In Philly, finding a place for the homeless on opioids

After 20 years on heroin and six years living on the street, Anthony Messina just moved into a home of his own: a small one-bedroom, comfortably furnished and completely free.

He's clean for now, but he's always realistic.

"I'm not going to tell you I'm never going to get high again," said Messina, 54.

But if he does, he won't lose his new place.

"We see housing itself as a health-care intervention," said Christine Simiriglia,  president and CEO of Pathways to Housing PA, the nonprofit that runs a new city program that is helping people such as Messina. "If you are housed and healthy, you can move forward in life."

The Housing First model has been used for years to get chronically homeless people off the street. Many are seriously mentally ill, and quite a few are on drugs. Suburbs in both Pennsylvania and New Jersey have embraced it.

But Philadelphia's experiment is unusual: a team of professionals devoted exclusively to opioid users, set up in advance of the city's crackdown on the homeless heroin encampment along the Conrail tracks, and expanded since.

The concept: First provide housing, not in a shelter but a real apartment or a house. Then surround the newly housed with an intensive array of services — regular medical and psychiatric care, help with benefits, education, even showing them how to shop and do laundry. And treatment to stay off drugs.

The program is costly, but still far less expensive than the constant ER visits, hospitalizations, and prison stints common to people living on the street. It has money to house 75 people; so far, 53 are in their new homes.

Just after 9 a.m., the members of Team 7 — certified peer specialists, case managers, a psychiatrist — filled a conference table at Pathways' offices in north Philadelphia's Logan neighborhood. They zipped through updates.

A client had fallen. He'd be met at the hospital for an X-ray.

A woman's son had her SEPTA pass when he was arrested, so she couldn't get to the methadone clinic. A staffer got her some tokens but she needed a replacement pass.

Another woman had signed up to volunteer at a food bank, which seemed a smart way to get free food.

All clients are referred by the city; most of the funding comes from the state/federal Medicaid program and the U.S. Department of Housing and Urban Development. Tenants pay 30 percent of their income toward rent and utilities, but most on this team — who have generally been on the streets for years — have no income at all.

Treatment is always a goal. More than 40 percent of Team 7's clients chose to start medication-assisted treatment, which studies indicate is the most effective option; the staff helped arrange it. And a third more have expressed interest.

"We'll take them at whatever stage they are at and work with them there," said Matt Tice, Pathways' clinical director. "If we push this group they are likely to shut us out, which ultimately becomes dangerous for them."

Every Pathways employee carries Narcan, the overdose-reversal drug, even when going to fix a broken toilet. They have never needed it for a client, but have revived others they've spotted unconscious on the street.

Three Team 7 clients have died of drug-related causes. Still, Tice said, if they had been homeless, "they easily could have died earlier."

Anthony Messina's slight body shows the wear of repeated injuries from hard living. His gray hair is in a short ponytail, his face unshaven. He smiles easily and moves deliberately.

Pathways allowed him $50 for food to get his kitchen set up. At a ShopRite en route to the apartment, he scrutinized the circular for specials. "I've always loved American cheese," he said, buying three pounds at $1.99. Then rolls, bacon, eggs, tuna, milk, ice cream.

Gabriel Kalmuss-Katz, a social worker helping him move, hung back but observed something missing: "Vegetables?"

"No. I didn't like vegetables as a kid, and not now."

Kalmuss-Katz asked whether he had anything to move in besides the groceries.

Messina pointed to his T-shirt and baggy pants. "This is what I own."

Other than prison — some five dozen arrests, mainly for shoplifting, selling small amounts of drugs, violating probation — Messina has rarely strayed far from where he grew up in South Philly, a few blocks from the tourist-clogged corner dominated by Geno's and Pat's King of Steaks.

He was living at home in 2011 when a perceived slight — something about dope and a favored sibling — led him to tell his mother to drop dead.

"I'm headstrong," he said. And, from that point, homeless.

He remembers standing under I-95 to get out of the rain and thinking there weren't as many rats as he'd expected. About 10 people stayed there. "I chose to live on the street. It is close to where I was panhandling," Messina said. "Dope motivated me."

The city of Philadelphia oversees more than 10,000 housing units, from shelter beds to apartments. Some have bad reputations, others strict rules. Chronically homeless people often prefer to stay on the street. No one has turned down an apartment on Team 7, although some, such as Messina, wait until there's something available in a neighborhood they know.

A special team for opioid users made sense, said Liz Hersh, director of the city's Office of Homeless Services.

"Even if they tackle the addiction and are successful in their recovery, then what?" she said. On the street "there is no future. This gives them a future."

Pathways negotiates leases slightly below market price with landlords and property managers around the city, who can count on steady rental income. "And it makes them feel good" to help the homeless, said Sandra Romeo, who oversees the organization's day to day operations.

Each slot costs $28,500 a year, including housing, treatment, medical, psychiatric, and social services. Even so, studies have found that Housing First saves more than it costs.

Researchers reported in JAMA in 2009 that a Seattle program for chronically homeless people with severe alcohol problems cut the cost of government services by more than half after just six months compared with people still on the street.

Some small studies have found these housing initiatives also help people get clean. The most recent large analysis, from Canada, did not.

"Housing First was primarily designed to address a person's homelessness," said Ben Henwood, who helped set up Philadelphia Pathways in 2008 while in graduate school and now researches similar programs at the University of Southern California. "It doesn't really have a significant impact on substance use."

But with all its proven benefits, Henwood, like most in his field, supports the notion.

Sept. 11 was move-in day for Anthony Messina, who was thrilled to be within a mile of his old neighborhood.

Up a dark set of stairs, his front door opens onto a kitchen/living area with a small table, chairs, love seat, and a new television. His bedroom was down the hall. The water pressure in the shower was good.

"This is like perfect for me. Perfect," he said.

"You can have a girlfriend. You've got a place."

A week later, an ex-girlfriend came for a couple of days. She stole his TV while he was out. He called the police.

Messina last shot heroin before a late-August jail stint on a contested probation violation. After being released, he stayed away from it.

He said he doesn't care for the heroin that is available these days. Sometimes mixed with the powerful opioid fentanyl, he finds it unsatisfying, not to mention potentially deadly.

"I gave it up because it ain't dope," he said.

He's on Suboxone, a medication that treats opioid addiction by helping him avoid painful withdrawal symptoms. For now.

"I'm willing to try it," he said. "The more I stay off drugs the clearer my mind is."