Over 900 people died of drug overdose in Philadelphia last year. Solving the epidemic will take time—and a focus on the surrounding community.
by Sharon Christner and Jack Hostager
“Oh, he’s dying. He’s dying.”
He was sprawled out across the middle of the train tracks, his head bent back at a sharp angle. He was still breathing, but only in shallow, intermittent gasps. Charito Morales, a community advocate and our tour guide in El Campamento heroin gulch in northeast Philadelphia, looked at him with concern and dialed 911.
Two policemen were already patrolling the gulch about a quarter-mile away. “He OD?” they asked. We nodded. One officer retrieved a dose of Narcan, a drug that counteracts a heroin overdose, from the back of the squad car and sprayed it into the man’s nostril. After about 30 seconds, he suddenly sat up and let out a loud moan, then a piercing cry. He would have died, the officers told us, just a couple minutes later. His name was Jésus.
We encountered Jésus at about 9:15 a.m. on Tuesday, August 1. It was the second day of the Gurney Street Clean-Up, a massive effort to take back the half-mile stretch of railroad that has become El Campamento and connect the addicts living there to treatment. After he came to, we invited Jésus to come up to the street with us, where the city had tents with free food, water, HIV testing, and social workers ready to help.
For over 20 years, upwards of 100 addicts made their home along these tracks at any given time, sleeping and shooting up among piles of garbage, human waste, and an estimated 500,000 used syringes. Under the bridge, we passed pink mattresses where prostitutes work and a wall of blackened concrete, where nine people were burned to death in a gang war in May. But today, an army of social workers and community advocates is making this the frontline in America’s fight against opioids.
The opioid crisis has its roots in the 1990s when, according to the National Institute on Drug Abuse, the number of opioid-based painkillers prescribed by American doctors exploded from 76 million in 1991 to 207 million 2013. Opioids, even in prescription form, are highly addictive. Some people become addicted to their own medication, but most addicts get hooked from medication prescribed to someone else. A curious teen might open her parents’ medicine cabinet, or a construction worker with a back injury might accept a half-empty bottle of Percocets from a sympathetic friend.
Abusers of prescription opioids quickly become desensitized to the painkillers, needing more pills to get the same high. But street pills are expensive, so they turn to heroin, a cheaper and more powerful alternative.
The making of a crisis
Philadelphia is known for having some of the purest and cheapest heroin in America, so users flock here in search of the best high. The average purity in heroin samples from Philadelphia was 65% in 2014 — the highest of any city in the country. Starting in 2014, dealers started enhancing heroin with synthetic opioids like fentanyl and carfentanil (used commercially to tranquilize elephants). Synthetics are especially dangerous, because even the smallest quantities can be lethal. “These guys that are mixing these drugs, they’re not scientists,” says Chris Marshall, a former addict who ran a recovery support center called Last Stop Sobriety for four years. “They’re mixing this s— up in their basements… with playing cards, and if you get one or two extra grains in your bag you’re done for.” Last year, fentanyl was involved in half of Philadelphia’s overdose deaths.
The trade is centered in the neighborhood of Kensington, in northeast Philly just off the Market-Frankford line. For years, city officials let Kensington’s heroin problem fester. At first it was mostly users from Philadelphia and the surrounding suburbs that came to Kensington to obtain opioids. Many of the addicts had been congregating in El Campamento for decades, neighbors told us, but it became a hotspot for users about three years ago. Then addicts started staying in more public spaces in Kensington, especially parks like Harrowgate Park and the grassy area around the McPherson Square Library.
Then in late 2016, the problem exploded. The city saw 50 overdoses and five drug-related deaths in a single day on November 17, then another 35 overdose deaths in a five-day period in early December. By the new year, 907 people had died of a drug overdose in Philadelphia, and 80 percent of those deaths involved opioids. Philadelphia Mayor Jim Kenney acknowledged the problem had cascaded into a full-blown epidemic and announced a taskforce to tackle it.
But through the spring of 2017, things only got worse. The crisis began attracting media attention, which brought more resources to the area but also attracted more addicts. Neighbors noticed “drug tourists” traveling from as far away as Nebraska and Wyoming to obtain Philadelphia heroin. Some of them, unable to get back home, became trapped and homeless in Kensington.
