Drug dealers on the East Coast had in recent years begun mixing xylazine, which can have devastating effects on people, with the opioid fentanyl, causing a surge in emergency room visits in Philadelphia and other cities. But there had not been much evidence of it in California.

Now state and local officials are ramping up efforts to combat xylazine, commonly called “tranq,” by monitoring its spread, distributing test strips, and pushing to “schedule” it, meaning classify it as a controlled substance. Still, some worry it will be hard to prevent the pernicious drug — which has also begun appearing in Los Angeles, Santa Clara, and San Joaquin counties — from worsening the state’s overdose epidemic.

“Unless significant change happens in scheduling xylazine and really reducing its availability, we could be on the heels of what’s happening on the East Coast,” said Jeffrey Hom, director of population behavioral health at the San Francisco Department of Public Health.

Hom, who previously led overdose prevention services in Philadelphia, said San Francisco’s public health department is collaborating with the medical examiner, the San Francisco AIDS Foundation, the city’s fire department and homeless and supportive housing agencies, and methadone clinics and hospitals to collect data, share updates, and conduct regular testing for xylazine.

“We’re trying to think through how do we develop a system that can surveil for drugs like xylazine — or whatever the next drug will be,” Hom said.

The California Department of Public Health is monitoring news reports of xylazine and has posted an about it, but a spokesperson told ºÚÁϳԹÏÍø News it does not yet have a “standardized and uniform statewide monitoring system.”

Xylazine is a cost-effective way to extend the strong yet short-lived fentanyl high, said Philippe Bourgois, a UCLA anthropology and social medicine professor and co-author of the book “Righteous Dopefiend,” the product of a 10-year immersion in San Francisco’s heroin and crack street culture. But the trade-offs can be catastrophic.

Taken on its own, xylazine is so powerful it can knock a person out for up to 18 hours, said Bourgois. In Philadelphia, people who use tranq are getting “,” which are similar to bedsores but are caused by lying passed out on the sidewalk for long periods, he added. Xylazine also has that rot the skin and lead to amputations.

Most troubling of all, Bourgois said, is that xylazine constricts breathing, increasing the risk of an overdose when it’s mixed with fentanyl. By itself, it doesn’t respond to the overdose reversal drug naloxone, which has been one of the in trying to reduce overdose deaths. But since xylazine is often mixed with fentanyl and other opioids, health authorities advise using naloxone to respond to suspected overdoses.

“Xylazine is a disastrous drug,” Bourgois said. “Public health has to get ahead of this tragedy.”

About a dozen people who smoke or inject fentanyl and live on the streets of San Francisco told ºÚÁϳԹÏÍø News they are at the mercy of what drug dealers sell and have little insight into what’s actually in the drugs. They said they’ve never used xylazine knowingly and didn’t want it in their drugs.

Kris Franklin, 41, has been buying fentanyl in San Francisco for five years and acknowledged she’s gambling with her life. She’s lost count of the friends and acquaintances who have died from overdoses or street-related illnesses but estimates it at around 40 people.

“I’m scared it’s going to be in my dope,” Franklin said of tranq. “You don’t know what you’re getting. … It’s not like a prescription from a doctor.”

Rep. Jimmy Panetta (D-Calif.), whose district includes Santa Cruz and Monterey, introduced federal legislation in March to make xylazine a controlled substance.

“It gives our law enforcement the tools that they can use to crack down and hopefully remove this type of deadly combination of fentanyl and xylazine off the streets,” Panetta said of the bill. “I think we got a good chance of getting this passed this year.”

Governors in Pennsylvania and Ohio are to to xylazine. In California, lawmakers are wrestling with several measures that would increase penalties for fentanyl dealers, but none address xylazine.

One potential downside to any crackdown is that it could make it much harder for veterinarians and other customers to obtain the drug for their animals. And the FDA said late last year that it was not known whether tranq was being diverted from the animal supply or manufactured illicitly.

Siddarth Puri, associate medical director of prevention at the Los Angeles County Department of Public Health, noted that the data was sparse but that xylazine was likely more widespread than is known.

Puri and his public health colleagues learned only recently, from , that county law enforcement officials had been spotting xylazine in the fentanyl supply for years. The county Sheriff’s Department recently to track the presence of the drug.

“There are probably hundreds of other illicit synthetic substances that are being cut into the drugs that we don’t know about yet, and we don’t know how they’re going to impact people,” Puri said. “Right now, the spotlight is on xylazine.”

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“I became a massive cocaine addict,” Sarabia said. “It started off just casual partying, but that escalated to pretty much anything I could get my hands on.”

At one particularly low point, Sarabia was homeless for three months, sleeping on public transportation to stay warm. Even with plenty of money in the bank, Sarabia said, he’d lost the will to live. “I’d given up,” he said.

He got back on his feet, sort of, and for the next three years lived as a “functional cocaine addict” until his best friend, . Finally, Sarabia checked himself into a rehab in Southern California — ostensibly a luxurious one, although Sarabia didn’t find it to be so.

Still, the place saved his life. The clinicians really cared, he recalled, although their efforts were hampered by clunky technology and poor management. He had the feeling that the owners were more interested in profits than in helping people recover.

Just days off cocaine, the tech entrepreneur was scribbling designs for his next startup idea: a digital platform that would make clinician paperwork easier, combined with a mobile app to guide patients through recovery. After he left treatment in 2017, Sarabia tapped his remaining wealth — about $400,000 — to fund an addiction tech company he named inRecovery.

With the nation’s opioid overdose epidemic hitting a record high of more than effective ways to fight addiction and expand treatment access are desperately needed. Sarabia and other entrepreneurs in the realm they call addiction tech see a for their products and an addiction treatment field that is, in techspeak, ripe for disruption.

It has long been torn by opposing ideologies and approaches: medication-assisted treatment versus cold-turkey detox; residential treatment versus outpatient; abstinence versus harm reduction; peer support versus professional help. And most people who report struggling with substance use never manage to access treatment at all.

Tech is already offering help to some. Those who can pay out-of-pocket, or have treatment covered by an employer or insurer, can access one of a dozen addiction telemedicine startups that allow them to consult with a physician and have a mailed directly to their home. Some of the virtual rehabs provide digital cognitive behavior treatment, with connected devices and even mail-in urine tests to monitor compliance with sobriety.

Plentiful apps offer peer support and coaching, and entrepreneurs are developing software for treatment centers that handle patient records, personalize the client’s time in rehab, and connect them to a network of peers.

But while the founders of for-profit companies may want to end suffering, said Fred Muench, clinical psychologist and president of the nonprofit Partnership to End Addiction, it all comes down to revenue.

