Editor’s Note: Contributor David Brand is a licensed social worker. From 2011 to mid-2014, he worked as a case manager at two supportive housing sites in Manhattan. Since 2015, he has run wellness programs for supportive housing tenants at four sites in New York City. He has not worked at any of the organizations referred to in this article.
Ronald Glover encounters a lot of opioid users in his daily travels. There are the heroin-addicted friends he hangs out with at his favorite park in the Bronx; the acquaintances he meets when he visits a local drop-in center (a place where homeless people can get meals, counseling, and medical attention); and the strangers he passes, slouched and nodding, in local subway stations.
And then there are his neighbors at The Brook, a six-story, 190-unit residential building in a section of the South Bronx with one of New York City’s highest overdose death rates. Overall, 342 Bronx residents died from confirmed opioid overdoses in 2017 compared to 128 in 2010, according to city data.
Three Brook residents died from overdoses in the first two months of 2018.
The gruesome number reflects the fact that, as one staff member estimates, as many as 40 percent of The Brook’s tenants use heroin or other opioids on a regular basis, or are in recovery. Scott Auwarter, an assistant executive director of BronxWorks, which provides social services to The Brook, endorses that estimate.
The Brook was developed in 2010 by a nonprofit group called Breaking Ground, New York City’s largest supportive housing organization.
Supportive housing is a term for permanent, independent-living apartments reserved for formerly homeless adults and families, equipped with on-site social services. The federal Substance Abuse and Mental Health Services Agency estimates that 35-40 percent of all homeless individuals have a substance use disorder. Those problems don’t automatically go away when a person gets a stable apartment.
There are now about 300,000 units of supportive housing nationwide, according to the Corporation for Supportive Housing (CSH), which finances such developments in 48 states. The buildings are developed by nonprofits. Tenants sign annual leases and pay a monthly rent, usually subsidized by federal Section 8 funds or other housing voucher programs.
New York State is home to more than 50,000 such units, mostly concentrated in New York City. (Another 35,000 are envisioned over the next 15 years, according to a commitment by New York City Mayor Bill de Blasio and a plan by Gov. Andrew Cuomo.)
Typically, supportive housing sites do not evict tenants for using illegal drugs, which would return them to homelessness. Though social service staff urge and assist tenants to seek treatment, supportive housing providers generally subscribe to a “harm reduction” philosophy, which holds that staff should respect individuals’ health choices—even those of people with addiction. The theory is also that a person is more likely to begin treatment once they have a safe and consistent place to sleep and store their possessions, than while homeless.
Spurred by the deaths at The Brook, BronxWorks asked the New York City Department of Health and Mental Hygiene (DOHMH) to conduct a training workshop in the use of Narcan, a naloxone nasal spray used to revive overdose victims. The city sent a team of health workers, part of the HealingNYC initiative and the state’s Opioid Prevention Program, which trained tenants and provided each of them with kits containing two doses of Narcan.
Glover, 49, recently took the workshop.
“I don’t want to see someone in the elevator and then find out the next day that they’re dead,” says Glover, 49. “That’s horrible,” he continued. “I want to see people do better and if I can save one person, then I’ve done a lot.”
Since March 2017, the city has distributed more than 90,000 naloxone kits citywide, including roughly 14,000 to the Department of Homeless Services, according to DOHMH. Although Narcan ordinarily retails for about $125 to $150 per two-dose kit, the city pays about $70 per per kit, according to a DOHMH spokesperson.
In 2016, drug overdose became the leading cause of death among homeless New Yorkers, with 61 drug-related deaths among that population, including 20 opioid-overdose deaths at the city’s homeless shelters. In the first four months of the 2018 fiscal year, the city recorded 81 overdoses inside shelters (counting nonfatal incidents)—up from 12 in the same period last year.
Over the past few years, the city and state have been training staff and homeless people in the use of Narcan at needle exchange programs, drop-in centers, and homeless shelters.
In addition, last year the City Council passed a bill mandating that shelters have at least one staff member certified to administer naloxone at all times.
But no comparable law compels the city’s supportive housing sites to take similar precautions, though tenants are virtually the same population.
Many supportive housing organizations have yet to embrace the concept of universal naloxone training, according to staff members and advocates. In fact, in some buildings, no staff member has yet been trained to administer it.
At one site, a supportive housing director tells Opioid Watch that the idea of training tenants failed because administrators worried about liability and questioned who had the authority to approve the initiative.
Advocacy groups are now trying to persuade these providers to change their minds.
“We urge providers to incorporate these trainings — and not only for the benefit of tenants,” says Robert Friant, a spokesperson for CSH. “We think supportive housing is an integral part of addressing this issue in the community. If I’m equipped with the right tools, whether I’m in a supportive housing residence or not, I can save a life.”
When people with opioid use disorder move into supportive housing, their newfound privacy — solitude that is impossible inside a cramped and busy homeless shelter — can actually be an overdose death risk factor, says BronxWorks administrator Auwarter.
Since supportive housing staff typically work nine-to-five schedules, it is imperative that neighbors learn to administer life-saving naloxone the other 16 hours of the day, Auwarter says.
Critics have argued that naloxone can instill a false sense of security that actually deters those who are addicted from seeking help. Some economists have raised the issue of “moral hazard”—the notion that people engage in riskier behavior when society rescues them from the consequences of their acts.
Jessica Steyers, an assistant program director at The Brook, rejects this argument.
“In order for people to change their lives when they’re ready, they have to be alive,” she says in an interview. “People say: ‘They should go to treatment.’ But they have to be alive to make that change. Narcan keeps them alive and it’s the best chance we have.”