Maryland has the nation's highest rate of hospitalizations for opioid use, according to newly released federal data that illustrates the depth of the addiction problem in a state where many people have died from overdoses of the drugs.
Tens of thousands of people are admitted to state hospitals or visit an emergency room each year related to opioid withdrawal, overdose or complication, according a decade's worth of statistics provided by the U.S. Agency for Healthcare Research and Quality.
Those numbers far eclipse the 1,259 deaths from all drug and alcohol overdoses in Maryland in 2015 and the 1,468 fatal overdoses in the first nine months of 2016.
"It's an epidemic, and it's only increasing in numbers," said Dr. Chirag Chaudhari, chair of the emergency department at the University of Maryland Baltimore Washington Medical Center in Glen Burnie. "As more and more attention is paid to it and resources become available, we hope to see declines."
The rate of hospital admissions in Maryland was 362 for every 100,000 residents in 2014, the most recent year for which the federal data is available, far exceeding the national average of 225. Maryland's rate was eight times Iowa's rate of 44.
The ranking didn't surprise health officials who know that prescription painkillers and heroin have had a long-standing grip in Maryland and particularly Baltimore. But several said Maryland's numbers may be higher because of the state's comprehensive hospital reporting standards.
The state's Health Services Cost Review Commission collects wide-ranging hospital data from billing records and uses it to help set hospital prices, an unusual arrangement that requires thorough accounting. As a result, Maryland looks worse compared with the other 46 states and Washington, D.C., that voluntarily report billing data to the federal agency.
The federal data shows that the rate of emergency room visits in Maryland was 288 per 100,000 residents, exceeding the national average of almost 178.
The data also show that the epidemic affects men and women and people of all ages and backgrounds in Maryland.
Rural and suburban areas had rates of opioid-related emergency visits above the national averages, but the heavy concentration in the Baltimore area stunned federal researchers. Many other states showed opioid addiction growing more rapidly or at least more evenly in non-urban areas.
"It's a much bigger disparity than anywhere else," said Anne Elixhauser, a senior research scientist at the Agency for Healthcare Research and Quality.
The rate of emergency visits in Baltimore, the state's only large metropolitan area, was 977 per every 100,000 residents. Nationally, it was 177 for big-city regions.
Dr. Gentry Wilkerson, an emergency room doctor at the University of Maryland Medical Center in Baltimore, said there was nothing different about patients in Baltimore or Maryland compared with other states.
Baltimore, however, seemed to have a "culture" of heroin that has endured when other drugs like cocaine came into fashion elsewhere, said Wilkerson, also an assistant professor in emergency medicine at the University of Maryland School of Medicine. The relationship, he added, continues to grow.
He counted one person coming to his emergency room every other day for opioid overdose in 2015. In 2016, it increased to an average 1.2 people a day. That doesn't count those with other complications from opioid use.
"It is a ton of visits," he said, and likely fueled most recently by illicit fentanyl, a powerful opioid mixed into heroin unbeknownst to users that say it hit them "like a ton of bricks."
The admission rate in Maryland has long been high. However, it was one of four states that logged a slight drop in the rate of overall hospital admissions, potentially reflecting how patients are now treated, emergency room doctors say.
For example, Maryland's Medicaid health program, which covers low-income residents, no longer allows patients suffering withdrawal symptoms from opioids to be admitted after an emergency department visit. Maryland hospitals also operate under a unique agreement with federal regulators that switches their emphasis to health outcomes from fee-for-service, eliminating the incentive to admit patients who may not need it.
Many opioid abusers no longer need to be admitted, said Dr. Michael Fingerhood, chief of the division of chemical dependence at Johns Hopkins Bayview Medical Center.
The widespread use of naloxone, an opioid overdose antidote that has few lingering effects, and buprenorphine, a treatment drug that can mitigate harsh withdrawal symptoms and cravings, has made hospital admissions less necessary, Fingerhood said.
Those who are admitted must have some kind of complication or other disorder, including alcohol withdrawal that can be fatal, he said.
He said other states could see drops in admissions for opioid use in coming years as they adopt emergency room treatments and change their models of care, even if emergency room visits remain high, he said.
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The epidemic has so far proven stubborn to control.
"A huge number of people aren't in treatment," Fingerhood said.
Hopkins, the University of Maryland Medical System and other hospital systems that have long directed opioid-addicted patients to treatment programs outside their facilities are now becoming more aggressive in directly addressing the issue. They have launched or plan to begin efforts to train the patients to use naloxone for revival from an overdose and start them on buprenorphine-based treatment while they are in the emergency rooms.