Startup experts and clinicians working on the front lines of the drug and overdose epidemic doubt the flashy Silicon Valley technology will ever reach people in the throes of addiction who are unstably housed, financially challenged, and on the wrong side of the digital divide.

“The people who are really struggling, who really need access to substance use treatment, don’t have 5G and a smartphone,” said Dr. Aimee Moulin, a professor and behavioral health director for the Emergency Medicine Department at UC Davis Health. “I just worry that as we start to rely on these tech-heavy therapy options, we’re just creating a structure where we really leave behind the people who actually need the most help.”

The investors willing to feed millions of dollars on startups generally aren’t investing in efforts to expand treatment to the less privileged, Moulin said.

Besides, making money in the addiction tech business is tough, because addiction is a stubborn beast.

Conducting clinical trials to validate digital treatments is challenging because of users’ frequent lapses in medication adherence and follow-up, said Richard Hanbury, founder and CEO of Sana Health, a startup that uses audiovisual stimulation to relax the mind as an alternative to opioids.

There are thousands of private, nonprofit, and government-run programs and drug rehabilitation centers across the country. With so many bit players and disparate programs, startups face an uphill battle to land enough customers to generate significant revenue, he added.

After conducting a small study to ease anxiety for people detoxing off opioids, Hanbury postponed the next step, a larger study. To sell his product to the country’s sprawling array of addiction treatment providers, Hanbury decided, he would need to hire a much larger sales team than his budding company could afford.

Still, the immense need is feeding enthusiasm for addiction tech.

In San Francisco alone, over the past two years. Employers, insurers, providers, families, and those suffering addiction themselves are all demanding better and affordable access to treatment, said Unity Stoakes, president and managing partner of StartUp Health.

The investment firm has launched a portfolio of seed-stage startups that aim to use technology to Stoakes hopes the wave of new treatment options will reduce the stigma of addiction and increase awareness and education. The emerging tools aren’t trying to remove human care for addiction, but rather “supercharge the doctor or the clinician,” he said.

While acknowledging that underserved populations are hard to reach, Stoakes said tech can expand access and enhance targeted efforts to help them. With enough startups experimenting with different types of treatment and delivery methods, hopefully one or more will succeed, he said.

Addiction telehealth startups have gained the most traction. Quit Genius, a virtual addiction treatment provider for alcohol, opioid, and nicotine dependence, raised $64 million from investors last summer, and in October, $118 million went to Workit Health, a virtual prescriber of medication-assisted treatment. Several other startups — Boulder Care, Groups Recover Together, Ophelia, Bicycle Health, and Wayspring, most of which have nearly identical telehealth and prescribing models — have landed sizable funding since the pandemic started.

Some of the startups already sell to self-insured employers, providers, and payers. Some market directly to consumers, while others are conducting clinical trials to get FDA approval they hope to parlay into steadier reimbursement. But that route involves a lot of competition, regulatory hurdles, and the need to convince payers that adding another treatment will drive down costs.

Sarabia’s inRecovery plans to use its software to help treatment centers run more efficiently and improve their patient outcomes. The startup is piloting an aftercare program, aimed at keeping patients connected to prevent relapse after treatment, with Caron Treatment Centers, a high-end nonprofit treatment provider based in Pennsylvania.

His long-term goal is to drive down costs enough to offer his service to county-run treatment centers in hopes of expanding care to the neediest. But for now, implementing the tech doesn’t come cheap, with treatment providers paying anywhere from $50,000 to $100,000 a year to license the software.

“Bottom line, for the treatment centers that don’t have consistent revenue, those on the lower end, they will probably not be able to afford something like this,” he said.

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Echeguren fled the soccer camp and ran home, terrified the police were on his heels.

He tried to explain to his mom what was happening, but the words wouldn’t come out right. His parents rushed him to a children’s crisis center, where an ambulance arrived and transported him to the adolescent psychiatric facility at St. Mary’s Medical Center in San Francisco.

“I thought it was a joke,” Echeguren said. “I didn’t think it was really happening because I didn’t know what was real or not.”

Echeguren received antipsychotic medication, was put in a quiet room and looked after by attentive caregivers who helped stabilize him.

Many young people don’t get the care they need so rapidly after a psychotic episode, if at all. As a result, they can become chronically disabled, and some end up homeless, incarcerated or addicted to drugs.

“Early intervention preserves the most important pieces of a young person’s life — relationships with family and friends, success at work or school,” said Tara Niendam, executive director of Early Psychosis Programs at the University of California-Davis.

corroborates Niendam’s view, and California lawmakers have endorsed it: The California state budget signed earlier this year by Gov. Gavin Newsom provides to create early intervention programs and expand existing ones.

Only about half of the state’s 58 counties have such a program, and many of those that do struggle to keep them open because of a lack of funding and a limited pool of trained behavioral workers.

Nationally, the median time between the first symptoms of psychosis and the start of treatment is nearly a year and half, according to a by the National Institute of Mental Health. That is six times longer than the World Health Organization’s recommendation of or less.

Each year, an estimated 8,000 adolescents and young adults in California experience their first psychotic episode, according to Thomas Insel, Newsom’s mental health adviser. Insel extrapolated that number from data showing that every year about nationwide experience their first psychotic episode.

Psychosis refers to a group of mental disorders, such as schizophrenia, that cause people to lose contact with reality. The average life span of people with major mental illnesses is up to than for the general population, largely because they are at greater risk for multiple chronic diseases.

“These people don’t live beyond their late 50s,” said Insel, a former director of the . “It’s not a pretty picture. It’s a sad statement of where we are in the way we treat this illness.”

Mental health experts say the most effective early psychosis treatment is something known as coordinated specialty care, which incorporates medication and psychotherapy with case management, support groups for the patients’ families and assistance securing employment or education.

Experts say there is significant momentum nationally for expanding and improving early psychosis treatment.

The big question is how to implement a strategy across California, said Toby Ewing, executive director of the , the state agency tasked with ensuring that the early psychosis funding is spent effectively.

It will look to early psychosis models in Oregon and New York, which are ahead of California in statewide coordinated specialty care clinics, Ewing said. California will also partner with the federal government on a strategy for nationally, he said.

But there’s a complication: Unlike other states that have centralized mental health care systems, in California it is up to each county to decide whether to provide early psychosis services or not. Patients who live in counties without such services often must drive long distances to find a clinic that provides the specialized care they need.

Another barrier to access is insurance. “We have a disjointed financial system that impacts an individual’s ability just to walk in the door of a program,” said Niendam, who operates in Northern California. One of them accepts private insurance and self-pay; the other is for patients who are uninsured or on Medi-Cal, the state’s Medicaid program.

