PITTSBURGH — Every spring, when the Allegheny County Health Department released its final count of drug overdose deaths, Alice Bell used to weep.

She always knew what was coming. Bell runs the overdose prevention program for Prevention Point Pittsburgh, one of the few needle exchanges in Pennsylvania. For nearly a decade, she has watched what the opioid crisis has done to her community as the deaths continued to mount.

This year, though, the tears gave way to a sigh of relief.

After a record-breaking high of 737 overdose deaths in the county in 2017, fatal overdoses in Allegheny County dropped by more than 40% in 2018. They are expected to drop or to hold steady again this year.

“It’s like being in a war. It’s like battle fatigue. Year after year, you work so hard. And to think that these efforts have had some tangible effect,” she said, still marveling all these months later.

Alice Bell, director of overdose prevention at Prevention Point in Pittsburgh, speaks about the city's drop in fatal drug overdoses.
JOSE F. MORENO / Staff Photographer
Alice Bell, director of overdose prevention at Prevention Point in Pittsburgh, speaks about the city's drop in fatal drug overdoses.

Experts in Pittsburgh and the surrounding communities of Allegheny County say there’s no one reason for this startling success. Flooding the county with naloxone, the overdose-reversing drug — Bell’s primary task for more than a decade — has clearly saved lives, officials say. So has getting more people into medication-assisted drug treatment. Getting doctors to prescribe fewer opioid painkillers gets some credit.

So does targeting the city’s hardest-hit areas with such public health measures as Prevention Point’s needle-exchange van, which also dispenses naloxone and offers medical care for people who use drugs.

In many ways, the plan is similar to Philadelphia’s less successful attempts to cut its catastrophically high overdose rate. Though Allegheny County is just slightly less populated than Pennsylvania’s largest city, Philadelphia weathered 1,217 overdose deaths in 2017. The following year, overdose deaths declined by 8% — encouraging, but not dramatic.

Pittsburgh, with its proximity to the Appalachian region’s infamous opioid woes, has long struggled with drug use. But the efficacy of Allegheny County’s response to the overdose crisis underlines just how entrenched the problem is in Philadelphia — and how the scope of the crisis makes its challenges that much more unique.

“We are having a targeted strategy in the same way that Allegheny County has,” said Thomas Farley, Philadelphia’s health commissioner, adding that his colleagues pay more attention to the nation’s biggest cities than to Pittsburgh.

“But we, for decades, have become this big heroin market. We’re a distribution site for a very broad area. That drug availability is going to make it harder for us.”

‘A lot of selling’

Pittsburgh doesn’t have a Kensington — the long-neglected section of Philadelphia’s river wards plagued by open-air drug use and sales.

But there are hot spots around Allegheny County, and using data to identify them and focus harm-reduction efforts has been key to preventing deaths, officials said.

For instance, data showing that the Pittsburghers at the highest risk of overdose were those leaving the county jail led jail officials to offer naloxone to anyone being released. (Philadelphia’s jails offer naloxone and even go a step further, treating addicted inmates with buprenorphine, proven to offer a better chance of lasting recovery.)

In 2017, staffers at the Allegheny County Department of Human Services drew up a list of the 10 communities with the highest overdose rates, and hit them hard with outreach services and lots of naloxone.

They also discovered that in some towns, police officers still weren’t carrying the reversal drug in their cruisers. That meant an officer might respond to a call for help, yet be powerless to stop an overdose from becoming fatal.

“We had to do a lot of selling to the police departments,” said Latika Davis-Jones, who runs the county’s Bureau of Drug and Alcohol Services. “But the fact that we as a county had great data, we were able to get out into the community to really talk about this. It had a significant impact on people being willing to do something about it. We were well-prepared because of the information we had as a community.”

Farley says Philadelphia officials have also targeted aid to hot spots, sending needle-exchange vans to South Philadelphia and West Philadelphia. But Kensington remains the epicenter of drug deaths — and the city’s attention. Harm-reduction services are still scarce outside the neighborhood.

‘I thank God’

Carrick is a blue-collar neighborhood full of sturdy brick houses, overlooking the gleaming skyline of downtown Pittsburgh. Drug use is so rampant in the south-side community that the main drag was dubbed “Overdose Road” in a Pittsburgh Post-Gazette story two years ago.

Yet residents long resisted efforts to get a public health van with needles and medicine into the community.

“It’s a pretty arduous process,” Bell said. “We have to work hard to get additional sites to open.”

Unlike Philadelphia’s Prevention Point public health center in Kensington, Pittsburgh’s program doesn’t run a brick-and-mortar drop-in site for people with addiction. Instead, it sends vans out across the city to different locations, now including the south side. On Sundays, workers hand out clean needles and offer medical care at a health center in East Liberty, northeast of downtown.

Alice Bell shows different types of syringes and needles at Prevention Point in Pittsburgh.
JOSE F. MORENO / Staff Photographer
Alice Bell shows different types of syringes and needles at Prevention Point in Pittsburgh.

The vans are a literal lifeline, especially as the deadly synthetic opioid fentanyl has contaminated most of the city’s heroin — much like in Philadelphia — making overdoses far more likely.

Pittsburgh’s paramedics leave naloxone with overdose patients who are revived but refuse to go for treatment. It was one of the first programs in the country of its kind. Bell said Prevention Point asks some of its clients to give syringes and naloxone to friends who won’t come to the vans.

