“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 city of brotherly love, pockets of desperation are marked by tents. For years, Philadelphia authorities have struggled to contain the heroin camps–scenes of dystopian blight with addicts injecting in plain sight, through legislative proposals and on the ground mitigation efforts. Inhabitants are homeless and opioid-dependent Philadelphians who move with the uneven gait of zombies along underpasses littered with discarded needles. In 2018, the city conducted a major intervention, deploying social workers and police officers to coerce inhabitants to inpatient rehabilitation programs and/or alternate housing arrangements. Depending on your role and general philosophy, the sweep was either a rescue operation or a mass eviction. Authorities undoubtably felt good about exercising a moral course of action by forgoing arrests for treatment but residents raged against the mandated displacement. Five years later, I wonder about the interventions’ short and long(ish)-term success: how many addicts agreed to treatment or were placed in alternate housing in 2018 and where do they stand now?
It’s been years since I’ve thought about the outdoor communities and what progress, or lack thereof, has been made in Philadelphia’s epic battle against opioids. My brief stint as a Philly resident ended last summer and now back in New York, my attention is focused on this city’s efforts to treat addiction, suicide and serious mental illness under new policies under Mayor Eric Adams. But on a gloomy June afternoon last month, I found myself face to face with the atrocity of untreated substance abuse disorder. Waiting for a train on one of Philadelphia’s outdoor elevated platforms, I observed young men cloaked in tragedy one with a riotous open sore on his knee, another asking for the overdose reversal drug Narcane. Below us addicts strolled or sat in the sort of outdoor lawn chairs I associate with suburban sidelines but here occupy the scorched earth of urban desolation. I imagine that at least some of the individuals below are former camp residents for whom interventions failed. If the effort resulted in nothing more than a reconfiguration into smaller satellite communities, no one could claim the intervention was a success.
Like the post-wildfire orange light that descended on New York City several weeks ago, I felt the weight of the opioid epidemic’s magnitude settle all around me. All those trumpeted calls to action that animated the 2018 sweep seem to have grown fainter in recent years, softened by the insistence of forgone conclusions. A hideous space exists between what I saw that day and the city’s goal of facilitating recovery and symptom management. And though the city’s objective was certainly ambitious, it was not wildly unrealistic. Research supports a number of methods for achieving effective prevention and management of both serious mental illness (SMI) and substance use disorder (SUD). The best-practice frameworks vary but good outcomes share certain conditions, namely: 1) an evidence-based care spectrum, 2) voluntary patient participation and, 3) the existence of permanent supportive housing and community-based resources.
Because we so often find ourselves 0 for 3 in the calculation, many of us feel the bone-deep exhaustion I experienced that afternoon. It’s a fatigue that, boiled down to its essence, stems from one legal and idealogical question: how do we get people in desperate need of help and support services interested in receiving them long-term? But before we speak of fixing anything, we should recognize that this crisis won’t even be meaningfully minimized by the status quo’s quick hospitalizations and single rounds of rehab. What we as foot soldiers are trying to achieve involves vulnerable individuals opting in for a lifetime of treatment: therapy, check-ins, medication when necessary and whatever else works. Audacious, without question.
The Road to Annihilation
The good news is that the mental health profession knows how to successfully treat SMI and SUD with an expanded continuum of care including behavioral therapy, medication and support services. The bad news is that this kind of wrap-around, long-term care isn’t reaching people. And just as critically, we are not focusing enough energy upstream, working to understand the disorders’ root causes (loneliness, economic desperation, cruelty, genetics) or performing the universal early interventions scientists tells us are so effective in preventing disease.