Niendam said she can bill Medi-Cal for a greater number of services than she can private insurers, including at-home support for patients who are too sick to come to the clinic; family and patient advocacy; and education and employment support.

Echeguren, who was able to get adequate care on his parents’ relatively generous health plan, said that after several days in the St. Mary’s psych unit, the frightening auditory hallucinations that had sent him running from the soccer camp began to fade. “It felt good,” he said. “I felt like I had narrowly escaped disaster.”

After he left the hospital, Echeguren saw a psychiatrist and enrolled in a program called Prevention and Recovery in Early Psychosis, which connected him to a therapist and family groups that he and his parents attended.

Ultimately, Echeguren graduated from high school, and then college. He now works at a public relations firm in San Francisco and lives with his girlfriend.

He knows how lucky he is to have benefited from such rapid intervention.

“If I would have waited a year and a half for treatment, I would be dead,” he said. “I would have done something bad to myself.”

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La ansiedad duró tres meses, y al parecer estuvo relacionada con su trastorno bipolar. Durante ese tiempo, fue incapaz de pedir ayuda a sus empleadores o a sus compañeros de trabajo, por miedo a que la despidieran, o no la promocionaran, por su bajo rendimiento.

“No sabía cómo pedir ayuda. No sabía qué hacer”, dijo Switz, de 48 años, quien trabajaba como consultora asociada en negocios en Washington, DC, cuando ocurrió el episodio.

Mientras que un diagnóstico de cáncer puede generar simpatía en el trabajo y la oferta de comidas preparadas para ayudar a la familia, admitir un trastorno psicótico puede provocar juicio, miedo y evasivas entre los compañeros de trabajo. Pero, incluso si no se habla mucho de estas enfermedades, 1 de cada 5 adultos en el país sufre un trastorno de salud mental, y 1 de cada 22 adultos vive con una enfermedad mental grave, como esquizofrenia, depresión grave o trastorno bipolar, según el .

El Americans With Disabilities Act de 1990 prohíbe la discriminación contra las personas con discapacidades. La ley incluye ciertas afecciones de salud mental, y requiere que los empleadores proporcionen las comodidades necesarias para ayudar a sus empleados afectados a hacer su trabajo. Algunos empleadores también ofrecen apoyo de salud mental a los empleados a través de programas de asistencia, conocidos como EAP, que brindan servicios de asesoramiento a corto plazo y derivaciones a tratamientos por adicciones, entre otros.

Pero incluso con esas protecciones federales y los programas que ya establecieron algunas compañías, muchos empleados son reacios a pedir ayuda en sus trabajos. Se estima que 8 de cada 10 trabajadores con una condición de salud mental no reciben tratamiento debido a la vergüenza y el estigma vinculados a estas condiciones, .

Como resultado, aumenta la presión sobre los empleadores para que adopten mejores estrategias para lidiar con la salud mental.

California tomó nota y el año pasado aprobó una que lo ha convertido en el primer estado en establecer estándares voluntarios para la salud mental en el lugar de trabajo.

Bajo la nueva ley, el estado creará pautas para ayudar a las empresas a fortalecer el acceso a la atención de salud mental para sus empleados, y reducir el estigma.

La medida tiene como objetivo equiparar la estrategia de salud mental en el lugar de trabajo a la que empleadores ya promueven con la salud física, de modo que un empleado con síntomas graves de salud mental se sienta cómodo, por ejemplo, tomando una licencia médica, tal como lo haría una persona con cáncer durante los períodos de tratamiento y recuperación.

La ley se inspiró en el grupo sin fines de lucro de California . La organización había desarrollado una carta de principios de salud mental para guiar a las empresas. Pero debido a que la ley no tiene ángulos regulatorios, es posible que algunas compañías no entiendan cómo invertir en salud mental los volverá más competitivos en el mercado.

One Mind at Work ofrece una herramienta: una calculadora en línea para estimar cuánto dinero está perdiendo la empresa al no abordar la salud mental. La pérdida anual estimada de ganancias ligadas a afecciones de salud mental es de al menos en todo el país, especialmente debido al ausentismo y a la pérdida de productividad.

“Queremos mostrar pruebas económicas tangibles de que mejorar la salud mental en el lugar de trabajo es bueno para los negocios”, dijo Garen Staglin, cofundador de One Mind at Work, quien también es inversionista de capital privado.

El enfoque está funcionando.

Sutter Health, Bank of America, Walgreens, Levi Strauss & Co. y el estado de California son algunos de los empleadores que han firmado el estatuto de One Mind y han comenzado a incluir estrategias para abordar el bienestar mental.

Algunas compañías ofrecen entrenadores de salud, capacitación en concientización sobre salud mental para gerentes y grupos de apoyo en el lugar de trabajo, con la esperanza de crear una atmósfera de comprensión, para que las personas se sientan cómodas hablando de sus condiciones y pidiendo ayuda.

Algunos incluso tienen servicios de meditación en la oficina, y centros de bienestar para ayudar a los empleados a acceder a recursos de salud mental, como sesiones de asesoramiento gratuitas, consejería financiera y aplicaciones móviles que enseñan técnicas de control del estrés.

Hace poco, Levi Strauss & Co., con sede en San Francisco, dio a los empleados acceso a asesoramiento . Y Sutter Health está creando un curso en línea de concientización sobre la salud mental para todos los empleados, que resaltará lo que es vivir con una enfermedad mental.

Otra forma en que las empresas han estado trabajando para apoyar a los empleados es presionando a sus aseguradoras para que ofrezcan una gama más sólida de beneficios de salud mental.

“Los empleadores a menudo pueden sentir que están a merced de los planes de salud. Pero los empleadores tienen el poder del bolsillo”, dijo Angela Kimball, CEO interina de la National Alliance of Mental Illness. “Tienen una enorme capacidad para cambiar el mercado simplemente exigiendo algo mejor”.

Switz ahora vive en Seattle y es directora ejecutiva de Stability Network, una organización sin fines de lucro que fundó con la meta de reducir el estigma de salud mental en el lugar de trabajo. La red está compuesta por un grupo de profesionales que hablan públicamente sobre cómo es vivir y trabajar conviviendo con una enfermedad mental.

Durante la lucha de tres meses con su ansiedad, Switz recibió una pobre evaluación de su desempeño y estuvo a punto de perder su trabajo. Le dieron tres meses para cambiar las cosas.

Fue asignada a un proyecto más enfocado que le facilitó el manejo de su ansiedad. Además, los síntomas comenzaron a desaparecer por sí solos, lo que le permitió funcionar como siempre, a su mejor nivel.

