Philadelphia is arguably the epicenter of the urban overdose crisis. And while things became a little-bit better in 2018, we are very far from where we need to be.

Thread on a year that started with a huge announcement and ended with a tiny glimmer of hope.
Last year ended with a devastating overdose cluster that took the lives of 70 people in 30 days. @aubreyjwhelan and @MikeNewall reported on the year that claimed 1,217 lives: philly.com/philly/news/op…
In January it seemed like 2018 might be different. Philadelphia officials declared that the city will not stand in the way of private entities that want to open a safe-injection site. Philadelphia was celebrated as the first city in the US to have a site: philly.com/philly/health/…
The response was confusion and misinformation. People did not understand what the city actually announced (are they opening a site? when? where? not with my money!) and framed the suggestion as "real-life Hamsterdam." But that is not what was announced: philly.com/philly/opinion…
One grievance that came up immediately, and rightfully so, is "where were these sites during the crack epidemic?" The answer, of course, is that no one cared when black people were the ones dying. We should have had them then, and should have them today. phillyvoice.com/safe-injection…
Philadelphia District Attorney Larry Krasner and Mayor Jim Kenney tried to make that case -- we were wrong in the 1980s, let's not be wrong today. philly.com/philly/opinion…
But there is more to racial justice in harm reduction than admitting the mistakes of the past. @Lb_Sterling and @thesmallpicture brilliantly argue that to actually be inclusive, any site must be opened to consumption of all drugs, not just injection. philly.com/philly/opinion…
The conversation about race is one of the things that also moved the needle on the name of any future sites. Safe-injection sites --> Comprehensive User Engagement Sites --> Safe or supervised consumption sites --> overdose prevention sites. I will use overdose prevention sites.
The response of law enforcement was split. DA Krasner is supportive. Commissioner Ross said he is still torn but warming up to the idea. AG Shapiro said on multiple occasions that law must change to allow for overdose prevention sites. That isn't accurate: whyy.org/articles/setti…
The response from the community was also very divided. Again, lack of knowledge was the main driver of opposition. @MikeNewall participated in a community forum and came out of it with a call for the city to do more to "sell" the sites: philly.com/philly/columni…
But time continued to pass from the announcement and people were dying. @MikeNewall talked to @BrookeM_Feldman about Johnny who couldn't make it to a Kensignton residents conversation about overdose prevention sites because he died of an overdose. philly.com/philly/news/sa…
The overdose crisis also escalated as fentanyl and its analogs found their way into more drugs -- specifically cocaine -- putting opioid naive people who don't carry naloxone at high risk of overdose deaths. @aubreyjwhelan reports: philly.com/philly/health/…
Two months after the overdose-prevention site announcement, City Council held a hearing about the opioid epidemic. The hearing revealed that our lawmakers don't know some very basic facts about the science and dynamics of addiction and recovery: philly.com/philly/health/…
The @PHLPublicHealth continued to work to prevent overdoses. In March they invested $100,000 on a campaign to promote naloxone: philly.com/philly/health/…
But the big next act in the overdose crisis was the clearing of two of the four encampments of homeless people in addiction in Kensington. Some were optimistic about the plan: philly.com/philly/health/… @MikeNewall saw improvements: philly.com/philly/columni…
Others were skeptical about the evacuation plan: philly.com/philly/health/… I was concerned: philly.com/philly/opinion…
On the evacuation day, @MikeNewall beautifully tells the story of a father and son that were evacuated from the encampment that became their home: philly.com/philly/columni…
It's summer. Data shows that people are dying in every neighborhood in Philadelphia and there is still no overdose prevention site in sight. philly.com/philly/health/…
In two weeks in June, 20 people in west Philly overdose from crack cocaine that includes fentanyl or analogs. @MaxMMarin and @cmoraff investigate. The main question is how did the fentanyl get in the crack? philadelphiaweekly.com/news/what-we-k…
