What does addiction treatment look like for undocumented migrants in Philadelphia? The options are limited and often subpar.

In April 2019, Carlos* had only two forms of identification: a copy of an expired ID card from Puerto Rico that was more than 20 years old, and a piece of paper with his name and photograph that he was issued upon release from prison.

The prison ID is what once enabled Carlos, 41, to access Suboxone the brand name for buprenorphine, a medication used to treat opioid use disorder and is the reason that in April he was able to enter into a detox program in Philadelphia for the third time.

Carlos, like all Puerto Ricans, is a citizen of the United States. However, in 2015, he said his identity was stolen, which led to a multi-year battle of reclaiming his identity, disproving false murder charges committed in his name, and disputing accusations from Immigration and Customs Enforcement (ICE) that he is an unlawful resident. For people without any documentation, Carlos said access to addiction treatment is much harder to come by than for those who have it.

“Some people I know, they can’t take out medication,” Carlos said. “They can’t get into treatment. There’s a lot of things that they can’t do.”

Carlos said some of the undocumented residents he knows feel as though their hands are tied because they don’t have identification. He said he has seen people turn to crime out of desperation for money for out-of-pocket addiction treatment. He said that if it were not for his prison ID, he might consider selling drugs or buying a fake ID to get into a treatment facility.

According to the Pew Charitable Trusts, there are approximately 50,000 undocumented migrants living in Philadelphia, none of whom are eligible to receive help from government-funded welfare assistance programs, such as Supplemental Nutrition Assistance Program (SNAP, known commonly as food stamps), Social Security Income (SSI), and Medicaid. A lack of insurance means high upfront charges for medical care, which often restricts undocumented migrants from accessing simple routine check-ups, let alone long-term treatment such as addiction rehabilitation programs.

Undocumented migrants living in the United States are significantly less likely to seek routine medical treatments than those who live in the country lawfully, according to the Kaiser Family Foundation. The foundation found that their apprehension about going to the doctor is due in part to fear that their doctor will break HIPPA, contact ICE, and have them deported. This fear also affects those in need of treatment for substance use disorders, Carlos said.

“People gonna be afraid because they think they gonna send them back,” he said. “That’s why people don’t look for help. A lot of people don’t look for help just for that.”

“If they don’t have no health insurance, and they are not legal in documents, they’re not going to get their services.”

— Charito Morales, Registered nurse and community advocate

Faith-based recovery

Due to the difficulties people without documentation face when trying to access health insurance and the often prohibitively high out-of-pocket costs of addiction treatment, advocates say their options are limited.

Charito Morales, a registered nurse in Philadelphia who works to connect people affected by poverty, homelessness, substance use disorders, and undocumented migrants to available resources, said the most available options for people without documentation seeking refuge and recovery are faith-based programs and shelters.

Morales said there are around 300 faith-based programs in the city, and because they are privately funded and do not receive any money from the government, they are able to offer their services to people without documentation.

Although they are not medical facilities, Morales said that many of them have beds and Narcan, and some of them are staffed by nurses. She said that people who seek treatment in such places will likely be uncomfortable, but they will be safe and sheltered, and in the event of an emergency, staff members will call for backup and take people to the ER where they can receive proper medical care.

“They are not medical facilities,” Morales said. “But in the name of God in faith organizations, these individuals do the detox in there without medication, without no medical supervision. Just by the people who’s living there, and people who already [went through] withdrawal, and they know how to basically deal with it.”

Morales said many of these programs more closely resemble recovery houses residential facilities where people in recovery can live, but that do not offer medical services than actual detox or treatment centers. In order for someone without documentation to get into a licensed rehabilitation facility, they need to pay upfront, she said.

“If they don’t have no health insurance, and they are not legal in documents, they’re not going to get their services,” Morales said. “You’re never going to have a proper detox program, you are not going to have a proper rehab facility, space, or bed available for you unless you are paying cash or somebody is paying for you.”

However, Morales said faith-based recovery programs are not always the saving grace that they appear. She said that while some are well-intentioned, others are not transparent about how they use their donations, and some exploit those in their care. These malpractices often go unreported due to the fact that people without documentation or insurance are less likely to have the means to take action against a program that preyed upon them, she said.

“Sometimes some of them take advantage and they take their documentation and their money … and then throw them out in the street to become homeless,” Morales said. “But, some of them are good people. Some of them are really doing it because they really commit to this and help others.”

