED.

“Within the SF Department of Public Health, we like to be data-driven, and the data we have for this program really support a significant decrease in [emergency medical services] utilization,” Eveland said. “Having freed up the resources that were taking people to the emergency room three, four or five times a day, now those are resources that we can use to support more people getting on the road to recovery through other SFDPH services.”