Meanwhile Pennsylvania is in the middle of its second 90-day public health emergency declaration and legislators are trying to enact laws that will limit access to treatment instead of making treatment more easily accessible: philly.com/philly/opinion…
Another concerning development in Pennsylvania is the rise of drug induced homicide charges -- prosecuting friends and family of people who died of overdose because they used together. @Sentinel_Vaughn reports: theappeal.org/a-pennsylvania…
For more on drug induced homicides, read this important explainer by @ZachWritesStuff and @LeoBeletsky. Also follow @HiJAction who are collecting data on these charges. Pennsylvania is shamefully a national leader in charging. theappeal.org/charging-deale…
In July, more than 100 people find themselves in the hospital after using heroin. At first it seems like an overdose cluster. philly.com/philly/health/…
This time it wasn't fentanyl, it was K2 -- a synthetic cannabinoid. Again proving that when you buy drugs in Philadelphia you never know what you are actually consuming. philly.com/philly/health/…
It is because of this kind of poisoning clusters, and because that the vast majority of overdose deaths are attributed to fentanyl and analogs, that there is a good case for prescription heroin as a solution for overdose death. @ZachWritesStuff explains: theatlantic.com/health/archive…
Meanwhile, Philadelphia's women prison decided to start providing medication for addiction treatment -- which is known to be effective for decades. philly.com/philly/health/…
Pa prisons go the opposite direction. After incidents that the prison claims are exposures to substances, the Department of Corrections put all of its facilities on lockdown. When it is lifted books and mail to prison is banned. @samanthamelamed reports: philly.com/philly/news/bo…
The majority of the alleged guard exposures did not reveal any substance in toxicology testing or no toxicology testings was done. Experts argue that the more likely scenario is mass hysteria. Again @samanthamelamed reports: philly.com/philly/news/pe…
In response to public outrage about the book ban, the Department of Correction tweeted "proof" that people smuggling drugs into using books. Except that the photo that they tweet was of medications that the prison won't provide to those who need it. philly.com/philly/opinion…
Since the Department of Corrections partially repealed the book ban: philly.com/philly/news/pe… and @aclupa sued the DOC over their policy on legal mail: philly.com/philly/news/ac… Reporting from @samanthamelamed.
Back to the fight to open an overdose prevention site in Philadelphia. Late in the summer activists (shout out to @PhillyAct and @SOL__Collective) marched on City Council to protest the inaction in regard to an ops: philly.com/philly/columni…
And then, out of nowhere, Deputy Attorney General Rod Rosenstein issued threats against Philadelphia that the DoJ will crack down on an overdose prevention site if one were to open: philly.com/philly/health/…
Enter SafeHouse.

In early October, former-Governor Ed Rendell announced that he is incorporating SafeHouse, a nonprofit that will open Philly's overdose prevention site. philly.com/philly/health/…
Rendell said in response to Rosenstein's threats, "arrest me first." There is something historically neat in that. As Mayor of Philadelphia, Rendell said arrest my first when against state law he authorized the city's first syringe exchange to combat HIV: philly.com/philly/opinion…
The day after the SafeHouse announcement, Philadelphia declared Kensington, the neighborhood most impacted by the overdose crisis, as a disaster zone. No mention of an overdose prevention site in the declaration: philly.com/philly/health/…
In response to SafeHouse, Philadelphia US Attorney William McSwain said: "The bottom line is that the sort of facility that is being proposed is illegal under federal law. We're not going to look the other way." philly.com/philly/news/pe…
SafeHouse's response to McSwain: come at me bro. philly.com/news/supervise…
Another way to protect SafeHouse legally is to have the Church of Safe Injection open it: philly.com/opinion/commen… The DEA gives religious exemption from drug laws. Why not from the bizarre interpretation of the crack house statute that encompasses overdose prevention sites?
