The intersection of Massachusetts Avenue and Melnea Cass Boulevard, close to methadone clinics and Boston Medical Center, has become Boston's visible epicenter of opioid addiction and homelessness. Unhealthy, unsafe conditions have affected local school children and business owners, and in the face of a growing makeshift tent city, acting Mayor Kim Janey has just unveiled a sweeping new plan. Over the past few months, there's been no shortage of opinions about what should be done for the area known as "Mass and Cass." But whether it's placing people in a nearby vacant hotel, a hotel in Revere, or in an unused detention facility, resistance springs up from local residents, elected officials and even the ACLU.
At its heart, the situation at Mass and Cass is a humanitarian and public health problem. It demands treatment-centered solutions—for a population that often has trouble accessing treatment. Miriam Komaromy, MD, medical director at the Grayken Center for Addiction at Boston Medical Center (BMC), co-authored a recent op-ed describing the needs and fears faced by experiencing homelessness. She and her co-authors, Brendan Concannon, and Sarah Porter, argue that to provide a dignified "off-ramp" from the dire conditions at Mass and Cass, the city should offer low-barrier temporary transitional housing that allows people space and time, a few weeks or months, to stabilize.
HealthCity spoke with Komaromy about Mass and Cass, solutions and challenges, and the opportunity that Boston's $400 million in federal funds from the American Rescue Plan Act presents.
HealthCity: Can you describe the situation at Mass and Cass now? Who are the people clustered there and what problems are they facing?
Miriam Komaromy, MD: While it may look to passersby like it's one population, it's actually a fairly diverse group of people gathered there. At BMC's low-barrier urgent care clinic for people with addiction, Faster Paths to Treatment, we see quite a few people who are living on the streets who come in looking for services, so I hear about their situations.
There's a mixture. Some are people who originally came seeking treatment but have relapsed. Then there are people who take advantage of that situation and come to sell drugs to them, some running large drug operations, others just trying to scrape together money to avoid withdrawal themselves. The other component in the mix is people with serious mental illness. A substantial number have untreated mental illness and are not getting treatment.
We've always had a population of people struggling with addiction who have not gotten treatment or for whom treatment doesn't feel like a feasible option for whatever reason. They use substances frequently to avoid withdrawal or to avoid emotional pain or traumatic memories. Often, they are not able to maintain a job or live in a group setting indoors, and so they end up on the street. That population has grown during the COVID-19 pandemic. Those sleeping on their cousin's couch or the like were no longer welcome there because of contagion fears. Shelters had to decrease their density. People lost employment when places shut down. That had a major destabilizing effect. Addiction problems tend to get worse when people are stressed, isolated, and fearful—so we have a perfect storm of factors increasing the population living on the street.
HC: Clearly, it's a complicated problem with both social and medical dimensions. What needs to be done?
MK: A lot of the treatment offered now for both addiction and mental illness comes with strings attached. We demand certain behaviors as an "entry ticket" to getting help. People who have addiction and are not able to stop using drugs immediately and completely are often rejected from treatment, when in fact we know that addiction is a chronic relapsing disease, and relapse is a symptom of its severity. A much more rational approach would be to work with somebody who relapses to try to keep them engaged with treatment and strengthen the treatment supports, rather than rejecting them. In fact, I would say that it is the norm, rather than the exception, that patients who start to engage with treatment continue using drugs for a time, and then are often able to taper down or taper off with ongoing treatment.
Similarly, for mental illness, if people come into clinics and create a disruption, are loud, aggressive, talking to themselves, they may be told that they can't get help there. And yet they're the people most in need of treatment. Offering treatment that starts on the street has been demonstrated to be an effective model—and yet we're not doing very much of that.
A model called assertive community treatment has been shown to have an impact. An ACT team typically involves a psychiatrist, a case manager or social worker, and maybe a public health nurse who go out and interact with people on the street and gain their trust. There also are some long-acting anti-psychotic medications that can be given by injection that can help somebody who isn't able to take a pill every day or come into a clinic for care. But these require a real investment in outreach and relationship-building. This would be an excellent approach for people who have co-occurring SUDs and mental health problems, as well.
HC: What about calls from local residents and businesses to just get people off the streets or move them elsewhere?
MK: A big part of the problem in the Mass and Cass area is directly attributable to our lack of easily accessible housing. If you or I were unhoused and needed housing, we could go and sit in an office and cooperate and show our birth certificate and driver's license or passport. If someone ran a background check on us, they'd probably not find a serious criminal record. Many people living on the street can't sit still in an office, they don't have those documents, and they're often afraid of being incarcerated or mistreated. So what seems accessible and available is often actually unattainable for the people with the greatest need in our current system.
Our low-income housing is almost exclusively contingent on people stopping using drugs. People have to both say they're not addicted and behave as though they're not addicted. That is a huge barrier, and it sets people up for really bad outcomes, like overdose death. If I’m afraid, and I don't acknowledge that I'm addicted to fentanyl, you won't know to check on me frequently or give me Narcan.
Even at most shelters, people have to give up their drugs and even the sterile syringes that they got from the city's harm-reduction sites. They get into a shelter, then go into withdrawal in the middle of the night. They don't have the drugs, so they go outside and then are not allowed back in.
HC: Your op-ed emphasizes the need for transitional housing to help people stabilize. Do you think Boston is ready to implement that? What challenges lie ahead?
MK: I think the biggest barrier is buying a building (or ideally multiple buildings); but if the city would take the initiative to do that, using the federal ARPA funds, there are plenty of organizations that would be more than happy to run that facility with a low-barrier approach.
Most people on the street want help, they don't like being addicted, but they're caught in a vicious cycle where they don't have enough stability in their lives to be able to engage with treatment and stop using. We need to change our paradigm and say, "Let's get people housed, and then they have a chance of stabilizing."
But we have to allow it as a community. If every step that's taken is blocked, of course there's going to be a narrative that "Nothing's being done." In order for something to be done, people have to go somewhere—potentially to multiple sites around the city and the state. It doesn't all have to be in one place, it doesn't all have to be one building, but ultimately people have to go somewhere.
Addressing this problem directly requires intervention by a larger government entity. Municipalities and state government need to step up to say, "This is similar to a public utility. We have to site it somewhere."
HC: Do you see any hopeful signs that it could happen soon?
MK: Getting $400 million in federal funding is going to help shift the dialogue for Boston. I think the city needs to use a chunk of that money to solve this problem. And I think it could happen pretty quickly. I think the city could buy a hotel. You don't have to build something. You don't have to wait for the perfect setting.
HC: Are there programs in other cities that Boston could look to as a model?
MK: In Denver, they've implemented a housing first approach—in which people can obtain housing not predicated on their stopping substance use and receive supportive services along with housing—and are seeing good outcomes. Tiny houses is another idea to look at. Again, these require community cooperation and need to be well-run to be successful. It's quite possible that we'll have to spend more money than we save by housing the people at Mass and Cass. But, let's face it: The least expensive thing to do is let people die—and I don't think any of us want to live in that kind of society.