“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 exist in tents. These tent communities, often referred to as heroin hubs, are characterized by the active desperation of opioid addiction, and the city’s ongoing inadequate response. Back in 2018, city government and law enforcement joined forces to perform a controversial large-scale intervention on Philly’s principle hub, ushering residents toward inpatient rehabilitation or alternative housing. Was it a rescue mission or a mass eviction? The answer depends on who you ask.
Arguably the authorities took the moral high ground by making referrals instead of arrests, but residents resisted what they considered an enforced displacement. Now, five years later, I wonder about the short-and long-term outcomes of that 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 interest in Philadelphia’s ongoing battle against opioids faded after my brief residency there ended, but waiting for a train on one of the city’s elevated platforms recently, I became curious. My fellow platform occupants-one with a festering pink wound on his knee, another in search of the overdose reversal drug Naloxone-demonstrated the epidemic’s still-savage urgency. Below us, individuals roamed amidst their makeshift outdoor seating, planted on the scorched earth of an abandoned cause. Odds are at least some of this crowd were former camp residents for whom the intervention failed. Their presence begs the question: has Philadelphia merely refashioned its primary tent city into smaller, less visible satellite ones? And if so, what can we learn from that failure?
The Resilient Epidemic
Like the lingering orange hue after a wildfire, the opioid epidemic’s presence persists. Data published by the city’s Department of Health shows overdose fatalities in Philadelphia steadily increasing since 2018, reaching a record high of 1,413 deaths in 2022. This represents a 16% and 11% increase in deaths from 2020 (1,214) and 2021 (1,276), respectively. At the same time, mitigation efforts feel more and more haunted by creeping resignation. If complacency becomes operationalized, the existing chasm between the city’s once ambitious goals and its current state of play will only widen. The thought is nothing less than tragic because, though the plan was ambitious, it wasn’t wildly idealistic. Serious mental illness (SMI) and substance use disorder (SUD) are highly treatable conditions, with numerous evidence-based interventions, but 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 when it comes to getting people into active recovery. Transformative change requires willful participation from the patient in care that unfolds over a lifetime-along with the requisite housing and social supports.
The Road to Annihilation
On the road to chronic substance use disorder and psychotic illness, there are moments when detection and attachment to services overwhelmingly prevent manifestation. Indicators of increased risk of SMI and SUD often emerge in adolescence, sometimes even earlier, and generally respond to basic interventions. The increasingly popular practice of ‘task shifting’–empowering non-clinicians like teachers, administrators and coaches to detect warning signs and make referrals–supports early detection and treatment. Doctors also play an essential role: in recent years the addition of mental health and addiction screenings to primary care settings has connected more people to services. Sometimes PCPs perform interventions themselves: cases like mild alcohol misuse are well addressed by physician-issued advice.
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 offering 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
Early intervention and evidence-based treatment is half the battle in reaching prolonged recovery. The more complex obstacle for communities battling illnesses like SUD and SMI is what’s called treatment non-compliance. Like Jay, many active addicts resist rehab and SMI individuals often suffer from anosognosia, or being too ill to know you’re ill. Controversy rages over the acceptability and extent to which authorities can intervene before life or death crisis presents in such cases. The disagreement regarding the ethics of involuntarily hospitalizations and assisted outpatient treatment (AOT) is so highly charged, productive dialogue between the factions rarely occurs.
The practice of AOT, also known as Kendra’s Law, mandates mental health services for a small number of individuals who have difficulty engaging in rehabilitation and can pose a risk to themselves or others in the community. It faces robust opposition from patient advocacy groups and civil rights proponents who argue that a 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 scenarios. On the opposing side 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 common occurrence in the real world, 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 choose the high price of episodes of mania or intoxicant induced pleasure over medication-supported stability.
Research suggests harm reduction methods and education are the best ways to reach the SMI and SUD populations, but 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?
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.