“We were making sure we got the naloxone to people on the street, who were, by a second or third degree, distributing it to someone who would never encounter us,” said Dan Palka, who runs the street outreach team for Pittsburgh Mercy, a behavioral health nonprofit. He regularly visits homeless camps around the city — which, though persistent, are much fewer and smaller than Philadelphia’s. “It’s almost rare now that someone should tell me they don’t have it,” he said.

The widespread availability of naloxone, advocates say, can help keep people alive long enough to realize they have to get treatment.

People such as Billy Golya, who’s now in recovery, and who overdosed three times in three weeks at the height of the city’s overdose crisis in 2017. Now, he lives in recovery housing in Carrick.

Eventually, he said, “I was just broken down enough that I was ready to do just about anything to get clean."

Joanna Bernstein, a writer and service coordinator at a Latino outreach center on the south side of Pittsburgh, developed an opioid addiction after years struggling with pain caused by a serious bacterial infection and undiagnosed endometriosis. At first, she was prescribed painkillers — and then, when the pills ran out, she began to buy them on the street. By 2018, pills were too expensive to satisfy her rising addiction, and she turned to heroin.

Joanna Bernstein, a writer and Pittsburgh native who's been in recovery for more than a year, is reflected in the review mirror of her car as she drives to the neighborhood where she used to buy drugs at the height of her addiction.
JOSE F. MORENO / Staff Photographer
Joanna Bernstein, a writer and Pittsburgh native who's been in recovery for more than a year, is reflected in the review mirror of her car as she drives to the neighborhood where she used to buy drugs at the height of her addiction.

She knew overdose deaths had been skyrocketing for years. She was terrified of dying. But she was unable to quit. And so she kept naloxone near whenever she used, and tried not to use alone.

“There’s undoubtedly more awareness of where you can acquire [naloxone] now,” she said in an interview at a coffee shop in Squirrel Hill, a leafy neighborhood known for its colleges and Victorian architecture that is just minutes from the corners where she used to buy heroin.

Bernstein had a terrifying near-overdose just before she entered inpatient treatment — which led to lasting recovery. She’s maintained it with the opioid-blocker Vivitrol for nearly a year.

“I work. I write. I thank God that I haven’t died from this disease like countless others have,” she wrote in an essay for Public Source, a Pittsburgh-based nonprofit newsroom.

Mr. Rogers’ neighborhood

Peer specialists at hospital systems such as the University of Pittsburgh Medical Center are on call to meet people with addiction in emergency rooms and help them enter treatment. Philadelphia hospitals also have vigorous peer specialist programs, and have reported success in getting more people into treatment than physicians could do on their own.

But Philadelphia is a bigger city with numerous health systems. Pittsburgh officials and health workers say that with only two major health systems in the area — UPMC and Allegheny Health Network — collaboration is easier.

“We’ll get ODs, bad withdrawal cases, medical issues that come from addiction,” said Ashlie Mikush, a peer specialist who has been in recovery from a heroin addiction for three years. “You get people who are just like, Get out of my room. Or people who say, ‘I don’t want to quit.’ But I always come in with a smile, and meet them where they’re at.”

Another difference many Pittsburghers think has helped: the famous friendliness that feels almost endemic in the home of Mister Rogers’ Neighborhood .

Ashlie Mikush, a UPMC peer specialist.
JOSE F. MORENO / Staff Photographer
Ashlie Mikush, a UPMC peer specialist.

“There’s an interesting thing about Pittsburgh — the neighborliness,” Palka said. “From Mr. Rogers all the way on down, it resonates with a lot of people. It’s very effective to say to someone, ‘Be a good neighbor.' People in [homeless camps who accept naloxone to rescue someone else] are like, ‘Yeah, we’re just trying to be good neighbors here.’”

Philadelphia outreach workers have also noted that distributing plenty of naloxone has meant people in addiction use it to revive one another, rather than wait for police or paramedics. On both sides of the state, officials say, people who use drugs realize that as drugs get stronger, they have to save one another.

Cutting fatal overdoses is critical, agree health officials and advocates for people in addiction. But it’s just the start in addressing a crisis that’s still killing hundreds in the county.

At Allegheny Health Center’s HIV clinic, the center’s longtime director, Stuart Fisk, says he’s seeing fewer patients die of overdoses, but more are suffering with infections that can develop from years of drug use, or even brain injuries after overdosing and being deprived of oxygen for too long. It’s a pattern that’s also playing out in Philadelphia.

It’s imperative, he said, to take care of those patients, even as the county celebrates a drop in fatalities.

“The decrease in deaths is great,” Fisk said. “But there’s still all this collateral damage.”

On a smaller scale

Can Philly glean lessons from the Pittsburgh experience?

“The difference isn’t necessarily Pittsburgh’s success compared to Philadelphia, but Philadelphia’s challenges,” said Rachel Levine, Pennsylvania’s secretary of health. Philly’s location on the I-95 corridor has long contributed to its status as a national hub for drug use and trafficking — and drug use in Philadelphia is more widespread and more entrenched.

Outreach workers in Pittsburgh who visit Philadelphia say they’re shocked by the extent of drug use here.

“We have a lot fewer organizations and resources that are doing the work that some of your amazing partners are doing in Philadelphia,” said Laura Drogowski, critical communities manager for Pittsburgh’s Bureau of Neighborhood Empowerment.

“I want to be able to say there was something remarkably different that occurred here,” she said of Pittsburgh. “But I think the scale of the challenge is smaller here."

A neighborhood in the south side of Pittsburgh.
JOSE F. MORENO / Staff Photographer
A neighborhood in the south side of Pittsburgh.