Even before the year is officially over, health officials are declaring 2018 to be a landmark in Philadelphia’s opioid crisis, marking the first time in at least five years that overdose deaths will have declined. More people sought treatment. More doses of Narcan, the lifesaving overdose reversal spray, were handed out in the city’s hardest-hit neighborhoods.

In short, “all the key numbers are moving in the right direction,” Health Commissioner Thomas Farley said last week.

Yet, Philadelphia’s overdose death rate is still shockingly high. An estimated 1,100 people will have died of overdoses here by the end of 2018. The peak was 2017′s loss of 1,217 people to drug overdoses — the vast majority driven by the powerful synthetic opioid fentanyl.

“I’m hopeful that this is the turning point,” Farley said of 2018. “It’s still at crisis levels. But the fact that things are finally moving in the right direction is a definite sign of hope.”

Still, a drop in overdose deaths doesn’t necessarily mean a drop in drug use, and Farley said it’s hard to tell what caused this year’s decline. Some advocates believe the decline is mostly thanks to the 21,000 doses of Narcan the city handed out this year. First responders and emergency departments also saw fewer nonfatal overdoses in 2018. But that too could be deceiving because so many advocates, bystanders, and drug users themselves administered Narcan, meaning those overdose cases never were counted.

Those under-the-radar cases represent the city’s biggest task in the new year as it continues to battle the worst big-city overdose crisis in the country.

In 2018, the city turned its full attention to long-neglected Kensington, the epicenter of the epidemic. Now, advocates and city officials say, they must reach people whose addictions are less apparent — but no less deadly. Three-fourths of the city’s fatal overdoses in 2017 occurred in private homes, and there’s no reason to think that will change much when the 2018 data come in. Neighborhoods like South Philadelphia, where the overdose rate skyrocketed but where addiction is rarely seen or spoken of in public, have almost no resources to help those in addiction.

In 2019, Farley said, the Health Department will promote medication-assisted treatment — proven to dramatically increase the chances of lasting recovery — in those neighborhoods. “We know that the people we see who are homeless who are using opioids are a very tiny piece of the problem, that the larger problem is much more hidden," he said.

Renewed attention in drug-plagued Kensington

As city officials review what worked and what didn’t to combat the epidemic in 2018, they point to Kensington. Unprecedented resources went into opening drug treatment and shelter space, clearing camps of homeless people in addiction from sidewalks, and distributing Narcan. Still, those signs of progress have been tempered by the stark reality of a drug crisis entrenched for decades.

Even after clearing two heroin encampments and ultimately getting more than 100 people into treatment or shelter, the number of homeless people in the neighborhood doubled this summer to 703, about half the city’s entire homeless population.

It was a statistic that led to an unprecedented move by Mayor Jim Kenney this fall: declaring a disaster over a public-health crisis in a city neighborhood. He extended the declaration through June last week. The resulting emergency operations center in Spring Garden, where seven city agencies meet daily, has lifted the usual bureaucracy while forcing agency officials to personally confront conditions in Kensington.

“Sitting in our office, it’s really easy to forget about the challenges the community faces,” said deputy managing director Brian Abernathy. “It’s very sobering to recognize what these folks live with, day in and day out.”

The Emerald Street camp is still there, however, as city officials search for open beds for its residents.

Councilwoman Maria Quiñones-Sánchez, who represents much of the neighborhood, said she is pleased with some results of the emergency declaration. Regular neighborhood cleanups have improved persistent problems with trash and discarded syringes, she said: “It’s a little thing, but if you’re a child or a senior walking past that, it’s huge. And that happens when you can put people in the room, and make sure to be smarter about what we’re doing.”

The city is getting closer to offering easier access to addiction treatment, she said — largely because of a 24-hour treatment center that opened in Spring Garden this year. But she still fields complaints about barriers to treatment.

That’s something Carol Rostucher, who runs the addiction advocacy group Angels in Motion, knows all too well. Rostucher, who spends most of her days driving around Kensington offering care packages — and help getting treatment — to hundreds of young people in addiction, has been encouraged by efforts to make it easier to get help.

In 2019, she hopes the treatment process becomes more welcoming. Rostucher has seen clients wait hours for clinical assessments — long enough that they begin to experience the pain and nausea of withdrawal — or receive such poor treatment from front-desk staffers, they go out to score another dose.

“People have to start treating people like they’re individuals, not just throwaways," she said.

Radical efforts to save lives

At Prevention Point, the city’s only needle exchange, where staffers reverse dozens of overdoses each week, executive director Jose Benitez said the drop in the death toll was encouraging.

“I think it’s due to how much Narcan we got on the street,” he said. “People thought, you couldn’t possibly train [people in addiction] to reverse each other’s overdoses. But they did. And we’re going to save 100 extra lives [in 2018] because Narcan is on the street.”

Benitez is also behind Philadelphia’s most radical effort to save overdose victims, establishing a supervised injection site where users can get medical help if they overdose, and access to treatment. It has been nearly a year since city health officials announced support for a site.

But Kenney and others are lukewarm in their support, stressing that the site will be privately funded. Quiñones-Sánchez, for her part, is opposed to the idea, and wants people injecting drugs in public taken away by police to a treatment facility. Still, a nonprofit to open a site, helmed by Benitez, Ronda Goldfein, the executive director of the AIDS Law Project of Pennsylvania, and former Gov. Ed Rendell, launched this fall and may make Philadelphia the first U.S. city to open a site.

The city’s progress in the opioid crisis mirrors that of many people in addiction struggling to recover — slow, painful, and complicated, but progress nonetheless. At the beginning of 2018, a man who would identify himself only as Mike had been homeless and struggling with addiction on the streets of Kensington for months.

He was forced out of the Tulip Street heroin encampment during the eviction in May. He didn’t get a shelter bed at first, but eventually moved to one of the two shelters on Kensington Avenue, which don’t require sobriety to enter.

In November, he started the process of getting his own apartment, a place where he might find the stability he needs to get sober. Two weeks later, he went to his mother’s Thanksgiving dinner. Last week, he made his vow for 2019: Get housing, get healthy, get a job. Get his life back.