Streets of Philadelphia: Those caught in US fentanyl crisis say solutions lie at home, not in China

28-Jan-2019 Intellasia | South China Morning Post | 6:00 AM Print This Post

Streets of Philadelphia: Those caught in US fentanyl crisis say solutions lie at home, not in China

It was windy, bitterly cold and just after 9am on a recent Sunday morning in Philadelphia’s northeastern neighbourhood of Kensington, but the area was brimming with activity.

A man, bent double, vomited into the street. A drug dealer called a friend to warn him of an unmarked police car doing the rounds. Men mumbled “works, works, works” at passengers disembarking from the city’s elevated “El” train, indicating they had needles to sell. A passing police car honked to disperse them, but didn’t stop.

To some, Kensington will always be known as the home of Rocky Balboa, Hollywood’s boxing hero whose fight against adversity captivated audiences around the world. But to Robert Reif, 62, a US Army veteran and Kensington resident who manages the Last Stop, a community rehab centre, this area is “ground zero” in a very different battle.

The unseen enemy in Reif’s metaphor is fentanyl, the potent synthetic opioid that is fuelling a public health crisis in American cities like Philadelphia, where in 2017 it was the primary killer among the city’s 1,217 overdoses. In the words of community outreach worker David Tomlinson, himself a survivor of a fentanyl overdose, the drug is “literally decimating an entire generation of humans”.

Thousands of miles away from Kensington, pharmaceutical labs in China prepare shipments of the white powder that ultimately end up on the streets of the United States, where, according to the National Safety Council, you are now more likely to die from an opioid overdose than a motor vehicle crash.

At 50 times the strength of heroin, small amounts of fentanyl can go a long way; 2 milligrams just several flecks of the white powdered substance is enough to kill an adult.

As such, fentanyl can be shipped directly to the US from China through the mail in small, difficult to detect but highly profitable batches. In addition, the US Drug Enforcement Administration (DEA) says, fentanyl enters cities like Philadelphia via Mexico, where cartels handle ready-made fentanyl from China (or create the substance from fentanyl precursors produced in China) before smuggling them into the US through ports of entry.

China’s role in the outbreak of the deepening US fentanyl crisis which, along with fentanyl derivatives, killed almost 30,000 Americans in 2017 was thrust into the spotlight last month.

As part of high-level trade negotiations, Chinese President Xi Jinping agreed to clamp down on fentanyl production in China by classifying all fentanyl analogues as variations of the substance are known as illegal.

The as yet unfulfilled commitment was lauded by US President Donald Trump as a triumph. In a tweet, he said: “If China cracks down on this ‘horror drug,’ using the Death Penalty for distributors and pushers, the results will be incredible!”

Far from the lofty heights of bilateral diplomatic negotiation, though, and back on the streets of Kensington, many active fentanyl users, recovering users, community outreach workers and health care professionals say that the US administration’s fixation on Chinese supply is misplaced.

War on drugs

“There’s only so much you can do, there’s only so much barring you can put up, so many walls before somebody digs a hole or climbs over it,” said Kensington resident Anja Lesniak, who has battled with fentanyl addiction on and off since 2016.

It was his first overdose and it was his last

Anja Lesniak, on her boyfriend’s death from accidentally taking fentanyl

“Great, we made a deal,” Lesniak, 21, said, referring to the December agreement brokered by Trump and Xi. “But in my addiction I made a lot of deals that I never held up my end.”

To Lesniak, who works night shifts handling shipments for a major e-commerce company, prohibition is ineffective she cites the failure of the US government’s “war on drugs” to stop the flow of heroin into the country as proof. Instead, she believes that government resources would be better spent engaging with users to pull them out of their dependency cycle.

In early 2017, Lesniak yanked herself out after the traumatic loss of her boyfriend James Diffendarfer, who died at 19 after injecting what he believed was heroin. His toxicology report, confirmed by his mother, Janie Bowman, indicated that the substance was in fact fentanyl.

“It was his first overdose,” Lesniak said, “and it was his last.”

I put it in my arm then run out into the middle of the street. Because if I’m going to OD, I want somebody to be able to bring me back

JR, a Philadelphia drug user

Lesniak, whose dependency on fentanyl had driven her to living on the streets and engaging in sex work for money, got high one more time following her boyfriend’s death. But she realised that the “oblivion”, however alluring, did nothing for her grief.

“I realised that [I should] give sobriety a shot,” she recalled. “Because the worst thing that could ever happen is maybe I’ll be happy. The worst thing that could happen if I keep going is I’ll die.”

