The San Francisco Bay Area is putting homeless people with COVID-19 in hotel rooms. Some are given alcohol to prevent withdrawal.

• California counties are sheltering homeless residents who are infected with COVID-19, or at high risk of getting infected, in hotels and motels.
• In the Bay Area, San Francisco and Contra Costa counties are offering alcohol to guests who might otherwise experience withdrawal.
• San Francisco is also allowing guests to purchase their own medical cannabis, while Contra Costa is purchasing tobacco for guests out of its own budget.
• The programs are part of a "harm reduction" strategy that aims to keep homeless residents from leaving the hotels to retrieve substances.

When the San Francisco Bay Area issued the US's first stay-at-home order on March 16, officials knew there was one subset of the population who couldn't follow it: the homeless.

Those who sleep outdoors lack access to sanitation facilities, making it difficult to wash their hands or practice other forms of basic hygiene that lower the risk of getting and transmitting the coronavirus. Traditional homeless shelters, however, can create breeding grounds for outbreaks. Because of this, the Centers for Disease Control and Prevention recommends setting aside individual rooms for homeless people who have COVID-19, are awaiting test results, or have been exposed to the virus.

So the state of California procured thousands of hotel and motel rooms for this purpose, through a program called "Project Roomkey." Three-quarters of the funding comes from the Federal Emergency Management Agency, while the remaining quarter — around $150 million — is financed by the state government.

Gov. Gavin Newsom announced the program on April 3. Within a couple weeks, the program had secured more than 10,000 hotel and motel rooms across 42 counties.

But one aspect of San Francisco's operation of the hotels has stirred controversy: The city's Department of Public Health is giving alcohol to guests struggling with addiction and facilitating the delivery of cannabis.

"I just found out that homeless placed in hotels in SF are being delivered alcohol, weed, and methadone because they identified as an addict/alcoholic for FREE," Thomas Wolf, a drug counselor in San Francisco, tweeted on May 1. "You're supposed to be offering treatment. This is enabling and is wrong on many levels."

According to San Francisco's health department, which staffs the hotels, funding for these substances in the hotels comes from private donations from individuals. But Contra Costa County, about an hour outside the city, has spent up to $1,000 in public funding so far on substances for vulnerable residents sheltering in hotels.

Officials from both health departments say the practice of administering drugs and alcohol has prevented people from leaving the hotels to retrieve substances, thereby limiting the potential for the virus to spread.

"This program was put in place in order to support isolation and quarantine practices for patients under investigation or those who were positive for COVID-19, so that they do not break their isolation and expose other members of the community," Dr. Ori Tzvieli, Contra Costa county's deputy health officer, told Business Insider.

The concept of harm reduction

The practice of offering drugs and alcohol to those who might otherwise experience life-threatening withdrawals — a strategy known as "harm reduction" — is seen as an exercise in compassion for people struggling with addiction. It's also a way to relieve the burden on hospitals by administering substances in a controlled environment.

"Addiction doesn't stop because there's an infectious disease pandemic," the National Health Care for the Homeless Council wrote in an April memo. "Failure to accommodate substance use disorders will likely mean increases in fatal overdoses/dangerous withdrawals, higher rates of vulnerable people leaving isolation and quarantine against medical advice, and compromised individual and public health."

So far, San Francisco's isolation and quarantine hotels have given alcohol to less than a dozen guests to prevent withdrawals, according to Jenna Lane, a spokeswoman for the city's public health department. Around 10% of guests are provided with tobacco at any given time, she added.

The conservative nonprofit Turning Point USA suggested that funding for these substances came at taxpayers' expense, but Lane said that's not true in San Francisco. She estimated that alcohol and tobacco donations so far have totaled around $3,000. Some hotel guests can also purchase their own medical cannabis — Lane said five people have used that service so far.

Contra Costa county, meanwhile, has set aside more than 300 hotel rooms with funding from Project Roomkey. Around 150 vulnerable residents have temporarily moved in so far, according to the county health department's website. Tzvieli said five of those people have used the drug and alcohol program.

"We bought small individual (airplane style) vodka bottles and beer," Tzvieli said. "Patients with alcohol use disorder get a choice of one or the other."

The Contra Costa health department has also purchased one brand of cigarettes for guests, he added.

"It may sound odd for a health department to give people alcohol and cigarettes, but we do it in order to maintain isolation and quarantine and help protect the community from COVID," Tzvieli said. "It's a trade-off."

The 'minimum possible quantity and quality' to prevent withdrawal

Project Roomkey gives funding priority to counties like San Francisco with significant coronavirus outbreaks and large homeless populations. Mayor London Breed announced on April 29 that San Francisco had access to about 25% of the rooms available for occupancy under the statewide program.

As of May 13, around 211 individuals without a safe place to shelter — people who either had COVID-19 or are vulnerable to catching it — were being temporarily housed in San Francisco hotels. More than half are homeless, Lane said.

Guests entering hotels in San Francisco through Project Roomkey are "screened multiple times to determine what substances they would be uncomfortable without," the health department said in a statement to Business Insider. For guests who require alcohol or tobacco, the department's medical staff calculates the "minimum possible quantity and quality" to prevent withdrawals. It then administers these substances under the guidance of licensed physicians.

Hotel guests are also given the option to receive support for reducing or stopping their drug and alcohol use. Those trying to quit have access to addiction specialists, who can prescribe medications like gabapentin to prevent withdrawal.

"This period in our care has allowed some people to connect for the first time with addiction treatment and harm reduction therapy," the department said in a statement.

The department also facilitates the delivery of methadone from local clinics for guests that already receive treatment for opioid addictions.

Guests who use medical cannabis, meanwhile, can purchase it from a local dispensary, Lane said: "Patients order their own for delivery, and pay however they usually would."

Contra Costa, too, provides medications like suboxone for opioid addicts. Tzvieli said alcohol and cigarettes are given to those who decline medical treatment.

Infected homeless people don't seem to be leaving Bay Area hotels

Critics of the Bay Area's harm-reduction strategy argue that it enables addicts and normalizes drug use. But there's evidence that the strategy promotes safer practices among alcohol users: A Seattle housing program that recruited homeless individuals with severe alcohol problems from November 2005 and March 2007 found reduced alcohol consumption among the residents, who were still permitted to drink in their rooms.

"Harm reduction has been the policy of the San Francisco Department of Public Health for well over a decade and is ingrained in all of our work," Lane said.

She added that she didn't have a way of quantifying how much the strategy costs as a line item in her department's budget, but said thus far, the program has at least prevented drug and alcohol users with COVID-19 from leaving the hotels.

"Guests who have used the managed alcohol and tobacco and/or received prescription medications while in isolation and quarantine have told our medical staff that access to these things has influenced their decision to stay," Lane said.

Tzvieli said Contra Costa has seen similar results: None of the hotel guests have broken their isolation or quarantine. Of the five guests who participated in the harm-reduction program, he added, "each received only a one-day supply until their test results came back negative." After that, they were discharged from the hotel.