Social distancing can be dangerous for people in addiction. Can a knock on the door help?

In any direction he went, Jackie could find heroin.

He rents a room on East Tioga Street, half a block from the Kensington Pub. On the concrete steps, stained with rust from the railing, Jackie sat one morning last week and watched the users and the dealers; they’re on every corner, the handshakes and highs that used to be his life. He adjusted the cloth mask covering his gray beard, and let it go by.

When social distancing began in the middle of March, Jackie had been sober for one month. A patient with Pathways to Recovery, a treatment program in Port Richmond, he had spent those first weeks in intensive counseling, attending group sessions like “Living in Balance” and “Adjusting to Change.” He said he was learning to communicate better, to speak his feelings.

But as COVID-19 shut down Pennsylvania, so went the face-to-face programs that kept Jackie and so many others from using opioids, crack cocaine, and alcohol. Twenty of the 50 participants who were with Pathways two months ago have fallen off, its therapists said, and are presumed to have relapsed.

“There’s too much down here, it’s all in your face," said Jackie, who is 47 and has shared the room with his wife since November. “It’s kind of hard to stay clean when you see people using everywhere. It’s like, now, I remember that.”

The coronavirus has created new and staggering barriers for people recovering from addiction. Most experts say that isolation is the single-worst risk factor for relapse, but it’s the cornerstone of social distancing. Job loss and homelessness, always triggers for drug use, have come on suddenly. And many recovering users, like Jackie, are sheltering in place on blocks haunted by their former habits.

Jackie had been clean for 13 months once, but then he started gambling, then drinking, then using heroin and crack again. He wanted it to work this time, he said.

“It only works if you want it," he said. "People are not going to stop getting high until they’re ready.”

He had liked going to groups at Pathways, getting out of the house for a bit. The therapy sessions were now available over Zoom, but Jackie’s phone had been shut off. He couldn’t pay his bill.

But Jackie has not started using again.

Late Monday morning, there was a knock on the door of his building. When he came to the window, he saw Troy Mouzon standing on the sidewalk in blue latex gloves, Ray-Ban sunglasses, and a black mask covering his nose and mouth.

Pathways and other treatment programs have realized they need to go beyond the screen if they are going to keep the most vulnerable people in recovery. What has followed is an all-out effort to find people where they are.

Mouzon, a peer recovery specialist with Pathways, and three years clean, knew what people in recovery were up against, the fear and the cravings that existed long before the pandemic. So the 50-year-old would spend all day Monday driving around the city, tracking down people who were trying to stay sober, trying to remind them they were not alone.

He asked Jackie about his search for a new apartment away from the neighborhood. (The Inquirer agreed to identify Pathways participants only by the first names they provided.) He was eyeing a place on 49th Street.

“Is that where you want to be, in West Philly?” Mouzon asked. He had a lead on a place at 54th and Walnut and promised to make some calls. “Every source I have, you have,” Mouzon said.

He told Jackie he would be back soon with updates, then climbed back in his van, a white Chevy Express. There were a lot more people he needed to check on, to try to keep from relapse, even if for one more day.

Philadelphia, with the highest fatal overdose rate among large cities, has the worst urban opioid crisis in America. It’s getting worse.

Data released by the city last week show that overdose deaths rose 3% in 2019, claiming 1,150 lives. Nearly half of these deaths were due to a combination of opioids with stimulants, such as cocaine and methamphetamine. Overdose deaths are rising fastest among black and Hispanic users.

Jennifer Smith, secretary of the state’s Department of Drug and Alcohol Programs, said she has received data from some counties showing that overdose rates have climbed even higher during the pandemic, but did not have numbers for Philadelphia.

“Some of the overdoses are occurring in people in recovery, but early in recovery," Smith said. "It’s important for support systems to be actively reaching out to individuals who are new in that journey.”

» READ MORE: Inside Philly’s coronavirus quarantine hotel for those with nowhere else to go

In-patient programs have largely remained intact, while outpatient treatment "pretty much had to switch to telemedicine on a dime,” said Patrick Vulgamore, a project manager for Temple Health. Medical appointments became virtual, and fewer patients were no-shows, with transportation to the appointment a nonissue. “It’s extremely easy to pick up a phone and have a doctor’s appointment,” Vulgamore said.

