How LA is failing the homeless

San Francisco is making real progress in the fight against homelessness; Los Angeles is not. And the difference is how each city treats addiction among the homeless population.

Addicts are a crucial subset of that population. It is a brain disease, and brain diseases, as they progress, result in the loss of the ability to manage the necessities of daily life.  

We are not referring to those who may experience transient homelessness, who can make use of various resources that are available for housing. 

We are concerned with those for whom their brain conditions have progressed to the point that they lie down on the sidewalk, and stay there.  

This is a population who throughout modern medical history was considered “gravely disabled,” and in need of medical and perhaps custodial care.  

Because of the various laws that have eroded our ability to bring patients to care for psychiatric illness, “gravely disabled” essentially no longer exists as a criterion for care.  

In the meantime, these individuals often remain on the street, where they are maintained in an open-air hospital, attended to by social workers or street outreach teams.

These may be wonderful people, but they have not gone to nursing or medical school and have certainly not completed a psychiatric residency.

Those providing addiction services in LA stick to a strict harm-avoidance strategy, which in many cases provides the homeless with their rigs and pipes for drug delivery, and may even provide the drugs themselves.

Worse, gangs control the drug trade on LA’s Skid Row. They also traffic the addicted women, and charge the homeless for the space on the sidewalk. 

As LA taxpayers continue to pour billions into housing without services for the homeless — paying up to $1.5 million per room — residents of San Francisco have rejected their city’s status quo and elected new leadership that is broadening funding to include sober-living transitional housing.

We now have an A/B test that shines a bright light on the deficiencies of the approach in LA and elsewhere in the state.  

During COVID, when the state instituted Project Roomkey, offering the homeless free hotel rooms, San Francisco housed people in more than 20 hotels across the city, including some of its most famous tourist hotels. These devolved into dystopian environments, with open drug use, sexual assaults, and chaos — including in one case, a meth lab.

LA’s more diffuse geography created far less backlash.

Many of San Francisco’s more affluent residents fled. But those who chose to stay began to organize, activating neighborhood groups and forming new alliances.

The new activism resulted in the election in 2024 of the political neophyte Daniel Lurie, who ran on a platform of accountability, an end to the fentanyl crisis, and safe streets.

San Franciscans’ cultural shift in rejecting open drug use has been especially dramatic, moving from a 2020 city-funded billboard campaign urging, “Do it with friends,” to the newly elected Mayor Lurie proclaiming, “We are no longer going to sit by and allow people to kill themselves on the streets.”

He was absolutely correct.

Consider needle exchange programs. They are well-intentioned, and do reduce the risk of medical complications of IV drug use. But these programs were not intended to be needle giveaways.

Treatment of addiction requires accountability from the patients, or they do not get better.

They develop anosognosia, which is literally a biological block that prevents them from having any insight into what is happening to them.

Physicians have to treat anosognosia in a clinical setting, but are not allowed to do so for the homeless. We cannot allow them to reach that point.

Mayor Lurie has followed through on his promises by stopping open-air drug markets and use, reforming the city’s harm-reduction outreach to help drug users access services, not just supplies.

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For the first time, the city is funding recovery-focused residential facilities, including Hope House, operated by the Salvation Army.

Underlying LA’s (and most other cities’) emphasis on building ever-more-expensive permanent supportive housing units that carry no work or sobriety requirements is the assumption that the homeless will never progress, and that they will permanently require support.

San Francisco’s turn toward recovery-focused residential programs reflects a growing appreciation that people can change.

As Steve Adam, executive director of the program operating Hope House — himself a former addict —declared, “People that have been homeless and addicted to drugs can really achieve great things.” It’s time to open more pathways for them.

To continue insist upon our present path in LA, given that we have clear evidence of more efficacious options, is foolish.  

It is time to build the infrastructure for doctors and nurses to treat the homeless population that has suffered so much.  

Dr. Drew Pinsky is a board-certified physician and addiction medicine specialist. Mary L. G. Theroux is chairman and CEO of the Independent Institute. They are contributors to the book Beyond Homeless: Good Intentions, Bad Outcomes, Transformative Solutions.