Switz dijo que sabe que otras personas con afecciones mentales no son tan afortunadas y son despedidas porque no obtienen la ayuda que necesitan.

“A veces, la gente necesita pedir un tratamiento especial para mejorar”, dijo. “Y creo que eso asusta muchísimo a los demás”.

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The anxiety lasted three months, likely related to her bipolar disorder. During that time, she felt unable to ask for help from her employers or co-workers, afraid that her poor performance would get her fired or passed over for promotion.

“I didn’t know how to ask for help. I didn’t know what to do,” said Switz, 48, who was working as an associate business consultant in Washington, D.C., when the episode occurred.

While a diagnosis of cancer might garner sympathy at work and a casserole to take home to the family, an admission of a psychotic disorder might elicit judgment, fear and avoidance among co-workers. And even if such illnesses are not talked about much, 1 in 5 adults in the U.S. have a mental health disorder, and 1 in 22 adults live with a serious mental illness, such as schizophrenia, major depression or bipolar disorder, according to the

The Americans With Disabilities Act of 1990 prohibits discrimination against people with disabilities, which includes certain mental health conditions, and requires employers to provide reasonable accommodations to help them get their jobs done. Some employers also offer mental health support for employees through employee assistance programs, known as EAPs, which provide services such as short-term counseling and referrals to treatment for substance use.

Even with those federal protections and existing employer programs, some employees can be reluctant to ask for help at work. An estimated 8 in 10 workers with a mental health condition don’t get treatment because of the shame and stigma associated with it, the National Alliance on Mental Illness.

As a result, the pressure is growing on employers to adopt better strategies for dealing with mental health.

California has taken notice and last year passed that makes it the first state to establish voluntary standards for workplace mental health.

Under the law, the state will create guidelines to help companies strengthen access to mental health care for their employees and reduce the stigma associated with it.

The measure aims to normalize workplace mental health in the same ways that employers already promote physical health, so that an employee having severe mental health symptoms feels comfortable taking medical leave, for example, just as a person with cancer might during periods of treatment and recovery.

The law was inspired by the California nonprofit group . The organization had developed a charter of mental health principles to guide companies. But because the law doesn’t have any regulatory teeth, some companies may not see how investing in mental health will make them more competitive in the marketplace.

One Mind at Work offers an online calculator tool to estimate how much money they’re losing by not addressing mental health. The estimated annual loss of earnings tied to mental health conditions is at least nationwide because of absenteeism and lost productivity.

“We want to show tangible economic proof that improving mental health in the workplace is good for business,” said One Mind at Work co-founder Garen Staglin, who is also a private equity investor.

The approach is working.

Sutter Health, Bank of America, Walgreens, Levi Strauss & Co. and the state of California are among the employers that have signed onto One Mind’s charter and have begun to include strategies to address mental wellness.

Some companies provide health coaches, mental health awareness training for managers and peer support groups in the workplace, hoping to build an atmosphere of understanding, so people feel comfortable talking about their conditions and asking for help. Some even have on-site meditation services and wellness centers to help employees access mental health resources, such as free counseling sessions, financial counseling and mobile apps that teach stress-management techniques.

San Francisco-based Levi Strauss & Co. has recently given employees access to counseling emergencies at work. And Sutter Health is creating an online mental health awareness course for all employees that will highlight what it is like to live with a mental illness.

Another way companies have been working to support employees is by pressuring their insurers to offer a more robust array of mental health benefits.

“Employers can often feel that they’re at the mercy of health plans. But employers have the power of the pocketbook,” said Angela Kimball, acting CEO of the National Alliance on Mental Illness. “They have an enormous ability to change the market by simply demanding better.”

Switz now lives in Seattle and is executive director of the Stability Network, a nonprofit organization she founded to reduce mental health stigma in the workplace. The network is made up of a group of educated professionals who speak publicly about what it is like living and working with mental illness.

During Switz’s three-month bout with anxiety, she got a poor performance review and nearly lost her job. She was given three months to turn things around.

She was assigned to a more focused project that made it easier to manage her anxiety, plus the symptoms began to wane on their own, allowing her to perform like her old high-functioning self.

She said she knows that other people with mental conditions aren’t as fortunate as she was and get fired because they don’t get the help they need.

“People need to ask for accommodations to get better at times,” she said. “And that, I think, is a scary thing for people.”

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The old-timer, who appeared to be in his 60s, could not find a viable vein, so a 38-year-old man named Daniel Hogan helped him. Hogan, a longtime drug user originally from St. Louis, leaned over the older man, eyeing his neck as he readied a syringe loaded with the powerful synthetic opioid fentanyl.

Hogan called the man a “jellyfish” because most of his veins had collapsed from years of intravenous drug use and he rarely bled when pricked. But the older guy still had his jugular vein, and for Hogan that would work just fine.

Hogan’s hands were pink and swollen, bearing scars and scabs from years of daily drug use and the harshness of life on the streets. But those hands were skilled in the art of street phlebotomy. He slid the needle into the man’s neck and pushed the plunger.

Hogan, who said he had taken fentanyl every day for the past two months, explained that he’d developed a tolerance for the drug, and the dose he gave himself would kill a less experienced user. So, he gave the older man only a fraction of that amount.

In case it was too much, Hogan was ready with a vial of naloxone, the overdose-reversal drug.

Grim drug scenes like this play out every day on — an area that spans the hard-luck sidewalks of the Tenderloin district and the transitional Mid-Market neighborhood, home to tech titans Twitter and Uber.

The area has become a beachhead for fentanyl, which has killed tens of thousands across the United States and is beginning to make itself felt in California.

The drug, which can shut down breathing in less than a minute, became the of opioid deaths in the United States in 2016. It is increasingly sought out by drug users, who crave its powerful high.

They feel a measure of security because many of their peers carry naloxone, which can quickly restore their breathing if they overdose.

Data suggests that in San Francisco the users may be reversing as many overdoses as paramedics — or more. In both cases, numbers have risen sharply in recent years.

In 2018, San Francisco paramedics administered naloxone to 1,647 people, up from 980 two years earlier, according to numbers from the city’s emergency response system.

That compares with 1,658 naloxone-induced overdose reversals last year by laypeople, most of them drug users, according to self-reported data from the , a Bay Area overdose prevention program run by the publicly funded Harm Reduction Coalition. That’s nearly double the 2016 figure.

“People who use drugs are the primary witnesses to overdose,” said Eliza Wheeler, the national overdose response strategist for the coalition. “So it would make sense that when they are equipped with naloxone, they are much more likely to reverse an overdose.”

The widespread availability of naloxone has radically changed the culture of opioid use on the streets, Hogan said. “In the past, if you OD’d, man, it was like you were really rolling the dice.” Now, he said, people take naloxone for granted.

