Stephanie Hamilton-El has been working from the same parking lot near Shuman’s Homewood restaurant almost every Saturday since February.
She’s an outreach worker for Message Carriers, an East Liberty nonprofit focused on addiction recovery. And she’s had a front-row seat to a recent spike in opioid overdoses.
It was still cold outside when she started showing up at the parking lot eight months ago, so she put a sign in her car window that read: “Ask me about Narcan.”
If she saw someone who she thought could use Narcan, she’d jump out of the car and offer it to them, she said.
She had just arrived for work one day at the beginning of the summer when she heard a cry for help. A 66-year-old man was slumped down in front of an abandoned building nearby. Hamilton-El ran over, administered Narcan and called 911.
The man had only been home from prison for about two months, a time period when people suffering from addiction are especially vulnerable, like when they exit rehab and their body’s tolerance for taking drugs has dropped off. He refused to be transported to the hospital when he became alert, she said, so she handed him a box of Narcan.
He died the next week of an overdose, she later found out.
Old problem, new face
At the time, just two months ago, the official story about the opioid epidemic in Allegheny County was still promising. The last public updates showed the number of overdose deaths in 2018 had dropped by more than 40%. But as Hamilton-El was seeing firsthand, those numbers no longer reflected reality.
Last month, PublicSource reported that the number of overdose deaths has been rising in Allegheny County for more than a year. For this article, we talked to 11 people who are working on the front lines of this new surge in the epidemic and asked them what they think is causing it and what it’s been like trying to handle it during a pandemic.
While the rise in overdoses was already underway when COVID-19 hit the region, they say, the pandemic has exacerbated the problem, making it more likely for people suffering from addiction to use drugs, overdose and die. The providers say the pandemic has made it more challenging to reach these patients and more expensive to treat them when they can.
And the source of the overdoses may be changing. The number of people overdosing from cocaine and fentanyl has been increasing faster than any other category in Allegheny County. While some of that may be due to opioid users who are mixing multiple drugs, Otis Pitts, the deputy director of public policy and community relations at the health department, said he believes some non-opioid users are overdosing from cocaine laced with fentanyl.
Frontline workers say the epidemic is taking an emotional toll as they find themselves witnessing drug overdoses firsthand; watching friends and family members lose their battles; and treating increasingly unhealthy patients whose bodies have deteriorated after being revived and treated several times already.
Hamiltion-El’s experience highlights an additional element of the latest surge: Black men are now the most likely to suffer from the epidemic in Allegheny County. They were twice as likely as white men to end up in the hospital from an overdose and 44% more likely to die in 2019. And the county health department says these trends have continued into 2020.
The man who she administered Narcan to in Homewood two months ago was Black. She recently gave out Narcan to another Black man who, 30 minutes later, she was told, died from an overdose when no one was with him to administer it.
The opioid epidemic has sometimes been portrayed as an issue that impacts white people more severely. But the rate of Black residents overdosing has been increasing faster than whites in a number of large cities across the country since 2014. Black overdoses had already surpassed the rate of white overdoses in Chicago, Phoenix, Newark and Washington, D.C., by 2017.
In Allegheny County, the rate of overdose deaths had, year after year, been almost exactly the same for Black and white residents.That changed in 2018 when the number of overdoses fell three times as quickly among white residents as among Black residents.
The Pennsylvania Commission on Crime and Delinquency decreased the amount of naloxone it gave out after the number of overdose deaths went down in 2018, according to Pitts at the Allegheny County Health Department. But after the number of deaths increased again in 2019, the availability of naloxone was increased again this year.
Addiction specialists at Allegheny Health Network [AHN] said they were being told they had to start coming up with their own funding sources. Some of the people who pick up Narcan from Hamilton-El told her they could no longer find the drug-reversal agent placed in tree branches, she said — a practice used by another nonprofit to get naloxone into users’ hands.
Hamilton-El was talking to the owner of a bodega in the Hill District recently who told her he was out of Narcan. She proposed to her boss and the county, who supplies them with Narcan, that they begin handing it out in the Hill District. So for the last two months, after she’s given out all 18 Narcan in Homewood, Hamilton-El goes over to an abandoned church on Perry Street and hands out another 18.
On a recent Saturday, Hamilton-El bought 58 pieces of fried chicken, wrapped them in plastic and dropped them in a bag, along with Little Debbie cakes, potato chips, a water bottle, recovery pamphlets and a box of Narcan. She’ll drop masks, gloves and even bus tickets into the bags when the county gives them to her.
"Now ... I don’t even get a chance to make the bags, people are right there,” waiting in the Homewood parking lot, she said.
Hamilton-El has been handing out the bags every Saturday just a few blocks away from the house in Homewood where her 31-year-old daughter passed away from an overdose three years ago. She was told that someone in the house had Narcan but didn’t administer it to her because the person had wanted to sell it.
The pandemic epidemic is worse
People suffering from addiction are isolated during the pandemic, which is exacerbating their addiction, several sources said. People feel lonelier by themselves and the routines they relied on for stability have been disrupted, causing some to use more frequently and alone.