Carlos echoed Morales’ warning. He said others have told him that some programs will take people who do not have documentation and allow them to stay in their facility, but with strings attached.

“People that don’t got documentation [programs] take advantage [of them],” Carlos said. “They put in work under the table, and [programs] take their money. They can make them do things that they don’t got to just to take advantage.”

And according to Morales, even the trustworthy, well-intentioned organizations don’t always help everyone who comes to them. Since they are privately owned, funded, and operated, they are able to discriminate against and deny help to anybody whose lifestyle they do not agree with, such as people who identify as members of the LGBTQ+ community, she said.

“The sincere faith-based organizations  if you told them you’re part of the LGBTQ community you [are] going to have issues,” she said.

Morales said that when working with members of the LGBTQ+ community, she tries to reason with treatment center employees and remind them that they are electing to turn their backs on fellow human beings. This strategy works around twenty percent of the time, she said.

“We can talk more, elaborate more, [and] say, ‘Come on — you can’t discriminate. God doesn’t discriminate,” she said.

“People that don’t got documentation — [programs] take advantage [of them]. They put in work under the table, and [programs] take their money." 

— Carlos*, Person who uses drugs

Unpaid work therapy

The Salvation Army’s Adult Rehabilitation Center is one organization that will accept people without documentation, according to Joseph Murray, the lead counselor of the Salvation Army’s Philadelphia rehabilitation center. He said that at no point during their intake process does the center question immigration status.

“It’s not part of our application processes,” Murray said. “Whether or not you are a citizen, that’s none of our concern. Our concern is whether they can fit within our level of care.”

However, Murray also said that during the 19 years he has worked at the center they have never employed a bilingual counselor, nor does he have reason to believe that they plan to do so.

“I can’t speak to the hiring and firing process,” Murray said. “I can tell you I am the lead counselor here, and we haven’t had a bilingual counselor since I’ve been here.”

He said they try to combat language barriers in other ways.

“We’ve had people that don’t speak English,” Murray said. “We just try to communicate the best we can. [We] seek outside resources, [such as] help from their peers that are here. A couple of different ways. Family, if they have it.”

According to Murray, the center is not a medical facility. Instead, they work to address the underlying cause of addiction through counseling, work therapy, and faith. Residents spent eight hours a day, five days per week participating in work therapy, which includes sorting through and tagging donations for the Salvation Army, working in the kitchen, and housekeeping. Residents are not compensated for their work.

“We’re addressing the issues that a person has that led them to the substance abuse issue in the first place,” Murray said. “The substance abuse issue is really not the issue — it’s just the one that’s caused the most damage.”

Murray said the rehabilitation center, despite the Salvation Army’s history of not welcoming members of the LGBTQ+ community, does not discriminate against them. He clarified that the center is separate from the Salvation Army Corps, and said that they will work with anyone who can meet their entry requirements, regardless of how they identify.

“If you can come in with a negative urine screen, and you can pass the breathalyzer test, and you have the medications and stuff that you’re going to need, and it’s not going to be — I guess you could say, a life-threatening situation — it’s pretty easy criteria to get into,” he said.

Many undocumented people living in the United States rely on such programs with little to no medical oversight, according to Morales. Sonia Soto, the director of Soldiers of the Lord, a recovery house located on North Front Street, said that she is not aware of any medical facilities that will help people access medical addiction treatment if they do not have documentation.

“The free clinics that I do know, it’s only for people that have IDs,” Soto said. “If you don’t have any ID you don’t have no free clinic. So either they share [with] somebody or you get medication from somebody else.”

“Not only are they being denied treatment that might help them, but they’re being denied the chance to get early release by participating in that treatment.”

— Jacob Schuman, Criminal defense attorney

Discrimination, language barriers, and rehabilitation in prison

Jacob Schuman, a criminal defense attorney in Philadelphia, said that when it comes to undocumented migrants with substance use disorders in prison especially those facing deportation upon release — their options are even more limited.

As someone who frequently represents undocumented migrants, Schuman said the best they can hope for is a light prison sentence and to quickly begin the deportation process.

“We’re really just trying to get them through the criminal justice bit of it as quickly as possible so that they can get deported and don’t have to sit in prison,” Schuman said.

Schuman said that people without documentation are ineligible to access any of the most effective addiction rehabilitation programs in prison, such as the Residential Drug Abuse Program (RDAP), because the government believes the cost of rehabilitating people facing deportation upon release from prison is simply not worth it.