On the road to chronic substance use disorder and psychotic illness, there are moments in which detection and attachment to services straightforwardly prevents tragedy. Through the practice of ‘task shifting’–empowering non-clinicians like teachers, administrators and coaches to detect warning signs and make referrals–large scale early intervention is feasible. Of course doctors also play an essential role: in recent years the addition of mental health and addiction screenings to general healthcare settings like GPs’ offices has routed more people to treatment services and greatly aided prevention efforts. The indicators for increased risk of SMI and SUD often emerge in adolescence, sometimes even earlier, and If caught generally respond to basic interventions. Cases of mild alcohol misuse are well addressed by physician-issued advice, overwhelmingly halting adolescents’ progression from misuse to abuse. And in instances where wrap-around care is needed, science shows SUD and SMI can be effectively managed, with recurrence rates no higher than other chronic illnesses like diabetes.
Beyond the drugs currently used most commonly for detoxification purposes, there are three FDA approved medications for alcohol use disorder and three for opioid disorders on the market. We have not seen the full impact of these medications because of a shortage in the number of treatment programs and doctors that offer them but their existence is promising. And behavioral interventions like cognitive behavioral therapy (CBT), contingency management, twelve step programs, family therapy and motivational enhancement therapy are all successful in ongoing recovery. Supportive services like peer coaching and public community centers are also shown effective. If we found ourselves in an ideal scenario in which these resources get to the people that need them tomorrow, experts would still have a final stubborn challenge to confront: how do we get patients on board?
Getting to Yes
Establishing successful treatment frameworks is only half the battle. Arguably the more complex obstacle to treating illnesses like SUD and SMI is the 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 exists. Broad disagreement regarding involuntarily hospitalizations and assertive outpatient treatment (AOT) is so highly charged and linked with personal experience, discussions between the sides is has been less than productive.
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 individuals’ freedom and autonomy. Critics insist that any and all psychiatric treatment must be voluntary irrespective of crisis severity. On the other end of the ideological spectrum are those who feel, at least in theory, that a homeless and seriously mentally ill person at-risk of freezing should be taken to a hospital, willing or not. In both cases, the question of whether long-term symptom management is achievable without the desire of a patient to stay healthy must be considered. There’s no obvious answer serious disorders like schizophrenia or chronic substance abuse must be managed over a lifetime. For the schizophrenic who forgoes medication, symptoms like auditory hallucinations immediately resurface. And treatment drugs come with serious side effects that limit functioning- sometimes harming internal organs, causing substantial weight gain, tremors and feelings of profound fatigue. Sometimes bipolar disorder or substance abuse diagnosed individuals decide episodes of mania or intoxicant induced pleasure are worth any subsequent periods of despair.
Research suggests harm reduction methods and education are the best methods of reaching this population but again, controversy exists. Should tax payer dollars fund the construction of places where addicts can safely shoot up? Some say absolutely not and others say yes to the idea but express violent opposition when it comes to having one in their own backyard. And how do you feel as a mother when your child’s psychiatrist asks him or her to reduce their use of stimulants instead of encouraging abstinence in initial treatment? This is an area where we need to do some soul searching. How far are we willing to go to help people get better and at what cost to ourselves?
The Post-Treatment Vacuum
In today’s treatment landscape of short emergency hospitalizations and 60 day rehab cycles, we face another hurdle. Even if all the addicts the city intervened upon had WANTED to go to rehab and successfully completed programs, the time comes when reintegration is necessary. After inpatient treatment (rehab, hospitalization), continued recovery depends on practical considerations like appropriate housing and outpatient care, both of which are in profoundly short supply. Extreme shortages in clinicians and community-based resources place people returning home in a literal vacuum. In a matter of weeks or months, they’re right back where we started. Here is where legislative action and financial investments become a necessity. The housing shortage is obscene across the country; patients discharged from hospitals overwhelmingly have nowhere to go without family able and willing to provide shelter. And even with family, well-resourced or not, a parent or sibling is simply not equipped to provide intensive round the clock care. Constant supervision, medication oversight and getting to appointments is a full time job for a trained professional. There is no work around: If we don’t make investments in these areas, tent cities and all the devastation they house will continue to thrive.
No one would blame you. But if we take on the challenges as a community and do the work in phases, think of all the tragedy we could prevent. It’s not too late and it’s not too complex-our failure would squarely rest on a decision not to act.