The city has also taken steps to bring community together by conducting cleanings at Kensington. Thats a great thing because there is only one community and the idea of users vs resident is made up and harmful. Harm reduction is a win-win, not sacrifice. philly.com/philly/opinion…
Another good development from Pa. is the state's Supreme Court decision that drug use while pregnancy cannot be defined as child abuse. Nothing America loves more than stigmatizing drug use and controlling women's bodies. This time, the court did neither. philly.com/health/pennsyl…
The year ends without a running overdose prevention site in Philadelphia. Thanks to the distribution of tens of thousands of doses of naloxone, Philadelphia will end the year with about 100 less deaths than last year. (moral hazard, hold my beer) philly.com/health/opioid-…
There is a lot more to say and a lot more that happened but this is the general narrative of 2018. We talked a lot about overdose prevention sites, some people showed some courage but little action on the ground.
Now to some not Pennsylvania related important reads on the overdose crisis and drug policy from 2018. In advance, I apologize for all the awesome people who and great piece that I will for sure forget. This will not be an exhaustive list.
.@ZachWritesStuff on the overuse of the term "epidemic" mainly in the context of drug use: "Our faith in finding solutions is strong enough, in fact, that we sometimes forget “epidemic” is only a metaphor for something much more resistant to treatment." nytimes.com/2018/08/14/mag…
.@germanrlopez learned in Virginia that the obvious is true: when bringing addiction treatment into the rest of the health care system through Medicaid, more people actually get treated. vox.com/policy-and-pol…
.@DanielBRaymond on the what we can lessons from the HIV/AIDS epidemic can be applied to the overdose crisis: "Stigma is the enemy, activism is the accelerator, and medicines work only when people have access to them." philly.com/philly/opinion…
.@SamuelKRoberts looks back to a moment in history when we could have decriminalized all drugs: "The war on drugs should be prosecuted, he argued, to its fullest extent."philly.com/philly/opinion…
.@Lb_Sterling and @thesmallpicture on the time Philly City Council adopted a resolution to give crack to people in addiction: "The goal of Resolution 789 was to explore a potential solution to the harms the illicit drug trade was causing Philadelphia." philly.com/philly/opinion…
.@MyHarmReduction writes that that what we don't know is killing us: "While death rates continue to rise, I wonder: How do we measure whether our policy solutions are effective and at what point must we change course to explore other options?" philly.com/philly/opinion…
.@maiasz sets the record straight on the myth of overdose from touching fentanyl: "Basically, if fentanyl could kill via skin exposure or just being near it, users wouldn’t need to inject or ingest it to get high." tonic.vice.com/en_us/article/…
.@LeoBeletsky and @JeremiahGoulka call to abolish the DEA: "The Drug Enforcement Administration, the agency that most directly oversees access to opioids, deserves much of the blame for these deaths." nytimes.com/2018/09/17/opi…
.@maiasz calls out the media for its use of language and narrative around the overdose crisis: "In order to do better, journalists must recognize that addiction is not simply a result of exposure to a drug, and that “innocence” isn’t at issue." cjr.org/covering_the_h…
Jeffrey Samet, @MBotticelliBMC, and Monica Bharel call for changes in law that would allow for physicians to prescribe methadone to their patients in the primary care setting. statnews.com/2018/07/05/met…
.@cmoraff shares the results of one of the most innovative projects in drug policy/ harm reduction/ solution journalism I heard of: "For over a year... I regularly asked drugs users on the streets if I could test their samples, and recorded the results." filtermag.org/2018/12/13/wha…
.@ZachWritesStuff reviews three books on the current drug crisis and challenges the emphasis on the supply side narrative. longreads.com/2018/09/20/hat…
.@thesmallpicture writes that MARA -- medication assisted recovery anonymous -- is the latest innovation in 12-step. All the support, none of the abstinence only requirements: slate.com/technology/201…
I'm going to take a break from this thread (it's been a while on here now) but if you want more, check out @adfoxMD excellent thread:
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