A block from Kensington Avenue on a recent January morning, two people stopped to help a man who lay unconscious on a cold sidewalk. One called 911. The other yelled out in the street, as if hailing a cab.

“Does anyone have Narcan?” she asked. “We need Narcan for this guy.”

Suddenly, a middle-aged man appeared from a nearby building and tossed them two doses of naloxone without a word. The Good Samaritans administered the opioid overdose-reversing nasal spray through the man’s nose. One dose at first, then another.

His breath returned, and he woke up. First responders were en route — but before they arrived, the man they came to help was gone.

Situations like that have become increasingly commonplace in Kensington, the primary axis of the city’s opioid crisis, which has claimed more than 3,000 lives via overdose in the last three years.

No victim was present nearly 40% of all overdose incidents that EMS responded to last year, according to city data reviewed by Billy Penn. The rate of “missing” victims for overdoses is double the total rate for all medical emergency responses. Thousands more were MIA when the ambulance arrived last year than in 2017, when overdose fatalities reached record highs.

Public health officials attribute the rise to the widespread proliferation of naloxone over the last three years.

The number of people affected is significant. The Philadelphia Fire Department, which handles the city’s emergency response teams, dispatched medics to 16,954 OD or poisoning incidents last year. On 6,619 of those runs — nearly two in five — medics found no one at the scene.

“This is rising,” Health Department spokesperson Jim Garrow told Billy Penn. “We think that people are calling 911, administering naloxone and then the person is revived. Their life is saved. And they don’t want to wait for the ambulance.”

The city’s medic fleet has been scrutinized over slow response times to emergency calls over the years.

Philadelphia’s paramedics have also been administering less naloxone themselves in recent years, thanks to the recovery drug’s widespread availability.

But the rising rate of MIA overdose victims means that public health experts and harm reduction advocates who are fighting back against the toll of the overdose crisis have fewer chances to meet users and try to get them into longterm treatment.

Why overdose victims don’t wait for the ambulance

Many people who use drugs don’t have good experiences with EMTs, particularly in Kensington, said Billy Ray Boyer, outreach coordinator for grassroots harm reduction group SOL Collective.

Naloxone temporarily blocks the opioid receptors in the brain, which can reverse the lethal effects of an overdose. It also sends users into immediate withdrawal.

“Their body goes into such a state of sickness and withdrawal that they don’t want to talk to anybody, ” Boyer said. “They don’t want to talk to their best friend. It’s hard to describe how bad it feels.”

Paramedics have long reported these broken relationships on the front lines of the opioid crisis. Administering the naloxone is the easy part, but effectively connecting people to treatment remains a source of constant frustration.

Of the overdose victims still on scene when paramedics arrive, hundreds decline the voluntary transport to the hospital each year.

Fear of law enforcement can also act as a deterrent for some, said Susan Sherman, a professor at Johns Hopkins Bloomberg School of Public Health.

While Philadelphia has lightened prosecution around some drug offenses, trepidation of getting caught in the criminal justice system is still prevalent here and elsewhere in the state. Under Attorney General Josh Shapiro, Pennsylvania as a whole leads now the country in pursuing drug-induced homicide charges.

She says some people using drugs many be ready for treatment after a near-fatal overdoses, but many will require additional resources first.

“People often jump to treatment — treatment is so important when people are ready,” Sherman said. “First and foremost, the goal of having someone be reversed for naloxone is keeping them alive.”

Sherman says other factors influence and complicate decision-making among people who use drugs, including poverty, hunger and sleep deprivation.

“These things all create very unstable grounds, sometimes so unstable that it feels like quicksand constantly trying to pull you,” Sherman added. “People need other things to get them on level ground, and then they can make other decisions.”

Naloxone training in Philly nearly tripled last year

To help bridge the divide between first responders and people using drugs, EMS launched an initiative last year called The Alternative Response Unit, or AR-2, a team of medical personnel, behavioral health and social workers who do daily outreach in Kensington.

The goal is “to connect people straight from where they are to treatment,” said Crystal Yates, the assistant deputy commissioner for EMS. The roaming unit has helped connect 144 people since last April, she said.

AR-2 also distributes naloxone into the community as well.

The city gave out 68,490 doses of naloxone in 2019. That’s more than double the amount it supplied three years ago, according to city data.

The Department of Public Health’s distribution list includes EMTs and paramedics, but also firefighters, police officers, health officials, county jails, and — more and more every year — the general public.

How many naloxone training sessions did Philadelphia host last year?

The city’s main health and mental health agencies instructed nearly 8,200 people in about 200 training sessions, according to Garrow. The year prior, those agencies trained just under 2,900 people how to reverse overdoses.

The effect, officials say, is obvious.

“More frequently,” said Garrow, “bystanders and the folks in the community are the ones saving lives.”

Other government and non-governmental agencies are also flooding the city with naloxone. Pennsylvania is one of many states with naloxone access laws that make it available to get without a prescription, and doctors regularly prescribe it to people at risk of an overdose death.

Largely attributed to the antidote’s availability, the number of overdose fatalities dropped from a record-high 1,217 in 2017 to 1,116 in 2018. Numbers are not finalized for last year, Garrow said, but health officials expect them to be similar to 2018.

Meanwhile, Philadelphia is still trying to open the first supervised injection site in the country to further quell the tide of overdose deaths.

Max Marin (he/him) was Billy Penn's investigative reporter from 2018 to 2021. A graduate of Temple University, he has produced award-winning journalism on local politics, criminal justice, immigration...