“I feel like as long as there is Narcan around, the opiates can’t kill you,” said Nick Orlick, 26, referring to one of the brand names for the overdose reversal drug.

As he huddled in the recess of a building along Mission Street, around the corner from high-rise luxury apartments, Orlick explained that he’d been revived with naloxone 15 times in recent years.

Despite fentanyl’s growing presence in San Francisco and other parts of California, it has not hit the Golden State nearly as hard as the rest of the country.

In 2017, 28,466 people across the U.S. died from overdoses involving synthetic opioids, which include fentanyl and related compounds, according to from the Kaiser Family Foundation. California, which represents 12% of the country’s population, had 536 of those deaths — fewer than 2% of the total. (Kaiser Health News, which produces California Healthline, is an editorially independent program of the foundation.)

However, use of fentanyl is likely to grow in San Francisco and Los Angeles, as people get accustomed to it and begin to prefer its more intense high, said Ricky Bluthenthal, professor of preventive medicine at the Keck School of Medicine of the University of Southern California, who researches injection drug use.

In California, as in many other states west of the Mississippi, heroin is smuggled in the form of a gooey or hard black tar. This “black tar” heroin, “a well-known garbage drug,” is diluted with fillers, which induces some users to seek out the much more powerful effects of fentanyl, said Kristen Marshall, manager of the DOPE Project.

Fentanyl is dangerous not only because it is up to , but also because people often take it unknowingly when their dealers mix it in with street drugs such as heroin. However, the black tar is difficult to mix with fentanyl, and that may help protect drug users who might otherwise ingest it unwittingly, experts say.

But even if they overdose on fentanyl, it’s not necessarily a death sentence. The widespread practice by community organizations in San Francisco and Los Angeles of distributing naloxone to the drug-using population also helps explain California’s lower rate of deaths from fentanyl and , harm reduction workers and researchers say.

On the streets around San Francisco’s Civic Center, homeless drug users gather on sidewalks with their dogs, some huddling under blankets to smoke their white, powdered fentanyl through hollowed-out pens. Others inject it, often ducking into alcoves, alleys or tents for a fleeting moment of privacy amid the bustle of government employees, tourists and tech workers. Some of them overdose in plain sight.

They employ various methods to reduce the overdose risk. Some, like Daniel Hogan, take methamphetamine or smoke crack between injections to keep themselves alert. Another technique is to delay the full dose by pushing the plunger only partway down.

If gathered as a group, they often stagger their fentanyl use so one of them will be physically able to administer naloxone.

One recent May afternoon near Market Street, a thin man in his early 40s who called himself Bud slid a needle into his arm and slowly pushed the plunger down, stopping every so often to gauge the effects of the fentanyl.

“Hey, stop there. Pull it out,” said his friend Seth Carus, 55. Bud’s eyes were vacant and his mouth drooped — telltale signs the fentanyl had taken hold.

Bud, wearing tight clothing and a blue beret, didn’t listen. He pushed the plunger all the way. Five minutes later, the color drained from his face, his eyes opened wide, his jaw locked and his entire body went stiff as he lay on the sidewalk.

Carus, living on the streets and a fentanyl user himself, sprang into action. He prepared a shot of naloxone and told a bystander to call 911.

But before Carus could administer the overdose reversal drug, Bud began to stir. Carus cradled him in his arms as the police arrived, followed quickly by the paramedics, who put Bud in an ambulance.

Carus blamed himself as he bent over and cried. The fentanyl was his, and he had been trying to do Bud a favor by getting him high.

A while later, Bud emerged from the ambulance and embraced his friend. “You did the right thing, man,” he told Carus. “I did the shitty drug addict thing. You said to stop, and I didn’t listen.”

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For many users, full-blown withdrawal is often foreshadowed by a yawn, or perhaps a runny nose, a sore back, sensitive skin or a restless leg. For me, the telltale sign that the heroin was wearing off was a slight tingling sensation when I urinated.

These telltale signals — minor annoyances in and of themselves — set off a desperate panic: I’d better get heroin or some sort of opioid into my body as soon as possible, or else I would experience a sickness so terrible I would do almost anything to prevent it: cold sweats, nausea, diarrhea and body aches, all mixed with depression and anxiety that make it impossible to do anything except dwell on how sick you are.

You crave opioids, not because you necessarily want the high, but because they’d bring instant relief.

Quitting heroin was my plan every night when I went to sleep. But when morning came, I’d rarely last an hour, let alone the day, before finding a way to get heroin. My first time in a detox facility, I made it an hour, if that. As I walked out, a staff member said something to the effect of “I didn’t think you’d last long.”

After my parents moved out of town, in part to get away from me, I would show up at their new home five hours away with big hopes of kicking the habit and starting a new life. But after a night of no sleep, rolling on the floor convulsing while vomiting into a steel mixing bowl, I’d beg them for gas money to drive the 300 miles back to where I lived and a little extra cash for heroin. I did this so often my mother once told me in frustration, “You show up, throw up and then leave.”

Going through “cold turkey” withdrawal is, not surprisingly, impossible for many. That’s why the medical community has largely embraced the use of methadone and buprenorphine — known medically as medication-assisted treatment, or MAT — combined with counseling, as the “gold standard” for treating opioid addiction. As opioids themselves, these drugs reduce craving and stop withdrawals without producing a significant high, and are dispensed in a controlled way.

“Detox alone often doesn’t work for someone with an opioid use disorder,” said Marlies Perez, chief of substance use disorder compliance at the California Department of Health Care Services, who estimated that it might be a realistic option for only 15 out of 100 people.

Studies have also shown that MAT reduces the risk of overdose death by 50 percent and increases a person’s time in treatment.

Yet even with strong evidence for MAT, there is debate over whether to offer MAT for people struggling with opioids. Some states, like California, have vastly expanded programs: The Department of Health Care Services has 50 MAT expansion programs, including in emergency rooms, hospitals, primary care settings, jails, courts, tribal lands and veterans’ services; the state has received $230 million in grants from the federal government to help with these efforts. But many states and communities hew to an abstinence or faith-based approach, refusing to offer MAT as an option. In 2017, only about 25 percent of treatment centers offered it.

Just as each person’s journey into addiction is unique, different approaches work for people trying to find their way out. Public health experts believe they should all be on the table.

Diane Woodruff, a writer from Arizona who became addicted to opioid medication prescribed for a bad back, described withdrawal like this: “If you’ve ever had the flu it’s like that but times 100.” Woodruff went through the sickness every month for five days until she could refill her prescription of OxyContin.