That means there is often no one there to administer naloxone if they do overdose. Some organizations are encouraging people to video-chat their drug use on an app like FaceTime with someone they trust, so that the person can call for help if they overdose.
"Social distancing is basically creating the perfect storm for a person to use drugs alone in their home, accidentally overdose and not have anyone look out for them because they are not supposed to see anybody anyway,” said Lance Rhoades, the senior pastor at Tree of Life Open Bible Church in Brookline, which has a large recovery program.
People suffering from addiction don’t have as many options for help. Many support groups have been canceled to adhere to social distancing guidelines, and fewer people are showing up to the virtual recovery meetings that have replaced them. Some in-patient recovery programs are taking longer to enroll people as they screen for COVID-19 and spots are scarce.
COVID has presented additional funding challenges for recovery programs as they try to meet in smaller groups and track people down individually. Some providers also said funding for Narcan was drying up and they needed to find additional funds.
“[Allegheny] County had unlimited Narcan and now … you have to pay for the Narcan,” said Hannah Cawoski, a pharmacist assigned to AHN’s addiction recovery unit. "So the amount of free Narcan going around was much higher than what it is right now."
The people who show up in hospitals and treatment facilities now have more severe and complicated illnesses than ever, such as heart failure, bone infections and Hepatitis C, in addition to complications with their overdoses.
"By virtue of Narcan saving lives and keeping people alive and getting into recovery, they’ve also had a lot of time to get infected and cause all kinds of medical issues,” said Amanda Primrose, an addiction counselor with AHN.
When these illnesses are related to addiction and lead to death, they aren’t showing up on the official death tolls as related to addiction, according to Mark Fuller, the medical director of addiction health at the AHN's Center For Inclusion Medicine.
"We had a patient that bled out because her valve was so worn from how many times it needed replaced,” Cowaski said.Fuller is in the process of trying to expand the addiction health program from two hospitals to all the hospitals and outpatient centers across AHN. The program tries to get patients to commit to treatment right after they recover from an overdose. “We try to strike when the iron is hot,” Fuller said.
His team recently convinced a 25-year-old who overdosed twice in a single week to try to get clean. It was the first week in years he had not used. "With having overdoses that frequent, he is at a tremendous risk to die,” Fuller said. "It took the overdoses to make that change. It’s an unfortunate motivator but if it works, it works."
One unexpected benefit of the pandemic: By scaling back in-person visits and doing most by phone, the no-show rate dropped from 25% to 7%, Fuller said. It seems the lack of convenient transportation was preventing people from showing up.
"For our patients particularly the youngest ones, COVID is not the biggest risk to their lives, substance and alcohol use, those are the biggest risk to their lives,” Fuller said. “The things we’re seeing our patients die from is not COVID."
Laurie Johnson-Wade was on a weekly Zoom call with recovery support leaders across the state in early July. They were seeing the same thing: More overdoses.
Then Johnson-Wade, the executive director of Lost Dreams Awakening in New Kensington, heard someone pounding at the door.
“Miss Laurie, Miss Laurie, I need help!” the woman said, before falling to the ground. Johnson-Wade put the call on mute, turned off her camera, called 911 and grabbed Narcan.
Johnson-Wade said she had been working with the woman for years. The woman’s child had recently been taken from her because of her substance use, Johnson-Wade said.
Supporting patients and families through grief has become increasingly common. The week before Johnson-Wade spoke to PublicSource in July, she said she had attended two funerals of people who died of overdoses.
Lost Dreams Awakening has continued to operate during the pandemic, while following COVID-19 health guidelines, and has actually seen the number of people she serves increase. One nearby church said they didn’t want a support group to meet there anymore during the pandemic. Johnson-Wade’s group took them in.
The Lost Dreams Awakening board hired Johnson-Wade full time to help deal with this additional load, using the Paycheck Protection Program. About 25 people show up for a morning meeting, and about 50 show up for an evening support group, twice as many as before the pandemic. Half of them sit inside and half of them sit under an awning outside, she said.
Johnson-Wade received a call at 5 a.m. one day in late July from a woman who she had been meeting with for years in a family recovery support group.
The woman was calling from the coroner's. Her son, a 30-year-old star athlete and college graduate, who she had been helping through treatment for years, had died of an overdose. He had become addicted to opioids after a sports injury and struggled with staying clean ever since.
On Mother’s Day, after a successful bout in recovery, he gave his mom a bracelet with the support group creed written on it: "God grant me the serenity to accept the things I cannot change, the courage to change the things that I can and the wisdom to know the difference.”
But on the phone the mother wondered if she’d done things differently, if her son might have lived. Johnson-Wade reminded her of all the efforts she and her husband had made over the years and the times her son was in treatment and healthy.
“I just felt so lost for her, while trying to maintain my own strength to encourage and support her,” she said. “And I told her, ‘We are going to get through this together.’ ...It was awful. It was just awful.”
Oliver Morrison is PublicSource’s environment and health reporter. He can be reached at firstname.lastname@example.org or on Twitter @ORMorrison.