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Millions of U.S. drug users now are addicted to several substances, not just opioids like fentanyl and heroin. The shift is making treatment far more difficult.
Kalamazoo, a small city in Western Michigan, is a way station along the drug trafficking corridor between Chicago and Detroit. In its parks, under railroad overpasses and here in the woods, people ensnared by drugs scramble to survive. Dr. Helmstetter, who makes weekly primary care rounds with a program called Street Medicine Kalamazoo, carried medications to reverse overdoses, blunt cravings and ease withdrawal-induced nausea.
But increasingly, the utility of these therapies, developed to address the decades-old opioid crisis, is diminishing. They work to counteract the most devastating effects of fentanyl and heroin, but most users now routinely test positive for other substances too, predominantly stimulants such as cocaine and methamphetamine, for which there are no approved medications.
Kalamazoo Harm Reduction distributes sterile equipment to help people use drugs safely, including needles, ties, cotton balls and cookers.
By Jan Hoffman Photographs by Hilary Swift Jan Hoffman, who covers addiction, reported from encampments and treatment clinics in Western Michigan.
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