Opioid overdoses now rank among cancer, strokes and heart attacks as the top killers in Maryland. State health officials say their goal for the next two years is to slow the rate at which the problem is worsening.
Looking back, Taylor Sprague's family realizes there were clues she used heroin. She often nodded off, her skin broke out and she lost pride in her appearance. She even wrote a pair of public posts on Twitter about it.
"Will someone tell me when I became an addict I seem to have missed that part of my life??" Sprague tweeted in December 2014. "I guess I was just too ... high, right?"
But her family didn't realize she was an addict until New Year's Eve morning 2015, when a police officer arrived at their Eldersburg home. The officer said Sprague, the 21-year-old student at the University of Maryland, Baltimore County who had interned at the Library of Congress and served as a page in the General Assembly, had died of an overdose.
"She doesn't have a heroin problem," Kerri Sprague, Taylor's mother, recalled thinking. "How could this happen?"
Taylor Sprague was among the last of 1,089 people in Maryland to die from an opiate overdose in 2015, and as the new year rolled around, the epidemic's death toll continued to mount. Final state data for 2016 is expected to show that some 2,000 people died after overdosing on heroin or other opiates.
Opioid overdoses now rank with cancer, strokes and heart attacks among the top killers in Maryland. State health officials say their goal for the next two years is to slow the rate at which the problem is worsening. Despite facing a $544 million state budget shortfall, Gov. Larry Hogan is expected to announce funding Wednesday to fight the heroin epidemic. The General Assembly launched a work group Monday to study 25 bills that would address opioid and substance abuse.
"Unfortunately, the resources aren't there," said Kerri Sprague, echoing a conclusion reached by many officials and medical professionals. "The people outside of these families don't like that resources would go to that — they think, 'Why would we put money towards junkies?'"
There is little consensus on how to use the state's limited resources as officials scramble for fresh ideas.
"We know what people need. Money is going to keep us from being able provide everything that people need," said Del. Eric Bromwell, a Baltimore County Democrat who has put together a package of legislation to address the epidemic.
Doctors and advocates for addicts say the most pressing need is boosting the number of people able to get into treatment. Baltimore Health Commissioner Dr. Leana Wen called the overdose death figures "horrific" and said they won't come down until more people are helped.
"We know that treatment works, that recovering is possible," she said. "We desperately need funding for treatment."
There's a yawning gap to fill. A study conducted for the state Department of Health and Mental Hygiene late last year found Maryland can provide methadone or buprenorphine — drugs widely considered critical to treating heroin addiction — to 30,000 patients. That's half of what is needed, the study concluded.
The department said the number of people receiving buprenorphine has grown significantly in recent years and that steps are being taken to increase the availability of treatment. A new federal rule is expected to allow nurses and physician assistants to prescribe buprenorphine, a measure the department endorses, and the state recently obtained federal permission to use Medicaid to pay for more inpatient treatment for addicts.
The federal government also is expected to provide the state $10 million for drug treatment under a law passed last year.
But the potential repeal of the Affordable Care Act and the resulting possible loss of funding to expand Medicaid looms over the issue. That money — a projected $215 million for the coming year — accounts for three-quarters of federal contributions to Medicaid for substance abuse treatment, according to state budget analysts.
"Some of the changes that they're suggesting would definitely decimate the good work that's being done," said Del. Kathleen Dumais, a Montgomery County Democrat who is vice chair of House Judiciary Committee.
Effects of fentanyl
The overdoseproblem, meanwhile, continues to worsen. Officials blame fentanyl, a powerful opioid being mixed with heroin. Health authorities in Maryland began warning in 2014 that the drug was causing a spike in overdose deaths.
Officials say fentanyl is almost irresistible to heroin distributors and dealers. They estimate that a kilogram of Mexican heroin costs $64,000, and acquiring it means dealing with dangerous drug cartels. Fentanyl, which is 50 to 100 times stronger than heroin, can be bought for as little as $2,000 a kilogram and shipped through the mail from China.
At the urging of the U.S. Drug Enforcement Administration, China has moved to crack down on suppliers of the drug, but the makers have tweaked their chemical formulas to evade the rules.
Van Mitchell, the former state health secretary, said fentanyl caught everyone by surprise. The drug's sheer potency challenges the usual ideas about how to battle overdoses.
"You can have all the treatment you want, but if they're taking fentanyl ... they're not going to be in treatment," said Mitchell, who stepped down as health secretary in December. "They're going to be dead."
The night Taylor Sprague died, her boyfriend bought a bag of fentanyl-laced heroin in Baltimore. He overdosed on his first hit.
Sprague then called paramedics, who administered the life-saving drug naloxone, which reversed the effects of overdose. As her boyfriend was transported to the hospital, she was left alone in the middle of the night with the rest of the deadly batch of heroin.
When her boyfriend was released from the hospital the next morning and returned to the lot where they had parked, he found Sprague dead.
Without significant sources of new money to boost treatment efforts, Hogan and Democrats in the General Assembly have crafted legislation to address the problem in other ways.
While their ideas are not incompatible, there is a difference in emphasis, said Bromwell, who is vice chairman of the House of Delagates Health and Government Operations committee.
"I think we're more focused on prevention of people becoming addicts, not necessarily what to do with drug dealers," Bromwell said.
The Democrats' most sweeping proposal would create 24/7 crisis centers across the state, publicize a hotline number for people seeking help with addiction and mandate payment rates for treatment to keep pace with inflation — a step advocates say is vital if treatment providers are to retain qualified staff.
Several other bills also have been introduced in Annapolis, proposing everything from rewriting rules for recovery homes to creating centers where addicts could safely use illegal drugs.
Hogan signed an executive order this year creating a command center designed to better organize the state's response; he also proposed bills that would limit how many pain pills doctors can prescribe to new patients and mandate stiff prison terms for people who sell drugs that lead to a fatal overdose.
Republicans and Democrats agree something must be done.
"We have to be all in," said Del. Nic Kipke, the House Republican leader. "We have to put our politics aside and do everything possible to, one, step up our law enforcement and, two, break down the barriers to effective treatments."
Kerri Sprague said she still has so many questions about what happened to her daughter. The one person who might have known the story was her boyfriend, but Sprague said she put off asking him.
Then last summer, during a trip to Montana, he overdosed and died.
"There's a ton I don't know," Sprague said. "Maybe I'm not supposed to know."