On his first day in El Campamento, photographer Dominick Reuter did not take a single picture. He had entered what many consider the epicenter of the opioid epidemic in Philadelphia: a half-a-mile stretch along Gurney Street that splits Philadelphia’s poorest neighbourhood, Fairhill, from West Kensington. Kensington, often used to reference the general vicinity, has a reputation for widespread drug use, prostitution, and violence, but El Campamento came to be the hub of the opioid epidemic. Reuter captured this situation best with his images of used drug paraphernalia piled and strewn across the dirt. Taking more careful steps than pictures, Reuter told the HPR that “heroin drug deals were basically halted while [he] was there because they all thought [he] was there to snitch”. He compared the scene to an emergency room, “where the doctors just stop operating, and people [were] like…We’re sick, we’re hurting, leave. You’re disrupting this situation.’”
Because the Philadelphia area is notorious for having some of the cheapest, purest heroin in the United States, those with drug use disorders flock to the area. This, when coupled with the rise of fentanyl-laced heroin, racial inequality in the user/seller demographic, and the advertisement and overprescription of painkillers, has long made the city no stranger to overdose and overdose-associated deaths. The city cites 907 drug overdose-related deaths in 2016, and an estimated 1200 such deaths in 2017. Ultimately, the government must act to address the structural problems that continue to fuel the drug epidemic.
Immediate Problems
A starting point in the fight to solve this problem would be to address the immediate need to ensure safety and harm-reduction. Dan Martino, the director of the Olde Richmond Neighbourhood Association, told the HPR in an interview that most people who use drugs currently have no place to go where they can take opioids with minimal risk. In his view, the lack of such a place makes it as if someone is condemning them and their neighbours to “a lifetime of stepping over needles” and also “condemn[s] police, firefighters, and EMTs to a lifetime of chasing overdoses.” The city government could take the first step towards solving this problem if it creates a supervised injection facility, also called a comprehensive user engagement site. Building one of these facilities is actually number thirteen of the eighteen recommendations that were suggested by the Mayor’s Task Force to Combat the Opioid Epidemic in Philadelphia.
Although safe injection sites like these could prove key to this effort, obstacles to their creation remain. The current political climate in the United States makes the federal feasibility of such a site uncertain. Policy advisor in the Philadelphia Department of Public Health Dr. Jeffrey Hom noted in an interview with the HPR that the controversy and legal issues surrounding supervised injection facilities was making Philadelphia officials hesitate to back a proposal.
Despite these obstacles, it is becoming more likely that the city will construct one of these facilities. Martino observed that “the conversation has shifted on the ground among people who were originally strongly opposed to [supervised injection facilities]”. Hom’s comments supported Martino’s claims, as he said that “the city is exploring [the possibility of building safe injection sites],” and that local officials recognize the potential benefits of such sites. Some of these benefits would include serving as a source of financial benefit for the city, having a positive effect on the local environment, and encouraging the safe practices of users. Safe injection facilities could additionally function as avenues for users to seek treatment for related health issues.
Deeper Issues
In addition to safe injection sites, other actions must be taken to address long-standing institutional and societal voids. One area that needs to be addressed is education of doctors on their prescription methods. Some have proposed promoting safe prescription through education on safe prescribing methodology. This approach resembles an often successful pharmaceutical sales method where individual drug companies visit prescribers. ack of education on this topic, however, is not the only gap that has contributed to this epidemic.
Looking at education from a more general standpoint, significant quality gaps that contribute to the opioid epidemic exist within even a ten-mile radius of Kensington. Many of these gaps stem from the early racial and economic disparities that have set Kensington’s heavily Puerto Rican population at a systematic disadvantage since the 1960s and 70s. Dr. Philippe Bourgois, a Professor of Anthropology and director of the Center for Social Medicine and Humanities in the Department of Psychiatry at the University of California at Los Angeles, discussed the situation in an interview with the HPR. He noted that while the Puerto Rican community represents around one-third of Kensington’s population, his team’s extensive ethnographic studies in the area observed “Puerto Ricans [to be] the majority of the opioid sellers in the area.” This comes as no surprise given the strong socioeconomic roots of this drug economy, and the severe disadvantages many Puerto Rican residents face. A systemic lack of recovery infrastructure has compounded these socioeconomic disparities.
To fill the vacuum, Bourgois detailed how the neighbourhood created its own recovery house system to accommodate for what he sees as a “linear relationship between de-industrialization and unemployment and the opioid addiction.” Due to the inaccessibility of existing pathways to recovery, operators in Kensington’s row houses and abandoned buildings aim, in some cases, to encourage recovery in a group setting.