Other people described the sickness as if ants were crawling under their skin or acid was being injected into their bones. Woodruff was able to quit for good after she went cold turkey, sort of. She used kratom and marijuana to help with the detox.

Noah, a 30-year-old from San Francisco who asked that his last name not be used, said that MAT was a “miracle,” therapy adding, “It saved my life.” Noah spent five years on Suboxone, a brand-name formula of buprenorphine and naloxone, right around the time fentanyl began taking lives with impunity. Suboxone took away his craving for heroin, but he kept drinking alcohol and injecting cocaine and using other drugs for a while until joining a sobriety community. He finally weaned off MAT half a year ago.

“There’s no debate that MAT works — the evidence is clear,” said Dr. Kelly Clark, president of the American Society of Addiction Medicine. Opioid use changes the chemistry of the brain, sometimes permanently. Buprenorphine and methadone stop the withdrawals, diminish cravings and, when taken as prescribed, block the high from other opioids. These medications “tone down and reset the brain,” helping to “normalize” the individual, Clark added.

Within the nine years of my heroin use, I tried to get sober many times: detox, residential rehab, and with morphine and methadone under the guidance of a health care professional. For me, Suboxone didn’t prove the answer, although (to be fair) I never took it as prescribed under the supervision of a doctor. I was ambivalent and incapable of following directions, let alone a treatment plan. I didn’t want to be shackled to another opioid or have to check in with a health care professional every week or month or have to go to counseling — even if all that could have helped me to function better. (A common critique of methadone or buprenorphine is that it is just replacing one drug for another.)

But Suboxone ultimately kick-started me into sobriety. One day in December 2008, I tried one more time to detox successfully off heroin at my parents’ house. To make it easier, I had a couple of pills of Suboxone, illegally obtained. So, after the body aches and that weird feeling when I peed, the buzzing ball of anxiety began to grow in the pit of my stomach and, just when life began to seem unbearable, I crushed one of the Suboxone tablets up and snorted it off my dresser. Unbeknownst to me at the time, when Suboxone is crushed, it releases an anti-tampering chemical that sends the user into full-on withdrawal.

I spent the next three days shut up in a room as my body and mind began to unravel. I barely slept and there was plenty of diarrhea and vomiting. After the worst of it was over, I apathetically roamed my parents’ house, not sleeping for two weeks. Then, I joined a sobriety community and haven’t touched an opioid in 10 years.

MAT was not the escape route from addiction for me, personally, and I have mixed feelings about these medications. But with tens of thousands of opiate overdose deaths each year, it makes sense that people struggling with addiction and facing the terrifying specter of withdrawal have every option available.

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It hurts too much to move. She needs a hip replacement and her legs are swollen. Next to her is a portable commode, and when it’s time to go, nurses and volunteers help her up and hold curtains around her to give her some measure of privacy.

“Never in my life did I think I would end up in a situation like this, but when it’s time to go, you got to go,” Saunders said. Under the circumstances, she is in good spirits, with a rotating cast of people stopping by to chat and take care of her.

Most of the fire victims here are older folks like her. They rest on cots, inflatable beds and recliners in a pop-up community of nearly 200 evacuees displaced by the Camp Fire and an army of volunteers.

The Camp Fire, the deadliest in state history, took ruthless aim at older people. Paradise, the Northern California town erased by fire, was largely a retirement community, with a quarter of the population 65 and older. The fire’s death toll was 77 at last count, and nearly 1,000 people were still unaccounted for — most of them seniors. The sheriff’s list of the missing includes many in their 70s and 80s.

Like everyone else in the wildfire’s path, older people fled swiftly, if they escaped at all, often leaving behind medications, wheelchairs, walkers and essential medical equipment.

Altogether, around 50,000 people are thought to have evacuated, now staying in motels, cars, shelters and a makeshift camp at Walmart in Chico. But the elderly refugees often need more support, especially with chronic conditions and infections that incubate and spread in close quarters. Some need dialysis but can’t get it. Others have respiratory illnesses aggravated by smoke. One woman in a Yuba City shelter was recovering from cancer surgery with a stapled wound.

“It’s been rough,” said Joy Beeson, 76, an evacuee who landed in the Chico church shelter. “Lost a couple of bedmates the other night. They all went to the hospital.”

They were felled by norovirus — a nasty stomach illness that causes diarrhea and vomiting. People were throwing up all day. Then, in the middle of night, paramedics came and removed the sickest, according to some evacuees.

Last week, nearly all the shelters from Chico to Yuba City were hit by an outbreak of the stomach illness — sending dozens to hospitals. Last week, the said 145 people in the shelters had been sick with the virus. Fearful volunteers and evacuees rarely shake hands anymore; fist bumps and elbow knocks are highly encouraged.

“Just threw up a few times,” said Martha Pichotta, 65, who was staying at the Red Cross shelter in Yuba City, about 50 miles south of Chico. After 24 hours of isolation behind blue curtains, she was released to mingle with other evacuees.

Adding to the physical and emotional stress, especially for seniors, was the hurried escape from longtime homes and the disruption of often predictable lives. There was little time for practical consideration, let alone sentiment — beloved pets and rooms full of memories were lost.

Beeson, whose shelter mates were taken to the hospital, said her adult son put his hand on her back to steady her, yelling, “Run, mama, run!” The only reason they escaped the fire alive was because a car picked them up and whisked them to freedom.

David Jackman, a 72-year-old man, said he shuffled down the road as fast as he could, leaving behind his dog and his walker as the flames overcame his house and propane tanks exploded behind him. A firetruck came to his rescue — likely saving his life.

Saunders, the 89-year-old Paradise resident, nearly burned to death in a car. One side of it melted.

Most of the older folks in the shelter said they couldn’t be more grateful for all the support and care they’ve received. Even so, life in a shelter is hard.

Denise Parker, a Red Cross volunteer in Yuba City, said they can offer displaced people Pepto-Bismol and lots of Gatorade. But some were so dehydrated they needed to be hospitalized. Parker said they double-bag all waste and isolate those who are sick.

Parker recently got a request for an oversize wheelchair but wasn’t sure how to find one, she said. One evacuee needed dialysis, but they didn’t have the resources to drive the hundred or so miles back and forth to get him to a clinic.

A nurse and doctors stop by to write prescriptions, Parker said, but for more complicated conditions the shelter struggles to meet the need. They aren’t a full-fledged medical facility.

Ron Cooper, a 78-year-old who evacuated his home in Magalia, 5 miles north of Paradise, was staying at the Yuba City shelter with his wife, Jacque. Days after the fire hit, Jacque was released from the Oroville Hospital, following surgery to remove a cancerous kidney, but couldn’t go home. Her husband said she is doing OK in the shelter, even with a stapled wound in her side, but was concerned that she won’t eat or drink.

