Combatting the opioid epidemic: Baltimore’s experience and lessons learned

Abstract

In the midst of a national opioid crisis, Baltimore City witnessed 393 deaths from drug and alcohol overdose in 2015. With an estimated 25 000 residents who are addicted to heroin or other opioids, Baltimore has been profoundly affected by the opioid epidemic. Other resources have commented on federal, state-based, and provider responses to the opioid crisis. This article examines what may be done at the city level based on the experiences of the Baltimore City Health Department. Local jurisdictions must play a critical role in addressing the U.S. opioid crisis through public health coalitions, overdose prevention, treatment expansion, and anti-stigma education.

Introduction

The USA is in the midst of an opioid epidemic. Nationwide, the rate of deaths from drug overdose increased 137% between 2000 and 2014, while unintentional overdose deaths from heroin and prescription pain relievers have more than quadrupled.¹ In many states, there are more people dying from overdose than from motor vehicle accidents, suicide or homicide.² Opioid prescribing practices are a likely driver of the increase in overdose rates;³ healthcare providers wrote 259 million prescriptions for painkillers in 2012—enough for a prescription for each American adult.⁴ The increased supply is compounded by enduring stigma surrounding addiction and a nationwide lack of accessible treatment options. A number of resources have commented on federal,^5,6 state-based⁷ and provider⁸ responses to the opioid crisis, including the Surgeon General’s Report on Alcohol, Drugs, and Health and opioid prescribing guidelines released by the Centers for Disease Control and Prevention (CDC).⁸ This article examines what may be done at the city level based on the experiences of the Baltimore City Health Department.

Opioid addiction and overdose in Baltimore City

In the midst of a national opioid crisis, Baltimore City witnessed 393 deaths from drug and alcohol overdose in 2015.⁹ With an estimated 25 000 residents who are addicted to heroin or other opioids, Baltimore has been profoundly affected by the opioid crisis. In a city of 620 000, drug addiction has touched every family, workplace and neighborhood in the community. Facing record drug-related overdose deaths, Mayor Rawlings-Blake convened the Heroin Treatment and Prevention Task Force in October 2014. The task force released their recommendations in July 2015 (see Table 1), the same week of the CDC’s report on the growing heroin epidemic.¹⁰ The plan for action, led by the Baltimore City Health Department, has served as a roadmap for close collaboration with partners across the city.¹¹ Baltimore’s response to combat opioid addiction and overdose built upon three key pillars of overdose prevention, treatment access and anti-stigma education.

Table 1.

Adapted from summary of recommendations from the Baltimore Mayor’s Heroin Treatment and Prevention Task Force Report^a

Summary of recommendations
1. Develop dashboard for ongoing monitoring to obtain real-time data for number of people with substance use disorders, near-fatal and fatal  overdoses, and local capacity for treatment
2. Implement citywide heroin overdose plan to save lives of our citizens
3. Develop a centralized, easy-to-access intake that is 24/7
4. Increase data-driven, high-impact options for treatment, including universal case management; access to treatment for people who are currently and  recently incarcerated, and increased access to buprenorphine
5. Ensure treatment on demand. This includes work towards a 24/7, ‘no wrong door’ treatment center for addiction and full capacity for treatment in  both intensive inpatient and low-intensity outpatient settings
6. Develop voluntary certification and review for substance use providers based on core standards of care. This includes a pilot to test and refine best  practice standards with key volunteer providers in Baltimore City
7. Facilitate an ongoing partnership and collaboration among key stakeholders to pilot programs, test economic incentives, and discuss integration with  state/federal systems of care
8. Develop standardized good neighbor agreement and establish best practices for substance use disorder providers and community members
9. Coordinate efforts with treatment providers and law enforcement
10. Implement comprehensive strategy to educate and inform residents, businesses, and other key stakeholders to help reduce fear and combat stigma

^aWen LS, Rawlings-Blake S. Baltimore Mayor’s Heroin Treatment and Prevention Task Force Report. Baltimore City Health Department. http://health.baltimorecity.gov/opioid-overdose/mayors-heroin-treatment-and-prevention-task-force. Published July 10, 2015. Accessed 25 July 2016.

