The Fentanyl Epidemic Is More Than an Affordable Housing Problem: A Tale of Four Cities Pt. 3

Willow Street in San Francisco’s Tenderloin district runs between Larkin and Franklin. For years it has been a focal point of the city’s homeless and fentanyl problems. It was here that the city increased its sweeps of large-scale homeless encampments, especially after the Supreme Court’s Grants Pass ruling, which gave cities more leeway to enforce public lodging bans.

By Terry White and David Therkelsen

Tom Wolf directed our attention to Willow Street to learn about the city’s strategy for addressing the intersection of homelessness, substance abuse, and behavioral health. Wolf is Board Vice Chair of We Heart Seattle, a Senior Fellow at the Discovery Institute, and a co-founder of the Foundation for Drug Policy Solutions. After foot surgery in 2015, Wolf became addicted to Oxycodone, which escalated to heroin and then to fentanyl. He spent six months on the streets in the Tenderloin, where he was arrested multiple times. Wolf credits a mandatory six-month residential treatment program for helping him get sober, a status he has maintained for eight years. The experience turned him into one of the leading advocates for a shift away from permissive harm reduction policies and toward treatment, recovery, and accountability. It’s a philosophy summed up by the foundation’s co-founder, Congressman Patrick J. Kennedy:

“We should meet people where they are at, but never leave them where they are at.”

Wolf was one of many people David Therkelsen and I interviewed during our trip west. We begin this piece with his interview because he, more than anyone, summed up the lessons we brought back to Minneapolis:

1. Housing First as a solution for homelessness is inadequate.
2. Greater investment in behavioral health services and recovery programs is needed.
3. The inefficiency of overlapping government agencies and programs is driving up costs and causing people to go without the help they need.
4. San Francisco changed from being a harm reduction city to a recovery-first city, creating a model other cities can learn from.

What is Housing First?

To understand the approach to homelessness over the last five to ten years, we need a working definition of Housing First. The approach prioritizes providing permanent, stable housing to individuals experiencing homelessness as quickly as possible, without preconditions or barriers to entry. In other words, the government, often working through nonprofit organizations, houses these individuals regardless of whether they are sober, experiencing psychiatric problems, or employed. In theory, this stability is paired with individualized services to help them work toward their life goals.

There are several issues with this approach. One is that use of services is voluntary. In the harm reduction approach often coupled with Housing First, it’s up to the newly housed person to decide what type of substance treatment or psychiatric treatment they want. It seems more obvious to expert observers than to public policy makers, but those still under the influence often fail to make choices in their own best interest.

Wolf pointed us to research by Gina McDonald, co-founder of Mothers Against Drug Addiction and Deaths (MADAAD). Her analysis, drawing on statistics from the San Francisco Department of Public Health, found that 26% of all unintentional drug overdose deaths in 2024 occurred in permanent supportive housing facilities. Too often, when someone is given an apartment, they are cut off from their social networks. They use drugs alone, and when they overdose, there is no one around to call for help. This data isn’t meant to suggest homes shouldn’t be provided. In many cases they will be a lifeline, especially for those motivated to put their lives back on track. It does mean this approach won’t fit every person or every circumstance. San Francisco changed its policy by passing an ordinance requiring all city-owned supportive housing to be drug-free, with lease language explicitly prohibiting illicit drug use. San Francisco found that despite spending $650 million a year on homelessness, the results were unsatisfactory. The city was ready for a new direction.

Brandi Tuck, executive director of Portland’s Path Home, is a passionate and articulate advocate of Housing First. Last year, Path Home served 2,129 children and adults. The organization is focused on finding homes for families. At first, you might expect her to contradict the direction Wolf points to in San Francisco. But the more you hear her speak, the more you realize their recommended solutions are similar: both believe more services are needed, and both believe too much emphasis is being placed on temporary shelter solutions. “The solution to homelessness is not shelter. The solution to homelessness is housing,” Tuck told us. She explained that temporary shelters, whether hotel rooms or tiny homes, often end up costing as much as or more than the ultimate goal: a home. She was critical of the low-service, low-barrier shelter solutions favored by Mayor Keith Wilson, arguing they were extremely expensive without moving people into actual housing.

Tuck advocated for more comprehensive wraparound services. These must come from qualified providers, because housing providers are experts in finding and providing housing. They aren’t equipped to treat mental health issues or substance use disorder. However, though it is rarely acknowledged and even less often practiced, both sides of this equation are required. Providing individual care with trained staff is complicated, often frustrating, and expensive work. Cities often cite statistics on how many people they placed in shelters or housed over the course of a year, but we are rarely given statistics on how many got sober and stayed sober, how many found employment, became parents again after losing their children, or were able to give back to the community that supported them during their darkest hours.

Let’s assume the services are available and funded. There are still many who would say that any form of forced treatment will be ineffective and therefore a waste of time and resources. Is that accurate? If you’re a parent with a child on the street, you might want them involuntarily housed just so you know they’ll be alive in the morning. Too often, the calculation weighs only the program’s impact on the person suffering from addiction, while the impact on family and community is heavily discounted, if it’s factored in at all. Tom Wolf’s own story shows a successful path. After a mandatory six-month stay in a treatment center, he was able to turn his life around, and he now travels the country explaining to cities and counties grappling with these issues what alternatives could work for them. He isn’t doing this work because he seeks to punish those disempowered by addiction. He’s doing it because he wants to help them, just as he was helped.

A final factor in whether Housing First and harm reduction are the programs most likely to succeed in today’s environment is the drugs themselves. As mentioned, these programs may work for some, but there must be an alternative for those unwilling or unable to choose this path. In Portland, 50% of police and fire calls are related to helping unhoused individuals suffering from addiction or mental illness, often both. In 1988, Tanya Tull, a Los Angeles social worker, founded Beyond Shelter, which pioneered the Housing First model. It gained favor throughout the 1990s, with evidence pointing to fewer ER visits, jail stays, and emergency shelter stays compared to previous treatment-first models. The George W. Bush administration officially endorsed Housing First from 2002 to 2004 as a strategy to target chronic homelessness. These are policies developed over 20 years ago.

When we spoke with Eric Zimmerman in Seattle, mayor of suburban Normandy Park and policy director at the Washington Policy Center, he argued that the data supporting Housing First policies is outdated. He was also critical of the methodology, calling the data set too small and the focus too narrow. Most of the underlying studies predate the fentanyl crisis and leave out other factors that contribute to homelessness, such as income disruption, substance abuse, and behavioral health.

In addition, we must consider the shifting nature of the drugs themselves. Housing First’s original research was gathered when alcohol and black tar heroin were the dominant substances. Today it’s synthetic drugs like fentanyl and methamphetamine, engineered in labs to be far more potent than heroin. Fentanyl wears off faster, pushing users into withdrawal sooner and driving a more frequent cycle of re-dosing to avoid getting sick. In Oregon, these drugs were responsible for 90% of the state’s 1,100 overdoses in 2025. And unlike the drugs behind the original data, today’s supply keeps changing, as dealers continue to “improve” and redistribute it.

It may be that San Francisco has come closest to developing an effective system. We’ll take a look at what they’re doing in the next installment.

Recovery advocate Tom Wolf makes a strong case that the resistance to holding drug users accountable is an overreaction to the excesses of the failed War on Drugs. A final quote from Wolf sums up the gap in many current solutions, which tend to under-emphasize the need for behavioral health and substance abuse services:

“Democrats,” Wolf says, acknowledging the errors blue cities are prone to, “went too far on homelessness, drug policy, and criminal justice reform, all with good intentions, but without building the infrastructure to support those changes.”