David Ramey, aÌý64-year-old with a scraggly beard, lounged on an inflatable bed at the Chico shelter, puffing on a nebulizer to soothe his emphysema. It was acting up because of the soupy smoke hanging in the air.ÌýHe bought the device soon after getting out of the danger zone.

Many of those who lost nearly everything are in a limbo state, not knowing what they will do next. Some are waiting on assistance from the Federal Emergency Management Agency or for an insurance check. Others are looking for affordable housing in nearby communities. Paradise was attractive not just because of its natural beautyÌýbut because housing was reasonably priced for retirees. Several evacuees, like Pichotta, had been living in mobile homes.

At the Yuba City shelter Saturday, Pichotta sat in a wheelchair puffing on a cigarette with a blanket over her legs. She was talking with her 33-year-old son about what they should do now.

The short answer: no idea.

“My mobile home is this high,” she said, placing her hand a few inches above the ground. They didn’t have residential insurance and their only monthly income is a $900 Supplemental Security Income check. While she doesn’t know where she will end up, she knows her life in Paradise is over.

“I never want to go to Paradise again,” she said, and cried.

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In a well-tailored blue suit and matching tie, Newsom strode to the elevator and casually leaned his tall frame against the corner, emerging on KQED radio’s third floor to banter with waiting reporters — the picture of a polished and confident front-runner.

Then, in gravelly tones, Newsom squared off with his Republican opponent John Cox, letting loose his inner wonk, delving into the weeds on all manner of issues in the Golden State. “If you’re looking for timidity, I’m not your person,” he said when asked about his temperament.

But not once did the Democratic candidate mention one of the most controversial pillars of his campaign: single-payer health insurance.

Nationally, Newsom’s support for single-payer is perhaps how he is best known — aside from his bold move as San Francisco mayor in 2004 to sign marriage licenses for same-sex couples, a prescient decision that then ran contrary to law.

Newsom’s backing for government-run, universal coverage has often been similarly bold, but other times it has been more muted, prompting conservatives to call him too liberal and liberals to label him too skittish. That dichotomy is likely a reflection of the political challenges he will face, if elected, even in one of the nation’s bluest states.

His notable omission of single-payer in the debate earlier this month could have stemmed from a tightly choreographed format and time limitations — but his immediately jumped on him for it, calling his past effort to create universal health care in San Francisco a failure of which he should be “ashamed.”

Newsom, 51, who declined requests for an interview, has at times attempted to dampen expectations, that the single-payer effort could take years. In part, he was acknowledging a practical hurdle: The federal government needs to approve the move if federal dollars are to be used, and the Trump administration is flatly opposed.

On his campaign website, however, Newsom has coverage in California. Last year, he endorsed the amended Healthy California Act, , which called for covering every Californian, including undocumented immigrants, under one public program.

The bill stalled, in part because it was projected to cost $400 billion a year, nearly three times the for 2018-19. But the California Nurses Association, which has endorsed Newsom, plans to sponsor a new bill in the coming legislative session.

Newsom’s supporters say he is committed to the effort — simply because he believes it is the right thing to do.

“There are some people who have health care coverage and others who don’t,” said Mitch Katz, director of public health in San Francisco when Newsom was mayor and an unpaid adviser to his campaign. “Everyone should be covered — for Gavin, it’s a fairness issue.”

(His opponent, Cox, dismisses the very idea. Asked earlier this year whether he supports single-payer, his answer was simple: “God, no.”)

Even some who respect Newsom’s motives see his goal as quixotic.

“I’ve followed his career and believe he is an individual of integrity who wants to advance meaningful legislation that helps people,” wrote Stanford professor and author Dr. Robert Pearl in . “That said, in a state that’s currently struggling to fund its schools and rebuild its infrastructure, Newsom will likely soon realize that turning California into a single-payer state is too expensive a promise to carry out.”

Newsom commonly pulls out his health care bona fides, namely his experience as mayor of San Francisco, when the city spearheaded a unique, all-embracing health care system for city residents.

“I did universal health care in San Francisco,” said Newsom on a progressive recently. “We proved it could be done without bankrupting the city. I’d like to see that we can extend that to the rest of the state.”

Healthy San Francisco is not a single-payer system — not an entirely publicly funded insurance plan. It aims for universal care by covering lower-income residents through a combination of city funds, charity care, copayments and contributions from employers. It’s not true insurance because it can’t be used outside the city.

Enrollees have access to a citywide network of preexisting safety-net hospitals and clinics. At its height, it enrolled 60,000 city residents, though enrollment plunged to 14,000 after the Affordable Care Act took effect. Today, undocumented residents make up the largest share of those on Healthy San Francisco.

Some critics on the left say Newsom took credit for Healthy San Francisco only after it was deemed a success.

“Newsom is claiming credit for something he didn’t really do and didn’t support,” said Tom Ammiano, the former San Francisco supervisor and state assembly member who was chief architect of Healthy San Francisco. “If anything, I would say he did his best to undermine it.”

While Newsom liked the idea of universal health care in San Francisco, he did not publicly support the requirement for restaurants to contribute to employees’ health benefits, according to Ammiano and others who worked on Healthy San Francisco. But the Board of Supervisors voted unanimously for Healthy San Francisco, blocking any chance for a veto, and then Newsom signed it into law.

After it passed in 2006, the Golden Gate Restaurant Association sued San Francisco, arguing unsuccessfully that forcing restaurants to chip in on employees’ benefits was in conflict with a federal law governing employee benefits. “We went to court three times, and three times we won,” Ammiano said. “Where was Gavin? He never entered that fray. He never supported it, never did anything publicly.”

San Francisco progressives, like Ammiano and others, have never cared for Newsom’s pro-business stance (Newsom has owned wine shops and numerous other small businesses with about 700 employees), or what they see as his slick persona when he was mayor from 2004 to 2011. Among some circles in San Francisco, Newsom was known as “Mayor Press Release,” meaning he had a lot of big ideas but little follow-through.

The San Francisco League of Pissed Off Voters, a progressive political organization that puts out a voter guide, called Newsom a “substanceless glad-hander” who “has been flashing fake smiles, pretending to be progressive for the cameras. … He’s a machine-politics climber who claims to fight for the dispossessed but never seems to get around to actually doing anything for them.”

But even as a vocal critic of Newsom, Ammiano said he plans on voting for him as governor. “There is no third option,” Ammiano said. “I don’t believe in not voting, and I could never do Cox.”

A governor would face numerous hurdles in fundamentally restructuring the state health care system to cover everyone, including getting buy-in from the feds and confronting opposition from insurers and others invested in the status quo.

