When Jessica Ney stopped by his office one morning in March, Joe Quinn thought she looked happier than he'd ever seen her. She'd just gotten out of rehab for her heroin addiction and couldn't wait to get her life restarted, she told Quinn and other outreach workers at Pathways to Housing, the innovative Philadelphia program that helped her get a place to live even before she got sober.
Quinn tried to coax her to stay for a group therapy session he was about to lead.
But Ney, 36, told him she just wanted to go home to the apartment that had become her pride and refuge after three years on the streets of South Philadelphia.
Quinn reluctantly said goodbye. He was terrified for her.
Drug recovery is precarious. Relapse is more likely than lasting sobriety. And for opioid users, being fresh out of rehab can be deadly if they pick up again at their previous dose, which now is too much for a brain that has lost its tolerance for drugs.
Medication-assisted treatment (MAT) helps deal with all-consuming cravings – about half of opioid users in recovery stick with such a program for at least six months. Decline it, however, and the relapse rate is as high as 90 percent within just 30 days. Time in treatment is another red flag; the National Institutes of Health says fewer than 90 days of inpatient or outpatient treatment "is of limited effectiveness and treatment lasting significantly longer is recommended."
Ney refused MAT, and had just 28 days at a suburban rehab clinic after her insurance declined to cover a longer stay.
A few hours after she said goodbye to Quinn, a frantic call came in from an outreach worker who visited Ney and found her unconscious on the floor.
Quinn raced over, praying the whole way. He pulled up to see the worker walking down the steps, shaking his head.
Ney died of an overdose of cocaine and fentanyl hours after leaving rehab. Her story illustrates another reason the opioid crisis is so intractable: Even when individuals agree to treatment, they are far from safe, especially if they don't get high-quality care. Indeed, they could be at even greater risk than if they had kept using, in large part because of deadly synthetic opioids such as fentanyl.
Ney followed a path familiar to many heroin users: more than a decade in and out of recovery houses, incarceration, and bouts of homelessness. Originally from rural Schuylkill County, she lived on the streets here for three years. The Queen of South Philly, Quinn called her. Everyone seemed to know her, as much for her tough exterior as for her concern about others on the street. Before she entered Pathways and got her own apartment, the outreach worker who found her body remembered, she was quick to help her friends into treatment — but never herself.
Still, once in Pathways, she entered a methadone clinic even as she was still using heroin, and it seemed to help her cut down. Quinn passed Ney on the street in Center City and barely recognized her. She had shed the ragged clothes she used to panhandle in. She looked put-together. Promising.
But methadone programs require almost perfect daily attendance. She missed treatment three days in a row — she told her mother it was because she had lent her bus pass to a friend, and told Quinn it was because she had the flu — and left the program. A few months later, she tried rehab again, at Valley Forge Medical Center.
Her insurance, through Medicaid, covered just 28 days, though Ney told Pathways staffers that she had begged to stay. (The standard monthlong inpatient treatment is a holdover from alcohol addiction treatments that date to the 1950s – which advocates and experts say is not nearly long enough to help people in opioid addiction.)
"We know that people who stay in [long-term] treatment, in general, have a much better outcome — less frequent incarceration, higher incomes, fewer relapses," said Karen Mechanic, the medical director of the substance-abuse division in the psychiatry and human behavior department at Thomas Jefferson University. "It's a chronic disease — so it's like a person who has diabetes, or high blood pressure. They need treatment forever."
Geoffrey Neimark is the chief medical officer for Community Behavioral Health, the nonprofit that handles treatment for Philadelphia's Medicaid patients. He couldn't discuss Ney specifically but said the agency does allow longer treatment depending on the person's mental and physical health, housing, and support systems. Rejections of requests for services, he said, are rare.
The agency also encourages MAT — indeed, decreasing the stigma surrounding those treatments is at the heart of the city's plan to fight the opioid crisis. But despite her earlier success with methadone, Ney refused it this time.
She told Quinn that she didn't want to rely on any assistance to stay sober, echoing a common – but medically incorrect – stigma that it's wrong to use drugs to get off drugs. "Liquid handcuffs," she called the treatment.
In the last year, since Pathways started its opioid-addiction program, 10 participants have died; six of them, including Ney, overdosed after a period of abstinence.
Experts say that more research is needed on the dangers of using drugs after a stint in rehab or a period of abstinence. But studies from the early and mid-2000s that followed people during those periods show that the risk of fatal overdose is significant – and that was before the even deadlier fentanyl began to contaminate the drug supply. A 2007 study conducted in Italy found heroin users were particularly at risk in the first month after leaving rehab. This year, a study of Rhode Island inmates who were started on MAT during their time in prison — and who continued with treatment after leaving — found that the program reduced fatal overdoses so much that it had "a significant effect on the death rate from opioid overdoses statewide."
"We game-plan when we know someone is getting out of" treatment or has detoxed in jail, Quinn said. He and his colleagues want to be encouraging and enthusiastic. But they have to be realistic. So they urge their clients to carry naloxone, the overdose-reversing spray, in case they slip. Don't use alone, they are reminded, and make sure your companion knows where the naloxone is.
"I feel guilty," sounding so negative, Quinn said. "You don't want to plant that seed. But I would feel worse if I didn't have that talk, and they passed away."
Jayne Grickis, Ney's mother, remembers the years when her daughter would insist she wasn't sleeping on the streets, that she was staying with one friend or another. By then, Grickis was taking care of her 8-year-old granddaughter, Brianna.
"All Brianna wanted was her mom, and all her mom wanted was her, but she couldn't get off drugs," Grickis said.
But in her own place, Ney was on an upswing. She got a cat, a sewing machine, and covered her apartment in fabrics and dressmaking patterns, planning what she would create. She reconnected with family, made pink tulle tutus for Brianna, and posted glowing photos on Facebook.
She was not naïve, though. A friend left treatment, used, and died. She told an outreach worker that wouldn't happen to her.
When it did happen, when the paramedics couldn't revive her, a police detective tried to console Quinn. He had relatives who struggled with addiction, too, he confided.
Grickis was driving when she got the call from Pathways. She waited two days, until her two surviving children could be with her as she broke the news to Brianna. The child picked out the last outfit her mother would wear, and made a collage of photos to display. She asked the undertaker whether she could braid her mother's hair.