A San Francisco Board of Supervisors hearing on the city’s Treatment on Demand annual report drew hours of testimony Thursday on how to speed and sustain access to substance use treatment.

The hearing, requested by Board President Rafael Mandelmann and convened by the Public Safety and Neighborhood Services Committee, featured presentations from Department of Public Health leadership, the Fire Department’s community paramedicine unit, Adult Probation, the Public Defender’s Office, providers and several community coalitions. The department laid out recent steps to reduce barriers and expand capacity but officials acknowledged persistent measurement gaps and subpopulations — notably people with co‑occurring severe mental illness and substance use disorders, monolingual non‑English speakers and justice‑involved individuals — where access remains limited.

“From the street you can see with your own eyes what is working and what is not,” Director Daniel Tsai said, calling the situation “an epidemic and a crisis” and noting the city is averaging “close to two people a day dying from overdoses.” Tsai described four priorities: speeding entry into care, expanding capacity across stabilization, treatment and recovery, improving access to medication‑assisted treatment, and strengthening “stickiness” — patient retention across levels of care.

Daniel Tsai and Dr. Hillary Conners (Director of Behavioral Health Services) summarized recent operational changes and investments. Officials said the city reduced average wait time for residential treatment from four days to three and recently implemented clinical protocols to admit people to residential treatment after a brief assessment while completing required Medi‑Cal paperwork over the first days of care. DPH said it has budgeted more than 400 treatment and care beds to open between the current year and 2028, with additional projects and out‑of‑county placements in development. The department reported increases in people starting medication treatments: telehealth buprenorphine access operates up to 16 hours a day, seven days a week, and methadone enrollment has risen. Retention for buprenorphine at six months was reported at about 30 percent.

DPH also described a wider continuum of new services: street health teams and coordinated neighborhood teams, expanded crisis stabilization capacity at 822 Geary, new recovery‑oriented residential step‑down settings, contingency management programs for stimulant use disorder (the department reported roughly 200–250 clients covered to date, with about three‑quarters of urine tests negative for stimulants at participating sites) and plans to apply for state capital funding including an approximately $21 million award for locked mental health rehabilitation beds and a proposed 16‑bed enhanced dual‑diagnosis program.

First responders and criminal justice officials told committee members that operationally the system is strained in particular moments: community paramedics emphasized the need for night and weekend withdrawal‑management “bridge” capacity so clinicians can accept people when they are willing; the Fire Department asked that alternate transport pathways be available to non‑hospital stabilization sites after overdose. April Sloan, assistant deputy chief for Community Paramedicine, said the department is piloting EMS transport to the newly certified 822 Geary crisis stabilization unit as an alternative to emergency departments.

Justice system speakers described bottlenecks. Olivia Taylor, a deputy public defender who staffs drug court and the Community Justice Center, said clients often wait weeks to months to enter residential treatment after a judge orders placement and that monolingual Spanish‑speaking clients face longer waits because fewer programs are available in Spanish. Adult Probation reported targeted investments, a Community Assessment and Service Center with frequent repeat visitors and a mobile CASC unit planned to bring services directly into neighborhoods.

Advocates and providers offered differing emphases. Tom and Cedric Akbar of a recovery coalition pressed for more abstinence‑based, long‑term therapeutic communities and called for stricter enforcement against open‑air drug markets; Salvation Army and Positive Directions described a continuum of more than 800 beds across programs the organizations run and unveiled five city‑funded projects including Eleanor Fagan Center (a low‑barrier, walk‑in stabilization/treatment site), Hope House (a 60‑bed abstinence‑based shelter), Wells Place (recovery housing) and James Baldwin Place (an independent‑living bridge for people exiting step‑down housing). Community coalitions and people with lived experience urged that harm reduction and recovery supports remain available and that the city restore transparent community input for any changes to the overdose prevention plan.

Speakers also cited data and monitoring shortfalls. DPH acknowledged it lacks comprehensive, real‑time tracking for “turn‑aways” (instances when people seeking withdrawal management or intake are unable to be placed immediately) and that existing reporting systems do not yet show full, cross‑system flow metrics. The department said moving substance‑use treatment records onto an electronic health record (EPIC) and improving resources such as FindTreatmentSF will improve visibility and reporting.

Public comment included people with lived experience praising harm reduction as life‑saving and others urging more recovery‑focused beds and enforcement of open‑air markets; several speakers urged better coordination between city departments and community providers.

At the hearing’s close, Chair Matt Dorsey moved that the committee “hear and file” the Treatment on Demand report; the motion passed 3–0. Committee members and presenters recommended a follow‑up push to define clearer outcome metrics and quantify gaps for priority populations so the city can measure progress toward the Prop T directive to estimate demand and close service shortfalls.