Homeless, occasionally incarcerated and about 24 hours after his last hit of heroin, Norman Jones walked into the big white van parked just steps from the door to Baltimore City’s jail looking for an exit from his way of life.
“Enough is enough,” said the 56-year-old Jones as he waited for a prescription for buprenorphine to ease withdrawal and long-term cravings.
The van, a mobile treatment facility launched two months ago, lures people leaving the Baltimore Central Booking and Intake Center with a sign advertising its services. It is the city’s latest and perhaps most in-your-face option for people who circulate in and out of jail and prison, often for addiction-related crimes, but receive no treatment on the inside.
Even though the opioid overdose crisis spurred Gov. Larry Hogan to declare a state of emergency in Maryland, dedicating more funding for treatment, the jail population remains largely overlooked, advocates say.
About 65 to 70 percent of those who are arrested and jailed in Baltimore have a substance-use problem, from alcohol to heroin.
“People are far more likely to overdose upon release from jail,” said Daniel J. Mistak, general counsel for a California-based nonprofit advocacy group, Community Oriented Correctional Health Services. “Your tolerance is down, you go back to using what you were using before. It hits you hard and you’re dead.”
It’s not clear how many overdose upon leaving jail or prison, but state figures show there were 1,172 drug- and alcohol-related deaths recorded in the first half of 2017, including record opioid-related fatalities that have alarmed treatment providers and advocates.
The Behavioral Health Leadership Institute established the van to help fill the void, said Deborah Agus, executive director of the Baltimore nonprofit.
“We had to pull up a van because there just aren’t enough places for people to go,” she said. “We had to be willing to just go and do it.”
Agus said she has the support of the state correctional department to serve opioid users who leave the jail building on Eager Street.
The state Department of Public Safety and Correctional Services, which runs the city jail complex and the state prisons, was among the first in the nation to offer methadone treatment in 2001, though only those who can prove they were already on methadone or buprenorphine can receive treatment. Those not already in treatment are offered limited amounts of methadone or another medication called clonidine to ease the extreme discomfort and pain of withdrawal.
“We don’t leave people to throw up and shiver in a corner,” said Sandi Davis-Hart, director of the department’s substance abuse treatment services.
Corrections officials say that about 100 of the approximately 2,000 people entering the system in Baltimore each month receive methadone treatment. They can stay on the medication while in jail, where stays average about 20 days, but are weaned off over 21 days once they are sentenced and sent to prison.
In October, for example, 140 men received methadone treatment, Davis-Hart said. To ease withdrawal, 282 got clonidine and 90 got methadone. Another 165 men received detox services for alcohol and benzodiazepines, withdrawal from which can be fatal. She said others may need treatment but don’t need detox, including marijuana users and those not actively using opioids.
She said the correctional system also offers counseling and referrals to services upon release.
In six county jails, the state has begun funding injections just before release of Vivitrol, which blocks the effects of opioids. Recipients are connected to community-based care for more monthly injections and counseling. State officials have spent about $800,000 on the effort and plan to expand it to more counties.
Meanwhile, new efforts to sign up ex-offenders for Medicaid, which provides drug treatment, have gone slowly. A program to instantly connect people temporarily to health care upon release has been delayed.
Corrections officials last year also cracked down on the use of buprenorphine because it was being smuggled into the system. The officials prefer liquid methadone because it is tougher to divert and misuse.
Local advocates say the system is short of manpower and funding, or treatment, and resources available after people are released are not enough.
“The criminal justice system has a lot of people who have an opioid use disorder,” said Noa Krawczyk, a doctoral student in the Johns Hopkins Bloomberg School’s department of mental health. “The population has a need for treatment. It can be a really good opportunity to steer someone in the right direction.”
Krawczyk recently completed a study of more than 72,000 opioid users that showed that those referred from courts and diversionary programs for treatment were the least likely to get medication for their addiction such as methadone or buprenorphine.
Close to a quarter of the users in the study were referred to treatment though the criminal justice system, but only about 4.6 percent of those were referred for medication-assisted treatment. Users outside of the system were referred to such programs more than 40 percent of the time.
Behavorial Health System Baltimore, which oversees substance use and mental health treatment in the city, including funding methadone treatment at the jail, plans to push for legislation to improve treatment in the correctional system during this General Assembly session, said a spokeswoman, Adrienne Breidenstine.
She praised the van.
“It is another access point,” Breidenstine said. “It’s a way to capture people released with no treatment plan.”
To pay for the van, Agus raised $220,000 from area nonprofits — Open Society Institute-Baltimore, the Abell Foundation, the Zanvyl and Isabelle Krieger Fund and the Leonard & Helen R. Stulman Charitable Foundation — funding that she said likely won’t last a year.
Already, the staff she’s hired mostly from Johns Hopkins Medicine are treating about 10 patients, who they plan to stabilize and transfer to brick-and-mortar facilities, including a handful run by Agus’ nonprofit.
Available outside the jail two days a week, the van’s doctors do physicals and write prescriptions for buprenorphine to begin treatment.
Agus said the van is less structured than many programs, taking nearly all comers with an opioid addiction and not requiring daily visits or counseling, provisions she said that can put off users initially. The medical staff swabs participants’ cheeks to ensure they take the buprenorphine and don’t have high levels of other drugs or alcohol that mix dangerously with the medication.
The quarters are tight, but there is a bench for those waiting for an exam or prescription to sit and sip cocoa and perhaps share stories. There is a small room for doctors to work and an office with a printer for prescriptions.
Mistak called parking a treatment van outside the jail a good idea because many people don’t have anyone to meet them at release and can easily slide back into bad habits that foster higher rates of HIV and hepatitis in the community and more drug-related crimes clogging the system such as possession or stealing.
He said there are few such mobile clinics because some states tightly control where treatment can be provided or who can bill Medicaid, which pays for much of the van’s medication. Agus’ nonprofit funds co-pays and the uninsured.
Scott Nolen, director of OSI Baltimore’s drug addiction treatment program, said the state should fund more treatment inside the correctional system in its overall opioid plan. Once people leave, he said, it may be too late to get them in treatment
“If they don’t have access, they go back to the same kinds of issues they had before,” Nolen said.
That’s what happened to Jones, whose record shows convictions for possession and theft. He was not recently jailed, however; a friend told him about the van.
As he sipped a second cup of hot chocolate, he said he enjoyed drugs but regrets their effect on his life. He said he was now older and smarter than the young man who succumbed to peer pressure years ago to get high.
“I have four girls, grandkids and a great-grandson,” he said. “They need me.”
He planned to go directly to a nearby pharmacy for his first-ever prescription for buprenorphine. Still, he said, the power of addiction is strong. Would the it keep him from heroin?