Prevent overdose deaths

The central focus of the opioid overdose prevention campaign has been the extensive expansion of access to naloxone, the lifesaving opioid overdose reversal drug that can prevent death from opioid drug poisoning. In 2015, the Health Department successfully advocated for a number of legislative and regulatory changes, including the expansion of overdose prevention training to not only people who use drugs themselves but to all Baltimoreans; the increased scope of Good Samaritan laws including immunity for bystanders calling for assistance; malpractice protection for providers issuing naloxone prescriptions; and a one-dollar copay for any naloxone product on the Maryland Medicaid program’s Preferred Drug List, including generic injectable naloxone and intranasal Narcan.

Beginning 1 October 2015, the Health Commissioner acquired the authority to write blanket prescriptions for naloxone for Baltimore City residents under a ‘Standing Order’ approved by the Maryland State Legislature. In 2015, the Health Department trained 8017 Baltimore residents in naloxone use and distributed 5543 naloxone kits. Since October 2015, there have been >100 overdose reversals by police and >800 by lay people. More than 20 000 kits have been distributed through the standing order. In June 2017, the passage of the HOPE Act in Maryland removed the burdensome training and regulatory requirements that the previous naloxone standing order contained and essentially made the drug available over the counter, a best practice already adopted in other states.

Increase access to on-demand treatment and long-term recovery services

Nationwide, nearly all US states have greater rates of opioid use disorders than buprenorphine treatment capacity.¹² Though recent proposals by the Obama administration to expand medication-assisted treatment (MAT) may improve treatment access if implemented, fewer than 1 million of the 2.5 million Americans who misused or were dependent on opioids were receiving MAT in 2012.⁶ To integrate referral services given this gap, the Health Department and local partners in Baltimore streamlined existing resources and launched a 24/7 phone line for patients, family members and providers. This includes immediate referrals to addiction counselors, crisis services with outreach workers, and assistance with urgent appointments. Operational since October 2015, the line has already received >1000 phone calls. The city has also secured $3.6 million in capital funds to build a ‘stabilization’ center, the first step to starting a comprehensive, community-based 24/7 ‘ER’ for substance use and mental health disorders. The Health Department is currently working to connect people to buprenorphine treatment directly from the emergency department (ED) and to set up mobile treatment options in the community.

Educate and combat stigma

In July 2015, the Health Department and local partners launched a public education campaign, ‘Don’t Die’ which aims to educate residents on addiction as a chronic disease and to encourage individuals to seek treatment. This involved a website launch, social and traditional media, and billboards across the city. The city subsequently established drop boxes at every police station to remove prescription drugs from homes and communities. Following advocacy efforts to pass legislation increasing provider use of the state’s prescription drug monitoring program, the Health Department sent letters on best practices for opioid prescribing to every doctor in the city followed by a more in depth physician detailing campaign that sent outreach workers to educate on recommended prescribing practices. In August 2016, the Food and Drug Administration adopted a black box warning on the concurrent prescription of opioids and benzodiazepines following a citizen’s petition from city and state health directors led by the Baltimore City Health Department.¹³

Discussion

Main findings

Use evidence to counter rhetoric

One of the biggest hurdles to combatting the opioid crisis has been the stigma surrounding addiction. Initial community conversations were stymied by residents’ insistence on getting methadone clinics ‘out of my backyard.’ Baltimore’s approach has been to change the conversation by presenting evidence that addiction is a disease and that recovery is possible with evidence-based treatments like MAT. The Health Department has also used naloxone trainings to change the way frontline officials approach drug use and addiction. The Police Department has subsequently partnered with health officials in a diversion program to provide individuals with substance use disorders the opportunity to enter Drug Treatment Court rather than incarceration.

Go to where people are

Initially, naloxone trainings were held in public libraries. Few attended these trainings, and those who did were often not the individuals most at risk of an overdose. The Health Department changed course and started using city epidemiological data to identify areas of high drug use and overdose. It then sent outreach workers to the places most in need, including jails, neighborhood housing associations, bus shelters, needle exchange programs and specific city street corners. On International Overdose Awareness Day in 2015, nearly 1000 people were trained; to date, we have trained >23 000. In addition, every interaction became a point of possible intervention. As a Health Department with public health at our core, our goal is to be able to connect an individual to appropriate services or treatment at each point that they interface with clinical or public health programs.