But Newsom’s supporters say that a governor, at least, would have more authority than a mayor.

“The state has much more power over health care delivery than the county of San Francisco,” said Katz, now president and CEO of NYC Health + Hospitals. “There are many more levers when you are the governor than when you are the mayor.”

Ken Jacobs, chair of the Center for Labor Research and Education at UC Berkeley and a member of the council that helped craft Healthy San Francisco, agreed.

For instance, Newsom could push to expand Medi-Cal — the public insurance program for low-income Californians — to include undocumented immigrants, said Jacobs, co-author of . Also, he could prevail upon legislators to institute a state mandate for health insurance and provide state subsidies to help cover the cost.

That wouldn’t meet the definition of “single-payer” but would tap a variety of sources to pay into a system that aspires to cover everyone.

Whatever approach he takes, Jacobs said, “Gavin Newsom took the issue of health care very seriously as mayor, and I would expect him to do so as governor.”

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Haynes, then 32, had spent the previous two weeks in jail detoxing from methamphetamine and heroin. The judge told Haynes he could serve part of his yearlong jail sentence in a drug treatment program rather than locked in county jail.

Eileen Jao, an assistant district attorney, quickly interjected: “It has to be residential, not outpatient,” she said. “It’s residential or jail.”

Jao wanted the terms to be crystal-clear. Because of a new county policy that took effect at the beginning of the year, treatment for low-income residents like Haynes, with drug-related criminal charges, must be decided by clinicians and providers — not the court. Judges can order whatever they want in terms of treatment, and prosecutors can block designated treatment they deem too risky, but essentially the type and length of treatment deemed appropriate is out of their hands.

When conflicts arise between what the court orders and the providers decide, felons can languish in jail with no treatment at all.

Court-ordered rehab is increasingly falling out of fashion in California as begin to treat addiction like any other health condition — with the Medicaid program relying on evidence-based practices and trained personnel to make decisions on care. That has upended the status quo for judges, attorneys and defendants who often had agreed to residential treatment in lieu of jail — or at least to reduced sentences so inmates could get that treatment.

The California program appears to be unique in many respects, but other states — including Utah, Indiana, Kentucky, West Virginia, Virginia, Maryland, New Jersey and Massachusetts — also have sought federal permission to experiment with innovations in Medicaid-funded drug treatment.

In California, “these changes are a tough pill to swallow for the criminal justice system,” said Gavin O’Neill, drug court manager for the Alameda County Superior Court, which implemented the policy in July. “In the past, some judges and attorneys have been able to use residential treatment as a sanction and long-term monitoring mechanism, as well as a chance to address the underlying drug problem,” said O’Neill. “That option has been shut down.”

Proponents say that evidence-based treatment will lead to better outcomes and that residential care should be reserved for those with the most severe addictions. Under Medi-Cal, it is limited to 90 days.

“From the provider’s perspective, the judge ordering services has always been a problem,” said Katie Mayeda, a Santa Cruz County Superior Court clinician. “Judges have good intentions to put someone in treatment rather than in jail, but they don’t know the whole story. They don’t work in that realm — they’re not a clinical professional.”

Advocates of the new approach — a Medicaid-funded pilot program that eventually is expected to be implemented in 40 California counties — say residential treatment is the most expensive and invasive option, and in many cases, outpatient treatment works as well, if not better.

If clinicians don’t approve residential treatment and prosecutors or judges won’t allow a release to outpatient treatment, the case can stall and felons become doomed to spend more time in jail.

Nearly three months into his jail stay, Haynes still was waiting for someone from a drug treatment program even to evaluate him, let alone determine his care plan. In the meantime, Haynes said, he received no drug treatment.

Because of the policy change, some prosecutors say they are less likely to accept anything but jail time.

“We are more inclined to just say, ‘Hey, put him in the custody of the sheriff,’ and not worry trying to treat the substance abuse problem,” said Santa Cruz County assistant district attorney Archie Webber. “If you want to do a program, you can do it on your own time.”

Webber’s rationale: He doesn’t trust the care providers, drug treatment organizations that contract with the county, to act in the interest of the state.

“We don’t want someone else to come in after us — a care provider, who hasn’t been in the process — and make those decisions for us,” Webber said.

The new policy, operating now in a third of the state’s 58 counties, stems from the expansion of Medicaid under the Affordable Care Act. That increased access to health care, including drug treatment, to the more than 13 million low-income adults in California who qualify for Medicaid.

In the past, counties had to use general funds or to pay for court-ordered drug treatment for those who couldn’t afford it. Now, counties can pay for a range of drug treatment services — outpatient, medication-assisted, detox and residential — through Medicaid, or Medi-Cal, as it is known in California. But the new policy requires everyone seeking residential treatment to have a clinical assessment to determine whether that setting suits their diagnosis.

The counties that have begun providing drug treatment services under the so-called Drug Medi-Cal Organized Delivery System represent nearly 75 percent of the state’s more than 13 million Medi-Cal enrollees, according to the . (California Healthline is an editorially independent publication of the California Health Care Foundation.) The rules on clinical decisions apply to everyone, not just inmates.

Proponents hope all 58 California counties will come on board eventually, although the pilot Medi-Cal program is approved only through 2020, after which the federal government would have to reapprove the experiment.

Los Angeles County implemented the new Medi-Cal program just over a year ago and indicates it is running relatively smoothly.

“L.A. County got in front of it early on,” said Albert Senella, president and CEO of Tarzana Treatment Centers. “Treatment is now driven by medical necessity.”

But educating the courts on the new procedures can be a time-consuming process, and experts say it may take months or longer in some counties before the new rules sink in.

In addition, counties and drug treatment providers say they have been weighed down by an administrative and staffing burden unlike anything they’ve seen before.

“It has been a tremendous amount of work,” said Senella. “A huge sea change in the way things are done.”

Some offenders say delays in receiving care are tough.

Haynes said he just wanted treatment, ideally in a residential setting.

“I’ve tried the whole white-knuckling sobriety thing,” said Haynes, who has a 10-year history with methamphetamine and heroin addiction. “The only measure of success I’ve had being clean and sober was in a residential drug treatment program.”

He would like to be able to visit with his wife and three children in a setting more pleasant than jail. Haynes wasn’t much older than his school-age kids are now when he visited his own father, then behind bars. He shook his head as if to erase the image.

“I don’t want my kids to see me in jail,” he said.

Haynes was released from jail this summer. Court records say his probation was revoked on July 17 after he was discharged from a drug treatment program for defiance and non-compliance.

He was re-arrested and, as of late last month, jailed in Fresno County.

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