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In early April, the coronavirus slipped into the third floor of the Kirkbride Center drug rehab and made quick work of spreading among the residents who were trying to get clean.

“Someone became symptomatic,” said Fred Bauer, the facility’s medical director. “The next day someone else, the next day someone else.”

The outbreak ultimately infected around 30 people living at the West Philly facility, sending a number of them to the city’s Holiday Inn quarantine site. Kirkbride managed to contain the virus before it ripped through the rest of its eight-story residential building, but like so many other congregate care settings, the center was caught largely unprepared by COVID-19’s ferocious contagiousness.

Two people familiar with the outbreak said Kirkbride was too slow at implementing antiviral measures like social distancing and universal personal protection equipment for residents and staff. Management put a four-person ridership cap on the building elevator only after the outbreak happened. With assistance from Penn Presbyterian Medical Center and Philadelphia health officials, Kirkbride ultimately got its pandemic policies up to code — and quelled the outbreak, for now.

Much attention around the COVID-19 crisis has focused on it spreading rapidly in group settings such as jails and nursing homes, where infections and fatalities have skyrocketed across the country. But residential drug treatment centers have also been facing outbreaks.

Kirkbride isn’t the only one.

Since the pandemic crashed into Philadelphia two months ago, the coronavirus has infiltrated a full quarter of the city’s 263 residential rehabs and behavioral health treatment centers. In total, 214 residents have been infected, according to data released by Mayor Jim Kenney’s administration. Eight of those residents have died.

It’s unclear which facilities have been hit hardest. Officials refused to release the names or number of cases at each facility. They cited a fear that those facilities would stop disclosing cases or sending clients to get tested if they did so, although many facilities openly shared their struggles against the virus with WHYY and Billy Penn.

The outbreak is one of several punches the virus has dealt to the city’s rehab community. Admissions have stalled at many facilities. Nearly half of the 270 beds at Kirkbride sit empty right now. Some say the crisis has forced people to jump through extra hoops to get into treatment, creating a bottleneck that deters some from seeking help and slows admissions for those who are ready.

“It’s an emergency on top of the emergency,” said Gadi Aronson, chief community engagement officer at Gaudenzia. “We’ve been dealing with opioids — now add COVID on top.”

Instead of treatment, the virus takes center stage

Defending the decision to withhold case numbers for specific rehabs, city spokesperson Mike Dunn said it was to protect residents’ privacy. The city is also “worried that facilities will curtail testing, or not report case counts in an effort to appear to have fewer cases.”

But several treatment operators spoke candidly about cases at their facilities, and the measures they’ve had to adopt to maintain drug treatment and safeguard against the virus.

Some behavioral health providers have seen limited cases to date. Gaudenzia confirmed six infections among residents at its 30 facilities in the region, no more than one at any individual facility. Some small centers are also stricter than others with limiting group activities. The 36-bed Crisis Management Services hasn’t had any cases among residents yet.

Staff are also vulnerable. At Fairmount Rehabilitation Center, a 239-bed facility divided into a psychiatric hospital and inpatient rehab, dozens of employees on the hospital side have been infected, according to two people familiar with the outbreak. Such a dramatic staffing shortage can affect the entire operation.

At Pathways to Recovery, run by Public Health Management Corp., one beloved staff member tested positive for the virus and is currently hospitalized. Both staff and clients were told.

“She wanted people to know,” said Denise Botcheos, program director at Pathways to Housing.

“It’s really helped people that are attached to her — clients have been reaching out to her left and right.”

Virus response now takes up much of each facility’s energy, on top of trying to maintain treatment.

At Kirkbride, management has isolated residents into units and begun work on a COVID-19 ward should more infections come. At every facility, staff are trying to educate residents about the necessity of social distancing. And then there’s the omnipresent battle to secure more PPE.

“[The virus] has gone from nothing to about 85% of our work,” said Jim Kennedy, CFO at Crisis Management Services.

Admissions down 50% in some rehabs

Under normal circumstances, to be placed into residential treatment, a person is routed through one of several assessment centers scattered throughout Philadelphia. There, the individual is assessed by a counselor, who finds the appropriate placement based on a variety of factors ranging from insurance eligibility, to severity of condition, to available beds.

Since Philly’s stay-at-home order was issued on March 16, at least one crisis response center, at Temple’s Episcopal Hospital in Kensington, has stopped assessing patients altogether.

At NorthEast Treatment’s assessment center at Eighth and Spring Garden streets, social distancing measures and additional vital-sign collection to screen for COVID-19 have created a bottleneck. Staff have limited waiting room capacity to four people, meaning others have to line up on the street to be seen.

“We’ve had people wait six, seven, eight hours — nightfall sets, it gets cold, they just say forget it,” said Bill Kinkle, who works at CleanSlate, an outpatient recovery service that often refers people.

During that time, Kinkle added, people with fentanyl in their system may begin to enter withdrawal, pitting the urge to use again against the desire to enter treatment.

“It’s a horrific process,” Kinkle said.

He and other advocates worry that limiting access to treatment increased risk of overdose. Preliminary data from the Philadelphia Medical Examiner’s Office suggests the number of fatal overdoses throughout the shutdown is, in fact, slightly lower than the same time last year — although more than 100 pending cases remain to be investigated.

Despite consistent demand for treatment, the logjammed assessment process has left even the busiest residential treatment centers looking at empty beds for weeks.

Stimulus funds? See ya later

That irony was not lost on Ed, who is living on the streets, addicted to meth, and ready for help. WHYY and Billy Penn agreed to withhold his last name because he discussed illegal drug use openly.

Ed wanted to go straight to treatment on a recent Friday, but because he had symptoms of what appeared to be pink eye, which has been shown to be associated with the coronavirus, he was told he needed a medical evaluation before he was admitted to the assessment center.

To get the medical evaluation, which could only be conducted via telehealth, he needed to get his hands on a phone — which meant waiting until his counselor returned to work on Monday so he could call the doctor.

“I got myself stuck, and I’m trying to pull everything back together before it, like, totally blows up,” Ed said.

In some cases, low census numbers may also be due to people leaving treatment early. Part of what makes recovery possible for many is the feeling that they’re not alone. With the paring back of most group sessions and community activities, the sense of camaraderie is harder to come by.

“People don’t want to come in,” said Kennedy, of Crisis Management Services. “They can’t have their normal community activities. They have to eat alone in their room.”

It’s also common for people to “elope,” or leave rehab against medical advice, if they come into a bit of money, said a therapist at one facility who asked to remain anonymous because he was not authorized to speak publicly. He said while not all of his clients were eligible to receive federal stimulus checks, those who did were eager to spend them.

“I haven’t had one person who’s gotten [stimulus funds] stay,” he said.

Low occupancy hasn’t threatened the finances of Philadelphia’s treatment centers as it has hospitals or nursing homes, in part because Community Behavioral Health, the city’s nonprofit Medicaid pass-through, shifted away from its usual fee-for-service payment model to paying facilities a flat rate. That way, providers wouldn’t have to worry how many patients were coming through the door to be able to stay afloat.

“This way, we could really focus on the care,” said Adam Brooks, senior director of addiction services at Public Health Management Corp.

While preventing the spread of the coronavirus may be the principal concern for most, for those experiencing or treating substance use disorder, it can simply feel like the latest condition to adapt to, and avoid.

“Our touchstone has been, yes, COVID-19 is deadly, but so is addiction,” said Brooks. “We cannot shut down operations or withhold treatment because we can’t figure it out.”