According to the Bureau of Prisons’ (BOP) website, the RDAP usually lasts nine months, and is considered to be the most intensive rehabilitation program the prison system has to offer. Participants spend half of each day participating in program activities, and the other half on work, school, or vocational activities, according to the BOP. Additionally, those who complete the RDAP may be eligible for early release, Schuman said, which is another piece of the puzzle of institutionalized discrimination against undocumented residents.

“That’s just another part of the inequality here,” Schuman said. “Not only are they being denied treatment that might help them, but they’re being denied the chance to get early release by participating in that treatment.”

However, according to Jose*, who has spent a combined total of 26 years in the prison system, recovery programs in prison are flawed even for those who are allowed to participate. Jose, 50, said that rehabilitation programs in prisons cannot be effective since they do not foster honest communication, but rather incentivize lying about recovery progress. He has been out of prison for six years — the longest he has lived outside of prison since his first sentence.

“Only reasons people go here to these programs is because they know they have to — that’s the key to go home,” Jose said. “If they don’t go to the program, they will never go home. So, of course, they’re gonna go. But, they’re gonna lie their asses off. They’re gonna tell you what you want to hear.”

Jose became addicted to heroin as a child in Puerto Rico. He said his stepmother used to abuse him and his two younger siblings. As the oldest, Jose felt compelled to take the fall for all three of them, so he inevitably faced the harshest consequences when one of them tried to sneak food from the kitchen or use the bathroom inside the house, both of which were forbidden. Jose said that the day he first used heroin it no longer mattered how hard she hit him — he couldn’t feel it anyway.

Jose learned to read and speak English in prison. He said there were no bilingual staff members there and he never felt confident that conversations were being translated accurately. When he was offered the chance to borrow a library book he gladly accepted, thinking he would be sent a book in Spanish. Instead, they sent him Stephen King’s It — in English. When he finally became fluent in English he began working as an English tutor for native English-speaking inmates.

While undocumented, incarcerated migrants are not allowed access to the most well-regarded treatment options, they are technically eligible for some short-term rehabilitative programs, such as the BOP’s Nonresidential Drug Abuse Program, Schuman said. However, he also said that for-profit prisons, which are often where undocumented migrants are sent, are not required to offer such services. Additionally, they can be denied access to such services, as the limited spaces are given not on a first-come-first-served basis, but rather are given first to citizens of the United States and “authorized” migrants, and finally to those without legal documentation as space permits.

Schuman said it is not uncommon for judges to be unaware that undocumented migrants are not allowed access to the RDAP, and to give them longer sentences under the assumption that their extended prison time will include appropriate rehab and job training, from which they are also barred. These types of miscommunications stem from a broader issue where people who may have never before worked on criminal cases are appointed as district court judges, he said.

“You’ll have somebody who’s a former partner at a law firm who exclusively worked on tax, or exclusively worked on bankruptcy, and then all of a sudden, they’re handing down [criminal] sentences,” Schuman said. “They may not have ever even set foot inside a prison, and so I do think there’s a lot of lack of understanding or lack of knowledge about what actually goes on in prisons and the kind of services that are available.”

“If they want to change, they’re tired, and they want to turn a new leaf, then when we take them in, we don’t charge them, and [we] let them stay here for free."

— Sonia Soto, Director of Soldiers of the Lord

 A limited solution

Although the resources for people without documentation seeking addiction treatment outside of prison are limited and often flawed, Morales said there are good people working hard within these limitations to combat the problem — like Soto at Soldiers of the Lord.

Soto said that as long as people are respectful of the space and don’t bring drugs into the home, anybody is welcome, regardless of documentation. She said the program receives donations from several churches in the area, so when a person without documentation comes to them for help, they are able to take them in at no cost.

“If they want to change, they’re tired, and they want to turn a new leaf, then when we take them in, we don’t charge them, and [we] let them stay here for free,” Soto said. “We help them we give them that extra hand.”

The Soldiers or the Lord program lasts for eight months and can house up to 20 people, but Soto said they generally don’t like to have more than 15 people at any given time for the comfort of all the residents. Although they do not offer any medical services to those in their care, they do provide many other basic necessities, such as food, shelter, and support, she said.

“Where there’s three eating, you can add another one,” Soto said.

*Names marked with an asterisk are those of people who requested we use their first name only due to the sensitivity of the subject matter.