“They want to send everyone to rehab but rehab is only good for people who want to go”.
Jay, Tent City Resident, Philadelphia-June, 2018
The Great Relocation
In the heart of Philadelphia, amidst the ethos of brotherly love, pockets of despair manifest in tent communities. These areas, plagued by the active desperation of opioid addiction, are a product of multiple social failures. In 2018, the city initiated a controversial large-scale intervention, mobilizing social workers and law enforcement to guide residents toward inpatient rehabilitation or alternative housing. Was this a rescue mission or a mass eviction? While authorities arguably took the moral high ground by making referrals instead of arrests, residents resisted what they considered enforced displacement. Five years later, I wonder about the short and long-term outcomes of the mobilization. How many individuals agreed to treatment or found alternate housing at the time and where do they stand now? If the data exists, it’s not easy to find.
My thoughts on Philadelphia’s ongoing battle against opioids faded after my brief residency there concluded, but waiting for a train on a Philadelphia elevated platform recently, the issue resurfaced vividly. My fellow platform occupants-one with a festering wound on his knee, another in search of the overdose reversal drug Naloxone-announced the epidemic’s still-savage urgency. Below us, individuals clearly struggling with addiction roamed, their makeshift outdoor seating planted on the scorched earth of an abandoned cause. It’s highly likely that at least some of that crowd were former camp residents for whom the intervention failed. Their presence begs the question, has Philadelphia merely refashioned the primary tent city into smaller, less visible satellite communities? If so, what can we learn from the failure?
The Resilient Epidemic
Like the lingering orange hue after a wildfire, the opioid epidemic’s presence persists. Despite initial fervent calls to action in 2018, recent years have seen a gradual attenuation of efforts, overshadowed by resignation to seemingly inevitable outcomes. This complacency contributes to the widening chasm between the city’s once ambitious goals and the somber reality. The tragedy lies in the fact that while the plan was ambitious, it wasn’t unattainable. Serious mental illness (SMI) and substance use disorder (SUD) are highly treatable conditions, with numerous evidence-based interventions. Yet, the failure to provide comprehensive, long-term care to those in need hampers progress. And that’s not simply a system failure: coercion only goes so far as a means to getting people healthy. Transformative change requires willful participation in recovery-care that unfolds over a lifetime-along with housing options and accessible treatment.
The Road to Annihilation
While effective treatments exist for SMI and SUD, there is a glaring gap in their accessibility. Moreover, insufficient attention is paid to addressing the root causes of these disorders, such as loneliness, economic disparity, and genetic predispositions. Early intervention strategies, including task shifting and integrating mental health screenings into primary care settings, hold promise in identifying and addressing these issues before they escalate.
On the road to chronic substance use disorder and psychotic illness, there are moments in which detection and attachment to services prevent manifestation. The increasingly popular practice of ‘task shifting’–empowering non-clinicians like teachers, administrators and coaches to detect warning signs and make referrals–support early detection and treatment. Doctors also play an essential role: in recent years the addition of mental health and addiction screenings to general healthcare settings is getting more people connected to supportive services. The indicators for increased risk of SMI and SUD often emerge in adolescence, sometimes even earlier, and generally respond to basic interventions. Cases of mild alcohol misuse are well addressed by physician-issued advice, for example.
When SUD isn’t successfully prevented, there are three FDA approved medications for alcohol use disorder and three for opioid disorders, but we haven’t seen the impact of their use because of a shortage in the number of treatment programs and doctors that offer them. Fortunately, behavioral interventions like cognitive behavioral therapy (CBT), contingency management, twelve step programs, family therapy and motivational enhancement therapy have all been shown successful in high quality research.
Getting to Yes
Establishing successful treatment frameworks is only half the battle, however. The more complex obstacle to treating illnesses like SUD and SMI is widespread treatment avoidance and non-compliance. Like Jay, many active addicts decline offers of rehab and SMI individuals often suffer from anosognosia, the condition of being too ill to recognize one’s illness. Controversy rages over the acceptability and extent to which authorities should have the right to intervene before life or death crisis presents. The disagreement regarding the ethics of involuntarily hospitalizations and assertive outpatient treatment (AOT) is so highly charged, productive dialogue between the factions rarely occurs.
The practice of AOT faces opposition from patient advocacy groups and civil rights proponents who argue that the hands-off approach is the only way to protect individual freedom and autonomy. These advocates insist that any and all psychiatric treatment must be voluntary, even in life or death stakes. On the other end of the spectrum are those who feel that some scenarios, say a homeless and seriously mentally ill person found on an outdoor subway platform in danger of freezing to death, warrant involuntary hospitalization. For both camps, the question of whether long-term symptom management is achievable without patient buy-in should be central. Serious disorders like schizophrenia or chronic substance abuse aren’t managed over months or years like other medical conditions. When someone diagnosed with schizophrenia discontinues medication, a not uncommon occurrence, symptoms like auditory hallucinations immediately resurface. Patients struggle with the side effects of anti-psychotic drugs: substantial weight gain, tremors and feelings of profound fatigue take their toll. And sometimes bipolar disorder or substance use disorder diagnosed individuals accept the high price of episodes of mania or intoxicant induced pleasure determinbly.
Research suggests harm reduction methods and education are the best methods of reaching SMI and SUD population but again, controversy exists. Critics disapprove of tax dollars going to safe injection sites for addicts. And no one wants one in their neighborhood. Here we need to do some soul searching. How far are we willing to go to help people get better?
The Post-Treatment Vacuum
In today’s treatment landscape of short emergency hospitalizations and 60 day rehab cycles, we face another hurdle: if all Philadelphia’s addicts willingly entered and successfully completed rehab, the focus turns to reintegration. After inpatient treatment, continued recovery depends on the availability of long-term supportive housing and quality outpatient care. Both are in profoundly short supply.-people emerge from inpatient stays and face a service and housing vacuum. In a matter of weeks or months, sometimes even days, recently stabilized individuals revert to pre-treatment states. And this is where legislative action and financial investment become necessity. Long-term supportive housing developments must start going up across the country and in addition to the buildings, we need a workforce of trained professionals to provide supervision and support. Without such investment, tent cities and their attendant devastation will not go away.
Exhausted Yet?
No one would blame you. But if the challenges of SUD and SMI are addressed by entire communities instead of small groups and individuals, progress is attainable. It’s not too late or too complex: further failure rests on the decision not to act.
