Baltimore health officials are running low on naloxone, the opioid overdose reversal drug used hundreds of times by bystanders in the last couple of years to save lives.
Dr. Leana Wen, the city health commissioner, said demand has jumped significantly along with the drug epidemic and the health department needs funding for more supplies.
"We are rationing," she said. "We're deciding who is at the highest risk and giving it to them."
The city has about 4,000 doses left to last until next May. The department will distribute them, two at a time, to residents, including IV drug users encountered by the city's needle exchange vans or by outreach workers in "hotspots," areas where a spate of overdoses recently occurred.
"If I had 10,000 doses and gave them to everyone who requested them, I'd run out in about two weeks," Wen said.
Naloxone has become the cornerstone of the public health community's emergency response to skyrocketing fatalities from opioids that include prescription painkillers, heroin and fentanyl, a powerful drug commonly mixed into heroin without the users knowledge. The goal is to keep opioid users alive long enough to get them into treatment.
And though Wen has more units on hand than she's had in some recent years, she said it's not enough to keep pace with rising needs.
Maryland health officials recently reported that 2,089 people fatally overdosed in the state in 2016, up 66 percent from 2015. About a third of the overall deaths, 694, were in Baltimore and the shares were higher for heroin and fentanyl. There are an estimated 21,000 active heroin users in Baltimore.
The department bought 3,120 units for fiscal 2017, which is down from 3,340 the previous year. A state grant paid for about 20 percent. The total doesn't include some charitable donations, pharmaceutical company donations to schools, or first responder stocks.
Some county health departments are able to rely more heavily on grants from the state, which funded 27,870 units in fiscal 2017 for public health and other entities. But no county reports as many overdose deaths as the city.
Anne Arundel County, for example, dispensed 1,677 units of naloxone in fiscal 2017, with about three quarters paid for by the state. The county logged 195 overdose deaths last year, the third most in the state.
To fill in gaps, residents appear to be turning to sources including retail pharmacies and the Medicaid program that charges $1 for a dose.
State figures show a large increase in the past year in claims for naloxone from the federal-state health program for low-income residents, who make up a disproportionate number of those who overdose in Maryland. There were 1,945 claims in the first three months of 2017, compared with 757 in the same period last year.
Local officials say demand could increase because this week state officials eliminated a requirement for training to use naloxone. The remedy already was available without a prescription from pharmacies.
"As the opioid epidemic has evolved, we have worked steadily to expand access to naloxone," said Dr. Howard Haft, a state deputy secretary for public health, in announcing the move this week after legislative approval. "Pharmacies play an important role in providing access to naloxone and counseling on how to recognize and respond to an opioid overdose."
Pharmacies generally have been seeing demand for the opioid antidote. Amy Lanctot, a spokeswoman for CVS, said naloxone is available in all of the company's Maryland pharmacies, some on the same day it's requested and some the next day. The cost depends on a person's insurance. Those without coverage are charged $45 for a shot and $110 for a nasal spray.
"We can report that there has been significant interest in all communities where we make naloxone available," Lanctot said, but the company doesn't disclose sales.
Emergency medical responders still have the largest stocks of naloxone. The Baltimore Fire Department now annually orders 18,750 units of two milligrams each, costing approximately $675,000. The department orders more when stocks approach 700 doses.
"We are more than equipped to administer naloxone whenever needed," said Blair Skinner, a spokeswoman for the department. "We pride ourselves on saving lives and as the opioid epidemic rises, it is our duty to ensure we continue to remain well equipped to provide resources to help people."
All ambulances responding to emergencies across the state — more than 650 — have been required to carry at least 4 milligrams of naloxone since 2014, said Dr. Richard Alcorta, state EMS medical director at the Maryland Institute for Emergency Medical Services Systems, which sets policy.
"We're a safety net," Alcorta said. "So we have it."
He couldn't say how often ambulances were administering naloxone, though he said the state was seeking to count. An issue is that emergency responders have been instructed to give naloxone to anyone who is not breathing, just in case opioids are at issue.
Alcorta, an emergency physician, said naloxone is needed in minutes to revive overdose victims. He said bystanders without naloxone could perform mouth-to-mouth resuscitation until help arrives. (Chest compressions aren't necessary because opioids only depress respiration, not a beating heart.)
Wen, also an emergency physician, said getting naloxone into bystanders' hands likely would be more effective. To buy more of the drug, which she notes has jumped in price in recent years, she needs the city's share of the $10 million in funding Maryland received in May from the recently passed federal 21st Century Cure Act.
The money is to be used for a variety of measures statewide to counter the opioid epidemic, and state health department officials have said they still are working on a plan for distribution.
In letters this year to the state health department, Wen asked for at least a third of the money to fund more treatment, outreach, education — and naloxone.
"We need funds now," Wen said. "It seems unconscionable at a time of a public health emergency, when there is an antidote readily available and can save lives, that we have to ration."