Amid an Overdose Crisis, Many San Diegans Struggle to Access Detox

As drug overdoses surge, low-income and homeless San Diegans seeking a safe place to stop using are often forced to wait for a bed – or are never able to access one. 

The region has about 70 county-contracted withdrawal management beds where Medi-Cal patients can be monitored and receive additional support, typically for seven to 14 days. None are in the city of San Diego, home to about half of the county’s fentanyl overdose deaths in recent years.  

The limited number of detox beds, a lack of programs that can treat detox patients experiencing medical issues and intake processes have made rapidly obtaining a bed akin to winning the lottery.  

Exhibit A: In the last six months of 2022, the McAlister Institute reports that less than 8 percent of the 322 people who requested detox services after being brought to the sobering center it operates just outside downtown were linked with a detox bed within the 23 hours they could remain there. 

(Pictured above left to right) A partial stack of detox referrals to McAlister’s adult detox program that were not fulfilled in 2022. McAlister intake specialist Dannielle O’Brien speaks to a client. Photos by Ariana Drehsler

That’s despite agreement among experts, treatment providers, advocates and outreach workers that waits can be deadly and that detox should be available on demand. 

The county and leaders of three of the region’s largest providers – McAlister Institute in Lemon Grove, Interfaith Community Services in Escondido, and San Diego Freedom Ranch in Campo – say they want to add significantly more beds. The challenge, the providers say, has been finding places to put them.  

Complicating matters the past few years, providers have grappled with Covid cases and staffing challenges that have limited their capacity to take in patients and a program that once supplied dozens of detox beds shut down. 

The inaccessibility is so dire that San Diego Rescue Mission Vice President Paul Armstrong said his homeless-serving nonprofit’s outreach workers have stopped suggesting detox to unhoused clients who might qualify. 

“You get used to ‘no,’ and once you’ve gotten ‘no’ enough times, you stop even asking,” said Armstrong, who said waits and other hurdles such as the need to coordinate intake screenings with clients who don’t have phones were common when outreach workers were offering.  

The result of waits and barriers, Armstrong said, is that many vulnerable homeless residents who express interest in detox change their minds or can’t be connected.  

Others in need, like 30-year-old Ryan, try to hold on. The La Mesa resident – whose real name Voice of San Diego is not using for privacy reasons —  desperately awaited a bed for three weeks. Ryan, who had been sober for years, recently relapsed with fentanyl after his fiancée left him and took their young son.  

Despite help from a case manager at the methadone clinic central to his previous recovery, Ryan couldn’t get a bed at a detox facility. In the meantime, he was left waiting – and continuing to use so he could function.  

A couple weeks ago, Ryan decided he couldn’t wait anymore. He said he went to a local hospital hoping to start detoxing there and secured a bed after reporting that he was suicidal. Two-and-a-half days into the hospital stay, Ryan said he was miserable. He kept trying to think of his son and the job he’s determined to keep. 

“I couldn’t see. My bones hurt so bad,” said Ryan, who has lingering pain from a past car accident. 

But Ryan said the hospital discharged him after staff declared that his mental health condition had improved. Ryan started using again when he returned to the home he once shared with his son. 

“I feel like I’m like failing,” Ryan said a day after he was discharged. “Am I gonna make it through this moment?” 

After waiting 21 days, Ryan secured a bed at McAlister Institute’s Lemon Grove detox facility on Wednesday. 

Because of the time he spent waiting for a bed and took off work expecting he’d quickly get one, Ryan is now worried about whether he’ll have a job and a way to pay his bills when he’s done with detox. 

Lemon Grove resident Heather Jolie Jones, 35, said she spent about three weeks last fall calling the McAlister Institute every morning to try to get into their detox program and get off fentanyl and methamphetamine.  

“Every time I wouldn’t hear back from somebody, it would kind of hurt a little bit,” said Jones, who is now staying at a recovery home. “I would lose a little bit more hope. This isn’t going to happen.” 

Finally, Jones, said, a McAlister staffer called asking if she could come in immediately. Caught off guard after weeks of calls, Jones had to ask for 72 hours to make arrangements with her employer first. 

Detox providers say they are constantly reminded of their inability to immediately meet the volume of need. 

McAlister Institute and Interfaith Community Services each report receiving dozens of desperate calls for help each day. They often have to say there isn’t a bed immediately available. 

“You get a lot of, ‘If I don’t get in now, I’m going to die,’” said Dannielle O’Brien, an intake specialist for McAlister’s adult detox program. 

At least once a week, O’Brien said someone hurries to her car as she arrives for work in the morning, begging for a bed.  

Two providers – Freedom Ranch in Campo and North County Serenity House in Escondido – recently collectively added just over a dozen county-contracted detox beds, both far from the city of San Diego.  

Freedom Ranch also expects in coming months to get the go-ahead to provide limited medical services to support patients in its nine new detox beds, something now unavailable in Medi-Cal programs throughout the county. 