Long-standing groups like Alcohol Anonymous and Narcotics Anonymous moved to Zoom meetings, already chartered territory for some chapters. Philadelphia-based groups welcomed members from Maryland to London, calling in from kitchens and bedrooms, toddlers bobbing in the backgrounds. In a group called “Mid-Day Miracles,” people unmuted themselves to clap in staccato for a man celebrating 30 years sober.

But Pathways to Recovery occupies a more complicated space on the treatment spectrum. Before the pandemic, its 50 participants spent their days at the center off East Allegheny Avenue before returning to their homes or shelters in the evening.

Founded three years ago, Pathways serves participants who also have mental health issues, and tend to be less stable in their recovery than those receiving outpatient care. “Many people are using or are very newly clean, sober,” said Denise Botcheos, the program director. “It’s definitely a population that needs a high level of care.”

While the program’s physical center did not close, its staff has strongly encouraged patients to stay home. In a bulletin last month, Pathways leaders outlined how they would all get through this: group meetings with dial-in codes; daily calls for individual check-ins; video calls with doctors to discuss medication; a 24-hour line that someone would answer, always.

Yet Pathways clients don’t all have computers, phones, or reliable access to them. And not everyone wants to Zoom their way out of isolation.

» READ MORE: Philly’s overdose deaths rose again in 2019, especially in black and Latino communities

And so Mouzon steered his Chevy Express away from the curb, intent on seeing five more people before the day was out. He is one of two peer counselors for Pathways; the other one, a woman named Temple, was just released from the hospital after two weeks fighting the coronavirus.

He parked the van four blocks away, checking on a man with medical issues. He worried about him, knowing the man was in pain and prone to self-medicating. He had knocked on his door the previous week, only to see him sleeping through the window.

The man would sometimes have 10 days clean, 11 days, and then “have a moment.” But talking with him on his porch Monday, Mouzon saw that he was in good spirits. The man’s grandchildren had visited recently.

He was three weeks clean.

After another short drive, Mouzon found Tyrone, who was happy for the excuse to get out of his house. “Who wants to sit on the phone all day?” he asked, shaking his head at Mouzon.

Tyrone lived with his wife, his wife’s son, and the son’s girlfriend and their baby daughter in a house on Unity Street. Before the coronavirus, he had worked eight-hour days. Now he found yards to mow and picked up odd jobs, but work was never guaranteed.

Inside the house all day, his family complained, Tyrone said. He needed to be outside, getting things done, and said he tried to explain that to his wife. “She said: ‘Oh, it’s about you? I thought we were in this together.’ But how are we in this together when you’re always on my back?”

The stress, the 55-year-old said, was getting to him. The answer used to be cocaine and marijuana, with a chaser of beer.

“Keep doing what you’re doing," Mouzon told him. “Your recovery is what’s most important. A lot of times it’s easy to focus on other people. But we’ve got to focus on what we can do.”

He knew Tyrone needed work, and he had a good lead for him. But there would be a drug test.

“That sounds fair," Tyrone said, “because if I really want to work, if I want the job, I have to do what it takes.”

He said he was smiling, even though Mouzon couldn’t see it behind his paper mask. The men kicked shoes and bumped elbows, then Mouzon was back in his van, steering west through the city.

So much of recovery, he knew, was helping people to find something to fill the void left behind by drugs. It was harder now, but it wasn’t impossible. He liked to ask, What did you like doing when you were young? Or, What did you love before you started getting high?

For Mouzon, it was learning. When he stopped using three years ago, he enrolled at Chestnut Hill College, where he felt good from Day One. He just completed his bachelor’s degree in human services, with a minor in psychology.

He likes how it helps him to understand people, why they are the way they are. “If you have enough information, you can make it make sense,” he said. “It’s not a 100% science, but it’s like, ‘Oh, OK. I get it.’"

He drove through Nicetown, the neighborhood where he came up. As a little boy he liked to ride the 75 bus across town to Frankford Playground. But as a teenager and young man, in the ’80s and ’90s, it was “pills, the dust, the coke.”

No one thing made him stop using, he said. He tried a few times before it stuck. Family and friends backed away, he said, because they didn’t know what to do. “There’s not a playbook for it," Mouzon said, but he thought about how alone he felt in his recovery.