The situation reached a tipping point in June, when librarians at McPherson Square administered Narcan five times in one week. National media descended on the library, and videos of people shooting up amidst children in the park made their way to news outlets across the country. Al Jazeera, HBO, and even Dr. Oz came to film segments on the neighborhood. The city quickly responded: the police department stationed a mobile command center next to the library, and the parks department began daily patrols to pick up used syringes in the grass and keep drug users away from the playground. Now the Square is mostly drug-free. “We still have some trash laying around, but at least we don’t have people laying around,” says Judy Moore, a librarian at the McPherson Square Branch of the Free Library of Philadelphia.
It was not enough to end the epidemic. Addicts soon began to congregate at Ascension of Our Lord, a decommissioned Catholic church blocks away. The Philadelphia Inquirer published a front-page exposé about the drug “sanctuary” and the city swept in to clean up the property.
You can see the pattern emerging: “They’re going from one place to another to another, and no one is really being helped,” says Father Liam Murphy, who runs a mission in Kensington. He stressed that unless addicts are provided treatment and services, “we haven’t solved any problems.”
Moving the needle
At the Gurney Street clean-up where we met Jésus, everyone seems to share Father Murphy’s concern. But city officials are hoping that by closing off El Campamento and pushing the problem out into the open, they can reach more addicts and connect them to treatment. That’s why they kicked off the cleanup effort with a three-day “resource push” to reach as many addicts as possible before the area was cleared by heavy equipment operators. Though Jésus himself disappeared onto the street soon after the Narcan kicked in, the resource push succeeded in connecting 43 addicts to treatment programs.
This effort is part of a larger strategy laid out by the Mayor’s Opioid Task Force, which aims to address the drug problem as a “public health crisis” by prioritizing overdose prevention and treatment. The city is working to open more slots in treatment programs, and to support addicts who are not ready to quit with housing, medical resources, and Narcan.
The police are also playing a constructive role. While Philadelphia police are halting drug sales, they are also carrying Narcan to combat overdose deaths. As of July 10, officers have administered the life-saving drug almost 400 times; an officer carrying Narcan is the reason Jésus is alive today. “We’re working with our partners in the city to help the outreach to homeless and drug addicts,” explains Inspector Ray Convery, who oversees the 700 officers patrolling Kensington and the surrounding neighborhoods. “We’re also in the area, finding the users after they use and they get high, to try to get them to some kind of help.”
Despite everyone’s best intentions, helping addicts is complex. “It’s not as easy as, ‘Okay, let’s find a vaccine to fix it,’” said Dr. Priya Mammen, an ER physician at Jefferson Hospital and a member of the task force. “It’s human behavior, it’s physiology, it’s our social determinants of health, and all of the intricacies of the health system and penal system and all of the rest.”
There is strong social stigma around addiction, which sometimes makes it harder for users to admit they have a problem. Even when they do, opioids are so addictive that many addicts are unready to get help. “It’s a personal choice to a point, until it grabs you in,” says Marshall. “Why even take this service because somebody else who really wants it could have it? That’s what goes through an addict’s mind.” Once users do decide to get help, they usually relapse several times before they are finally clean, each time hitting rock bottom all over again.
There are also barriers to treatment itself. Medicaid covers treatment for most poor addicts, but providers are only reimbursed if the patient has a valid form of identification. Many users lost their ID long ago, or never obtained one in the first place. And without other points of identification, $30, and a ride to the DMV, an ID is impossible to get. Many addicts also have outstanding warrants, and getting treated might also mean paying fines or even going to jail. Further, there are simply not enough detox beds and long-term treatment programs to serve the estimated 70,000 addicts in the city.
The drug epidemic is intricately tied to other challenges facing the community. Kensington is a food desert: we struggled to find fresh fruits and vegetables for sale anywhere in the neighborhood. Economic hardship also facilitates criminal markets: “A lot of the dealers start dealing because they don’t have an alternative job,” Moore says.
Race is another complicating factor. Drug users come from all backgrounds, but many whites drive in from the suburbs —or further— to get high. And those drug users sometimes exhibit what neighbors describe as a sense of entitlement. “The elephant in the room is that these are all white people coming in and this is a Hispanic and Black neighborhood,” reflects Moore.