She has spent much of the two years since then reaching out to other users especially women, who are at heightened risk of physical and sexual abuse in Kensington to show them that sobriety is possible.

Short of a miraculous end to the flow of fentanyl into Philadelphia, she said that the priority was to help users “realise that you don’t have to end up like James”.

“I present it to people: you can either end up like him, or you can end up like me,” Lesniak said. “Because I don’t really like being a bag of ashes in my mother’s house at 19. It’s not a highlight.”

Getting well

Half a mile from Lesniak’s Kensington flat, under a railway bridge on Emerald Street, dozens of tents housing homeless residents many of them drug users line the sidewalk.

The last of Philadelphia’s tent cities, Emerald City as the encampment is locally known is scheduled to be cleared in the next few weeks by city authorities, who will encourage residents to move into shelters and enter treatment programmes.

But the encampment, however exposed, offers some security for those who choose to live and use drugs there, explained Kate Perch, housing coordinator at Prevention Point Philadelphia.

As an American, I think we should clean up our backyard before we start telling China to clean up its backyard

Anthropologist Philippe Bourgois

The Kensington-based non-profit employs the “harm reduction” approach to supporting drug users: accepting that the supply and use of drugs is unlikely to stop, and thus focusing resources on initiatives like emergency accommodation, clean needle exchange, medical care, and medically assisted treatment to drug users.

“When you’re with other people, you know that somebody has your back,” Perch said whether that is protection from violence or a guarantee that someone will notice if a user suffers an overdose.

To 29-year-old JR, who had been living in Emerald City for two weeks and who like many fentanyl users who spoke to the South China Morning Post declined to give a full name, the company of others is a precious thing.

“I will mix up in an alley, put it in my arm, then run out into the middle of the street and let it hit me,” he said, his voice breaking.

“Because if I’m going to OD, I want somebody to be able to bring me back. But if I have to be scared to do that [...] and I’ve got to hide, that’s how I’m gonna die.”

Like many current and recovering users, JR struggled to convey in words the sheer strength of fentanyl’s hold on the mind and body.

“We’ve always called it medicine,” he said. “I’ve broke my arm, I’ve got migraines, but nothing has compared to withdrawal”.

“Being dopesick is probably the worst feeling,” JR said, adding that withdrawal from crack cocaine, an extremely addictive form of cocaine that he also uses, pales in comparison to that of fentanyl. “It’s indescribable.”

[The doctors] set you up [with an opioid medication] and then they say ‘We have an opioid epidemic’. You guys are the ones prescribing it

In addition to its higher potency, fentanyl’s other distinguishing feature from other non-synthetic opioids is its considerably shorter “half-life” the time it takes for its effects to wear off.

That leaves users like Bud using the drug upwards of 10 times a day.

The 25-year-old, who used to work as a plumber before his dependency consumed him, has been living in Kensington for nine years. The high, he said, “only lasts about two, three hours [before] you have to ‘get well’ again”.

It’s that short, potent high that makes fentanyl so dangerous. The frequency of using means a higher chance of picking up an infection users sometimes resort to sharing equipment if clean needles are not at hand.

Potentially even riskier, frequent usage means a greater chance of coming across a bad batch with a lethal dosage, a risk that weighs heavily on Bud’s mind but is overpowered by the drug’s draw.

“This thing just took my whole life over,” Bud said. “People say ‘Oh, it’s willpower’. I lost the power of choice once I put it in me.”

Like many current and recovering users of fentanyl who spoke to the Post, JR said the US health system’s overprescription of pain medication not the supply of illicit drugs was to blame for the opioid crisis.

JR said that of the opioid users he knows, the large majority had been introduced to illicit drugs after having first used prescription opioid painkillers like Percocet and OxyContin.

“So it’s like you’re being set up to fail,” JR said. “They set you up and then they say ‘We have an opioid epidemic’. You guys are the ones prescribing it.”

It’s not just users who say this so too do academics studying the problem.

Anthropologist Philippe Bourgois, who lived for years in Kensington conducting fieldwork for a coming book on urban poverty and segregation in the US, believes that the aggressive promotion by US drug companies of opioids and their playing down of their addictiveness are ultimately responsible for the crisis.

“We’re just talking about crass, blatant, old-fashioned, primitive corruption taking place in the United States,” said Bourgois, a professor of social sciences at the University of California, Los Angeles.

China does have the responsibility to “lock up” the people who were exporting precursors to fentanyl, Bourgois said. “I’m not soft on crime in any way”.