Addiction always tricks people into feeling they are alone, he said. So he went to check in on a woman named Charlie who had graduated from Pathways two months ago.

“My list doesn’t go away,” he said. “It gets longer and longer.”

He goes looking through abandoned houses, jails, hospitals, morgues. He walks through neighborhoods where some outreach organizations won’t go. “People can hide in Kensington,” said Reagan Copeland, a Pathways therapist.

It means something to people, he said, when he shows up at their door and they realize they were worth looking for. “That look on their faces,” Mouzon said. “That’s my high now.”

Relapse happens. It is part of recovery, he says, and he has gone through it himself. People drop off.

One Pathways participant, who had connected well with the program and went regularly to group sessions, "was having difficulty feeling so isolated, and he just started drinking,” said Botcheos, the director.

“It’s heartbreaking," she said, “because you feel like they’ve got a handle on things, they’re moving in the right direction, and the pandemic has really decimated people’s support systems, and their ability to feel safe.”

Charlie was exactly where he expected her to be, on the front steps of her recovery house, four months clean. “The one thing is wanting it," she said of her sobriety. "You can’t only need it.” Mouzon pulled down his mask to show her his smile.

“I’m so proud of you. I can’t stop singing your praises,” he told her. She beamed back.

In the van, Mouzon took a bottle of Purell from his cupholder and rubbed his gloved hands together, then started driving the 20 minutes to Cheltenham. He wanted to check in on a young woman who had relapsed a few times, but was now going six months strong.

Mahogney, 31, sat on the porch of her parents’ home, a block from a cemetery. When she took walks around the neighborhood, she could see the burials, sometimes two at a time. “The coronavirus situation is scaring people,” she said. “I’m sitting across from the graveyard, I’m seeing the reality of it.”

But social distancing was actually helping her, Mahogney said. Her father was over 70, and mixing with her old crowd would mean exposing her family to the virus. She also liked avoiding going to the Pathways facility near Kensington, known for its open drug markets.

“One time I walked through Kensington to get to the bus stop,” she said, “and I’m not that strong yet, I’m sorry.”

“Knowledge of self is one of the most powerful things on the planet," Mouzon told her.

Last time she relapsed, she said she realized she’s more easily influenced than she thought. She learned to say no.

“You’ve got to be strong,” she said. “And you’ve got to want it. You’re always going to need it. It’s when the want and the need match up."

Mouzon smiled behind his mask. He told her he had chills: She was the third person that day to say the same thing.

Mahogney told him she’d be on his 9 a.m. Zoom the next day, and so he left to make just one more stop.

It was just after 3 p.m. when Mouzon parked the van in Strawberry Mansion for his last check-in. He went to knock on the door of the young woman’s apartment.

It was open.

He thought, This isn’t good.

Mouzon had been thinking about this woman, who started the program the same week that social distancing dismantled it. He knew she had wanted the in-person meetings, the face to face. She was just like Jackie, he said, in that her biggest challenge was her location. She did not just live down the street from a corner; she lived on a corner.

But she had a good attitude. Mouzon had enjoyed making his visits to her, keeping her engaged with the program. He had brought her extra masks and gloves. She had mentioned feeling under the weather, so Mouzon had packed soup and juice, too.

When he asked her why the door was open, the woman said she had been smoking a cigarette. She looked in the bag Mouzon had brought. She said, “Thank you.” But she barely said another word.

“What’s going on?” Mouzon asked her. “This isn’t us.”

And so it came out that she was using. He could tell anyway. She was repeating herself, checking her pockets too often, stammering when she spoke.

"I’m in my bag,” she said.

Back in the van, Mouzon let out a deep breath. It’s not like television, he said, where the person apologizes for their addiction, or makes excuses, or promises to never do it again. “When they’re at that point,” he said, “they don’t feel like they owe you an explanation.”

She had stood by the door, as if she wanted him to leave.

He thought what might have happened had the coronavirus not kept her in that apartment.

“For the stage of recovery she’s at, it’s hard for her to — it’s too much time and space in that little room.”

He hated that she hadn’t been upfront with him, when he walked in the door.

“I need her to fight a little harder," he said.

“But I come to the realization I can’t make my ready be her ready. So I’ll wait for it. I’ll wait for her to be ready.”

Until she was, he knew, he would keep coming back. He left the apartment, knowing she knew that, too.