Barriers to effective care: Specialty drug treatment in Philadelphia.

Introduction: In Philadelphia, the poorest big city in the United States, an estimated 60,000 people misuse opioids and more than 3500 have died of overdose in the past three years. In 2019, fentanyl was detected in 76% of drug-related deaths and 94% of opioid-involved deaths. While much attention has been directed at the public face of the city's drug problem, more than 75% of drug deaths in 2017 took place in a private residence.

Method: Based on qualitative research to understand the vulnerabilities of this hidden population of drug users, we interviewed kin of 35 people who had died of opioid overdose in 2017 to learn whether their loved one had interacted with any social services or harm-reduction interventions.

Results: In our demographically and geographically representative sample of decedents, we found that while most had received treatment at least once, many faced barriers to getting treatment when they needed it, including barriers related to stigma, structural racism, gender inequities, bureaucracy, insurance requirements, and cost.

Conclusion: We argue that these barriers place an undue burden on people with substance use disorder and their kin during particularly fraught moments of heightened vulnerability. The failure of state and federal policies, practices, and infrastructure to address these barriers, and the failure to require that evidence-based care be provided during treatment have deleterious effects on people affected by the opioid epidemic in the United States.