Connect emergency and primary care

The Health Department convened city chairs of local EDs to discuss connecting every patient who presents with a drug or alcohol overdose or intoxication with treatment appointments. Given evidence that almost all patients continue to receive opioid prescriptions following a non-fatal overdose,¹⁴ this has been a key piece in the city’s strategy. EDs began to use the 24/7 phone line to connect patients into treatment and are now, in two EDs, employing peer recovery specialists—individuals in recovery themselves—to connect people at the time they are ready to seek help. Four of our hospitals are early pioneers of the Screening, Basic Intervention and Referral to Treatment (SBIRT) approach, which provides universal screening of patients presenting to primary care and EDs. Future efforts will attempt to further report non-fatal overdoses from EDs directly back to the prescribing providers.

Adapt programs based on real-time data trends

In the first quarter of 2015, Baltimore saw a 178% increase in fentanyl-related overdose deaths (39 deaths) compared to the same quarter in 2014 (14 deaths).¹⁵ Surveys of those who visited the Health Department’s needle exchange vans found that clients were not aware that fentanyl was mixed in with heroin, thereby potentiating its effects and leading to an increased likelihood of overdose. The Health Department immediately changed its strategy and launched a targeted public education effort around fentanyl-laced heroin and safe injection practices. We now have real-time alerts for where overdoses are occurring and deploy outreach teams that day. Better real-time data tracking and collaboration across city, state, and federal agencies can have a profound impact on the targeting of public health services. Most recently, the Heroin Task Force found that there were an estimated 24 887 Baltimore City residents who used opioids and were potentially in need of MAT, while the MAT treatment capacity is only 17 587.¹⁶ This dramatic MAT service gap, previously thought to be narrower, has allowed for more targeted efforts to improve treatment access at the city level.

Sustainable local action requires state and federal support

Though other municipal and state jurisdictions have taken innovative action to prevent fatal overdoses, state and federal support remains necessary. Many of the initiatives in Baltimore City, including the naloxone standing order, have been facilitated and improved upon by state legislation and federal resources, though much work remains to be done. For example, the price of some naloxone formulations have increased by between 95% and >500% in a number of years, limiting the ability of local jurisdictions to purchase the antidote for use by paramedics and police officers.¹⁷ Federal action can also remove barriers to buprenorphine prescription. Bringing these reforms to fruition will require a concerted, multifaceted effort at all levels of government.

What is already known on this topic

Baltimore, like the USA more broadly, is in the midst of a crisis of both opioid addiction and overdose. The majority of these fatal overdoses occur in individuals with opioid use disorders.¹ Addressing these concerns will require a multisectorial approach at improving treatment, prevention, anti-stigma education and overdose prevention. Overdose education and naloxone distribution are evidence-based interventions to prevent fatal overdoses^18–20 in addition to a number of preventive, behavioral and medication-assisted therapies.

What this study adds

This article provides a case study of what can be done to address the opioid crisis at the local level by reviewing the successes and challenges of the Baltimore City Health Department. Over the past 2 years, this work has focused on preventing overdose fatalities, expanding access to long-term treatment sources, and providing anti-stigma education around opioid addiction. Key themes to emerge from this work were using evidence to make community and law enforcement partners; conducting outreach and trainings in a diverse set of city neighborhoods; facilitating ongoing connections between emergency and primary care; adapting programs based on real-time epidemiological data; and harnessing state and federal support to improve the sustainability and scalability of interventions at the local level.

Limitations of this study

Though the city has made significant progress over the past 2 years, there is still significant work to be done. Harm reduction efforts like naloxone distribution are powerful tools to prevent fatal overdose. Long-term change requires expanding treatment beds and primary care-based MAT in addition to reforming opioid prescription practices and substance use disorder prevention work. Expanding access to treatment, particularly to buprenorphine prescribers, has proven slower and more challenging at the city level, due to a lack of resources and prohibitive regulatory requirements at the federal level.

Addressing the opioid crisis

It is the mantra of the Baltimore City Health Department that every resident can save a life, and that we must save a life today to provide a better tomorrow. This is not only a moral argument but an economic one; every dollar spent on addiction treatment programs saves an additional 4–7 dollars in reduced criminal justice and societal costs.²¹ Today Baltimore aims to become a recovery capital at the center of innovative opioid addiction treatment and overdose prevention. This will require further prevention efforts for inappropriate acute and subacute prescription of opioids as well as broader and more timely access to treatment for opioid use disorders. The city has learned a great deal through its efforts over the last two years; in sharing these lessons, the Health Department aims to assist other providers and policymakers in combatting the opioid epidemic.

Funding

Katherine E. Warren’s participation was supported by the Rhodes Scholarships and award number T32GM007753 from the National Institute of General Medical Sciences.