Finally, the solutions to the many facets of this epidemic sometimes contradict one another. When we visited Kensington for the first time, we brought sandwiches to give away, innocently thinking such a gesture would be appreciated. However, we learned that some residents resent efforts to support addicts. “Every dollar you don’t have to spend on food or clothing is another dollar you can use to buy your next bag,” Marshall says. And handing out food in public spaces where addicts gather, like McPherson Square, only attracts them to areas that should be safe places for kids. “Everyone is focused on the users and not on the children,” says Moore. “That’s always my bottom line; I’m on the kids’ side.”
That’s the irony of this crisis: it pits compassion for addicts against that for children, and the immediate needs of drug users against their path to getting clean.
Community, not just sobriety
Though the opioid epidemic is expected to get worse before it gets better, it is being taken seriously at all levels of government. But the complexity of the situation lends no easy answers. The solution must be all- encompassing and as stubborn as opioids themselves.
In the short term, treatment must be made more readily available. This includes additional space in detox units and outpatient treatment programs, as well as expanding the availability of Narcan. Pennsylvania Physician General Dr. Rachel Levine issued a standing order for Narcan last year,
meaning anyone can pick it up from any pharmacy in Pennsylvania. Everyone should know what it is and how to use it. “It’s the new CPR,” Moore quips.
In the medium term, Philadelphia should explore safe injection sites where users can inject heroin under medical supervision. Studies show such sites mitigate overdose deaths by as much as 35% and bring users off the street and closer to the resources that they need, making them 30% more likely to enter a treatment program. “[Safe injection sites] prevent more problems than they cause,” says Dr. Henry Kranzler, Director of the Penn Center for Studies of Addiction. Such sites are rife with political and legal obstacles, but they have the potential to reach users who are not yet ready to enter treatment. Whether or not safe injection sites become reality, “it’s about meeting people where they’re at,” says Elvis Rosado, education coordinator at Prevention Point Health Clinic.
We must also minimize the number of people who become addicted to opioids in the first place by limiting the number of opioid-based painkillers that doctors prescribe. Pennsylvania has already instituted a database to track how many opioid prescriptions a person has gotten, and doctors nationwide are limiting prescriptions for opioids.
In the long term, we must find ways to empower Kensington as a whole. Most of the national media attention — and even the mayor’s Task Force report — has focused almost exclusively on the drug problem. While this is clearly important, it ignores other issues in the community. “To only focus on violence and the narcotics trade is unfair, and is actually a mistake,” explains Casey O’Donnell, President of Impact Services Corp., one of Kensington’s three community development groups. “While you can’t ignore how devastating the opioid epidemic has been in a community, to only tell that half of the story is unfair and sensationalistic.”
The other half of the story includes thousands of drug-free families who call Kensington their home. “Kids are growing up here, people are living their lives here, and making a good life here as far as they can,” says Moore. “They’re trying really hard.”
There are ongoing efforts to reclaim public spaces for beautification and for children to play. The Kensington Community Food Co-Op is attempting to bring fresh, healthy food to the neighborhood, and we heard talk of starting a community garden in one of the neighborhood’s parks.
Impact is working with stakeholders throughout Kensington on a comprehensive, “trauma-informed” neighborhood development plan. Though in its early stages, the plan will focus on affordable housing, educational opportunity, and creating good jobs.
“Part of the goal is to network strong blocks… where there is great leadership and hope on the block,” explains O’Donnell. He also predicts that the “maker community” – small, creative businesses that need cheap space – will move into the area, and that there will be investment to create “a more stable parks system.”
In writing this article, we visited Kensington regularly over the course of a month. Yes, we watched people shoot heroin in front of us in a SEPTA station; we were swarmed by dealers effectively running an open drug market in Hope Park; we observed women prostituting themselves to sustain their addiction. But we also watched children romp happily on the playground in McPherson Square; we observed outreach events, neighborhood cleanups, and block parties; and we were struck by the resilient community leaders determined to move Kensington forward. As Kevin, a longtime resident, says, “You got a whole lot that’s happening in the neighborhood – good and bad. The door swings both ways.”