Lecturer and fellow in Urban Studies at the University of Pennsylvania Dr. Robert Fairbanks noted in an interview with the HPR that “you can walk on a block in Kensington that’s 40 to50 percent vacant housing”. Since they act as an “unregulated, unlicensed, shadow welfare economy”, Fairbanks described these row houses as having the potential to “scale from micro-level, to street-level…to middle level organizations”. This gives them the power to connect and influence systems like “hospitals, social workers, prevention parole-all the way up to politicians, welfare policies, and federal policies,” ultimately affecting the “articulating, reshaping, and remaking… of poverty management” in a way that organized efforts have, on some level, failed to do. So long as proper recovery infrastructure fails to exist, unlicensed and unregulated recovery houses will continue to be a go-to avenue for recovery.
Enabling Recovery
Unfortunately, state of Pennsylvania recently revoked benefits from the 1982 Welfare Reform Act, a move likely to exacerbate the lack of proper recovery infrastructure. As a result, people with substance use disorders who previously qualified for $205 a month in cash assistance will no longer receive this money. Without these benefits, they will no longer be able to pay rent in recovery houses. Fairbanks suspects this may lead recovery house operators to partake in the “desperate economy of squeezing the addicts for more money that they’re generating from work, or finding ways to squeeze it out of food stamps,” the latter of which was not cut.
Despite this, Fairbanks says that “by and large…the majority of [recovery house] operators in [his] fieldwork were well intended…committed to recovery.” Unlike treatment centers, recovery houses provide an “environment [in which you wake up with] your peers…everyday,” and in which an individual and their peers are “collectively making food, keeping the house clean, governing one another through…self-help and mutual assistance.” Fairbanks suggested a scenario in which recovery house leaders mobilize under a single charismatic leader in order to more effectively advocate for the needs of people with substance abuse disorders. The probability of this course of events unfolding is low, given the “ruinous competition” which Fairbanks says to exists among houses.
Many critics of recovery houses argue that they lack legitimacy in their efforts to encourage positive living habits. In fact, there seems to be an underlying belief among many that the quality of the treatment is often poor. Director of the Health Equity Research Lab and assistant professor of psychiatry at Harvard Medical School Dr. Benjamin Cook told the HPR that stories about the successes and failures of treatment in places like Kensington spread quickly. Some individuals who have undergone treatment share stories of relapse, running out of money for medication, or lacking the time for medication assisted treatment using methadone or suboxone, and this deter others from making the recovery effort.
Dr. Bourgois also noted that treatment can be difficult because “most people fail it and they fail it seven out of ten times before they finally recover”. That, he said, is not the treatment’s fault. “It’s that fact that addiction is a difficult thing to deal with, and we don’t have any magic bullets for it…” Given this reality, it may be necessary to have more medication-assisted treatment spots, so that more beds are available for treatment.
It must also be acknowledged that readiness for treatment differs for people with different life circumstances. Factors such as lack of insurance coverage, monetary costs, and social stigma have long kept drug users from making what seems an obvious choice to many. Addressing the differences from a public health standpoint, Dr. Hom stated that one of the department’s primary concerns is how to “get individuals who are ready for treatment and who are interested in it into evidence-based forms of treatment such as methadone and suboxone”.
Interestingly enough, many people who receive treatment do so as mandates, which are provisions deemed required by judges often seeking reform over recidivism within the criminal justice system. This phenomenon explains why poor people and unemployed people, who Cook says “are interacting with the criminal justice system”, get treatment more often than wealthy people and employed people respectively. The Mayor’s Task Force addresses this point under the strategy of “Involvement of the Criminal Justice System”, which is one of four large strategies presented in a recommendation to the Mayor’s office.
A Better Tomorrow
At the end of the day, policy and economics aside, the world must remember that this issue is human. By paying special attention to the many infrastructural voids which have long allowed this epidemic to take hold, feasible solutions can be implemented.. While improved recovery houses and treatment options remain on the docket, it is imperative to prevent overdose deaths through the distribution and use of Narcan, the overdose prevention drug Naloxone. Hom also mentioned that part of the city’s goal was “making sure we have as much Narcan/naloxone out there as we can.”
Locals have come to expect the daily overdoses, and Narcan has become an emergency saving grace for those on the brink of death. Many inhabitants ranging from the “doctor” to the local police to private civilians have Narcan on hand, in anticipation of the worst. Given that Narcan helps to address the immediate problem of overdoses, the government should focus on increasing access to the drug while simultaneously prioritizing prevention and harm-reduction.
Harm-reduction efforts are also in tandem with the city’s attempts to limit the spread of disease through Pennsylvania House Bill 196’s expansion of needle exchange.
Martino and his community deal with this epidemic everyday. But they have had enough. “The people in the neighbourhood are sick of stepping over needles, and they are tired of having to worry about their kids seeing people injecting in public…Nobody wants to wake up to the news that somebody’s toddler picked up a needle and put it in their mouth….nobody wants that…” he says. This jarring image is what Reuter would consider the “ground truth”, and he deems it his job to remind experts of this truth. This reality should not be avoided, but rather addressed head on.
Image Credit: Pixabay/Overhook