“But as an American,” he continued, “I think we should clean up our backyard before we start telling China to clean up its backyard.”

What China needs to do to stem the flow of fentanyl to the US

Early last year, Philadelphia joined nationwide efforts to start that clean-up, when it joined a growing number of state and local governments to launch lawsuits against several major pharmaceutical companies.

Philadelphia’s suit, now pending, accuses companies like OxyContin manufacturer Purdue Pharma LP of misleading marketing by playing down the drug’s addictive nature, charges that Purdue which did not respond to a request for comment denies.

While the lawsuits may result in punishing fines, Bourgois believes that it will take nothing less than the prosecution and jailing of pharmaceutical industry executives to stop the overprescription of opioids.

“Instead we throw [in jail] the addict, who steals 10 dollars from someone walking down the street, for years and years,” Bourgois said.

“And then these corporate criminals who have killed tens and tens or hundreds of thousands of people just walk free and all they get is a little civil fine.”

We can point our fingers at China like the country had a sinister plan for America or something, but it comes down to supply and demand

Zachariah Donnelly, a former fentanyl user

Philadelphia Health Commissioner Thomas Farley told the Post that tackling overprescription is one of the city’s three prongs in confronting the opioid crisis.

In addition to developing policies that would prevent doctors from overprescribing pain medication, he said, the city’s Department of Public Health is also trying to reduce the bureaucratic hurdles that confront opioid users seeking treatment.

Five things to know about fentanyl

That sticking point has become increasingly pressing with the rise of fentanyl, the short half-life of which means the window for intervention is far narrower than that of traditional opioids like heroin.

The department also hopes to make naloxone the opioid overdose antidote more widely available to the public, and is convening open training sessions across the city to educate members of the public on how to recognise and treat opioid overdoses. Farley said he was not familiar with the Trump administration’s efforts to stem the production of fentanyl at its Chinese source.

His department “would love to be able to reduce the supply to the streets of Philadelphia”, he said, with an important caveat: “I don’t expect that to happen anytime soon.”

Pointing fingers

Back in Kensington, Zachariah Donnelly, a former fentanyl user who has lost friends to the drug, put that scepticism in even starker terms.

“We can point our fingers at China like the country had a sinister plan for America or something, but it comes down to supply and demand,” the 29-year-old mason labourer said.

Donnelly affords his empathy not only to producers of fentanyl in China but also to local dealers. “In all honesty, we’re human,” he said. “And at the end of the day you either have a mortgage to pay, you got a family to feed. I can’t hate on you for that.”

Since he became sober several months ago, Donnelly has been volunteering at Last Stop, the Kensington community centre that, in addition to running abstinence programmes, distributes clean clothes, food and other supplies to the local homeless community, many of whom are using drugs.

To Donnelly, reaching out to users on a one-to-one basis is by far a more measurable approach to countering fentanyl’s impact than attempts to stem its supply.

“I don’t have [college] degrees, I can’t get into something big,” he said. “But I can go on the street and be like: ‘My man, you good today?’”

One such simple interaction, Donnelly said, spurred him to realise there was somebody who cared about him and would immediately support his efforts to get clean.

How China plans to beat the fentanyl chemists

That camaraderie between recovering and active users, one of the often overlooked elements of the ways in which communities are coping with the opioid crisis, is a powerful thing, said Lesniak.

“Kensington, as morbid and dark as it is, is full of love,” she said. “All we want is for [active users] to get better, and all they want is for us to succeed.”

A never-ending struggle

As she has pursued that mission, Lesniak has held on closely to the memory of her former partner James, one of the many people she knew to have been taken by fentanyl.

“And as much as I wish he was here today, he didn’t die in vain,” she said. “You die twice. Once when they bury you, once when the don’t mention your name anymore.”

“And I don’t want to be one of those people that’s just long forgotten,” she continued, “just another number reported every year of how many people died from drugs.”

Just as statistics cannot adequately convey the human tragedy that fentanyl has brought to the streets of neighbourhoods like Kensington, words seem impotent to convey the drug’s powerful hold over those who have fallen into its orbit even for someone like Lesniak, who, in her own words, was “in love” with sobriety.

Early in the morning of January 19, just days after the Post visited her in Kensington, she relapsed on fentanyl and crack cocaine, abruptly ending almost two years of sobriety.

In the span of two days, she overdosed twice and had to be resuscitated after her breathing and pulse stopped.

“It can happen to anybody,” she said of her relapse in later messages.

She planned on getting sober again, she added, “hopefully sooner than later”.


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