That gap has meant detox clients need a medical clearance and often require hospital visits and prescriptions from doctors outside the program, dynamics that have challenged detox providers and kept some San Diegans from accessing detox. People with wounds common among drug users or health conditions such as incontinence are now often deemed ineligible.  

County spokesman Tim McClain said the county wants to expand capacity for all levels of detox, including residential programs that can provide increased medical services and outpatient programs for less vulnerable patients. In addition to the new detox beds, the county last fall inked a new contract to provide outpatient detox services in central San Diego. 

The county last year also took possession of a shuttered 120-bed Volunteers of America facility in National City that once supplied 66 county-contracted detox beds as part of a settlement. The county expects to eventually use the site to deliver yet-to-be-specified behavioral health services. 

And the county has pledged $12 million in county and city of San Diego redevelopment funds to McAlister Institute to expand treatment options in the city, a funding stream that McAlister said it hopes to use to provide dozens more detox beds and other co-located services. 

A large new facility has yet to materialize.  

Despite the push, McClain noted that detox beds aren’t necessary for all. He wrote in an email that many opioid and methamphetamine users can enter outpatient or other treatment services without first entering a detox program. The county is increasingly directing those in need to medication-assisted treatment, often dubbed MAT programs, which provide prescriptions to minimize withdrawals and cravings.  

Still, McClain acknowledged, some clients do need detox services – and it’s important they be “available in a timely manner.” 

Experts and advocates say residential detox programs are usually essential for alcoholics and people without adequate support systems or stable housing. Unhoused people can be particularly vulnerable as they experience symptoms such diarrhea, vomiting and exhaustion – and often remain surrounded by other users.  

People addicted to fentanyl also must begin withdrawing before starting buprenorphine, a common medication-assisted treatment option for opioids.  

“With the population of people who are not securely housed, it’s really hard to accomplish this without 24-hour care settings. Period,” said Dr. Keith Humphreys, a Stanford University psychiatry professor and former Obama administration drug policy adviser.  

In the absence of immediate detox options, many – both homeless and housed – give up altogether.  

Some, like Ryan, show up at local hospitals like Sharp Grossmont Hospital in hopes of getting help. 

Dr. Brian Miller, medical director at Sharp Grossmont Hospital, declined to comment on Ryan’s experience and discharge, but said that insurance companies – rather than hospital staff – decide whether it is medically necessary for patients to remain in the hospital while they detox and thus whether they will cover their treatment.  

He wrote in an email to Voice that the situation further highlights the need for access to detox programs, particularly for San Diegans addicted to drugs like fentanyl. 

“With opiates and stimulants, the withdrawal syndrome generally does not reach medical necessity requiring an inpatient stay,” Miller wrote. “This is a serious shortcoming given the high risk of relapse during the detoxification phase if someone is not in a highly structured setting.” 

That highly structured setting isn’t easily accessible for many people who need it. Experts say that needs to change. 

“You want to have low-threshold services that people can easily access and not a kind of roulette allocation of care,” Humphreys said. 

Dr. Steve Shoptaw, director of UCLA’s Center for Behavioral and Addiction Medicine, agreed. 

“I think at this point that everyone’s data points to the fact that it’s better to have treatment available when they’re ready for treatment,” Shoptaw said. “If you put that off for any reason, that person is less likely to show up for care when it’s their time.” 

In at least a few other communities, there are walk-in clinics where those seeking substance abuse treatment can be linked with help, similar to the sort of urgent care model that Humphreys said is not pursued enough in addiction medicine.  

Ryan recalled years ago going to a Nevada clinic known as the Las Vegas Community Triage Center to start the detox process and getting a bed within hours. He said triage center staff checked in with him as he waited. He has recently longed for that option in San Diego. 

Jones, who also recently waited for a detox bed, advocates a walk-in option too. 

“If you could do that, it would change the game,” Jones said. “I think a lot more people would get recovery and they’d feel better.” 

San Diego’s largest detox programs can’t accommodate many walk-ins, though McAlister Institute Executive Director Marisa Varond said her team makes every effort to aid patients who appear at their doorstep. 

Varond and Jerry Shirey, who leads Freedom Ranch, said a centralized hub where San Diegans could be assessed and linked with appropriate services – and perhaps remain for more than 24 hours or await transportation to other programs – could help keep patients from falling through the cracks.  

“We desperately need a wide and easy-to-access front door,” Varond said. 

In the absence of rapid options, many who express interest in detox never make it there.  

Michelle LeFever, a Father Joe’s Villages street health outreach worker who is in recovery herself, has experienced that harsh reality many times.  

She said she often spends days trying to help with intake processes and daily check-in calls, only to learn a client is no longer interested once there’s a bed. Many have already relapsed.  

LeFever prays she’ll get another chance to help. 

“For any addict to say, ‘I want to go into detox. I don’t want this life anymore’ – to me, that should be one of our biggest emergencies to make sure that we can make that possible, and it’s just not,” LeFever said.