More people in Maryland died of opioid overdoses in 2020 than any year on record, confirming health experts’ fears that the coronavirus pandemic would lead to a sharp uptick in drug use and deaths. The vast majority of the 2,499 opioid-related deaths involved fentanyl, a cheap and powerful synthetic opioid that’s magnitudes more potent than heroin.
But another concerning trend has emerged: A record number of people died from prescription opioids, the painkillers state officials have long blamed as the source of the opioid crisis.
According to the state health department, 445 people died of prescription opioids overdoses in 2020, the most ever recorded.
Another 136 people died of prescription overdoses in the first 90 days of 2021, up more than 37% than in the same period of 2020. Those 136 deaths compare with 107 heroin-related overdose fatalities from January through March this year. State officials say prescription deaths haven’t outpaced heroin deaths in a decade.
“If this trend were to persist throughout the year, it would represent a historic milestone, with prescription opioid-related deaths now outpacing heroin-related deaths for the first time since 2011,” state health officials wrote in a June report on the first quarter of 2021, the latest data available.
The increase followed a relaxing of rules by Republican Gov. Larry Hogan and state and local officials of restrictions on how and when doctors can prescribe opioids, in response to the coronavirus outbreak. With travel restricted and trips to the doctor more difficult, the state made it easier to get medicine remotely.
Experts in the field applauded the move, and continue to do so, but say the relaxed restrictions may have enabled prescription abuse.
Kristy Blalock, regional director for Gaudenzia, the state’s largest provider of substance use treatment, said she’s noticed a growing number of people entering treatment who had been prescribed large amounts of opioids and began abusing them.
“They believe that it’s because they’re not seeing their physician,” she said. “They’re just putting in refills over and over again.”
As deaths from prescription opioids rise, experts say the state needs to take a hard look at the data to see what happened.
“It’s concerning enough that we need to try to figure out where this is coming from before we write it off that this is pandemic-related,” said Gary Pushkin, an orthopedic surgeon who founded the committee on opioids for MedChi, the state medical society.
Pandemic prescription changes
When the coronavirus pandemic first forced businesses to close and people to socially distance from one another, Hogan, other state officials and local leaders worked to make sure people could continue receiving goods and services. Restaurants delivered alcohol, schools taught over the internet and doctors provided more medical services, including prescriptions and refills, over the phone or via video conferencing.
The logic was to reduce in-person visits to minimize the potential spread of COVID-19.
“That was important to do because you have a fair number of patients who use opioids legitimately,” said Dr. Paul Christo, associate professor at the Johns Hopkins University School of Medicine.
Behavioral Health System Baltimore, a nonprofit organization that acts as the city’s mental health agency, awarded $106,000 in to 15 organizations in fiscal year 2021 to fund the purchase of laptops, tablets and other technology for a more telehealth-centric approach to patient care. According to Adrienne Breidenstine, the organization’s vice president of policy and communications, it received requests for more than $300,000 worth of equipment.
Hogan’s executive orders that lifted restrictions on prescriptions ended Aug. 15.
Blalock said blame for increased deaths doesn’t lie with the governor’s executive orders or any policy changes. But she urged the state to use the data and other resources, like its Prescription Drug Monitoring Program, to try to target the physicians writing problematic prescriptions.
“Because we know if it’s not addressed now at the physician level, it will become a state crisis,” she said.
Isolation during the pandemic
The worry is that Maryland, which is still tackling a fentanyl crisis that killed nearly seven people per day in 2020, could repeat past mistakes by allowing the creation of a cohort of people who will turn to street drugs once their prescriptions become harder to fill.
It’s happened before. Maryland’s opioid-related deaths more than tripled between 2011 and 2016 to 1,856, which state officials said was partly fueled by some medical practitioners overprescribing legal opioid painkillers. The state enacted regulations in 2017 meant to curb excessive prescriptions for opioids in the state’s Medicaid program, only to see deaths from heroin and particularly fentanyl then surge.
Albert Smith, a 52-year-old from Glen Burnie, completed a Gaudenzia outpatient treatment program in September 2020. He said he’s taken a number of drugs, including cocaine and heroin, but began abusing opioid painkillers after he was prescribed some for avascular necrosis, a disease that effects the blood flow to bones.
He said he’s been fortunate to have a significant other at his side who motivated him to get sober, but said he understands the feelings of loneliness that could be exacerbated by life during the pandemic.
“I was isolated when I was using. I didn’t want anybody to see me,” Smith said. “For a long time, I was disgusted with myself. That’s where the isolation came in.”
Isolation is pronounced in rural areas, which saw some of the largest proportional increases in opioid-related deaths. While Baltimore City continues to see the most fatal overdoses overall, Allegany County in Western Maryland and Worcester County on the Eastern Shore saw the largest percentage increases in opioid deaths year-over-year.
So, some advocates are worried that isolation and easier access to prescriptions may have created a new group of people who’ve become hooked on painkillers.
“Their normal schedule has changed and not everyone has the ability to cope with that,” Blalock said.
The pandemic didn’t create telehealth. The concept of remote access to medical services began long before we could connect with people from across the globe with pocket-size technology.
The Royal Flying Doctor Service — a nonprofit program in Australia that brings medical services to people in far-flung areas and is considered the first comprehensive air ambulance service in the world — has operated for nearly 100 years, largely due to the advent of the radio and flight in the early 20th century.
But the pandemic and the resulting emergency orders by Hogan and others turbocharged the use of remote evaluation and prescribing. And it brought in new users.
Gaudenzia began offering outpatient treatment and started programs for patients being treated with medications such as methadone and buprenorphine, while reducing the use of live-in, abstinence-only programs. Baltimore’s behavioral health agency handed out laptops to local treatment providers to help them stay connected with patients.
For Smith, having outpatient programs available at Gaudenzia helped keep him in treatment. He completed the program in September 2020 and now works at the program’s Crownsville location, helping with daily events like group sessions and intake.
He said that when Gaudenzia and other providers cut back on in-person services, videoconferencing helped keep him on a path to recovery during the heart of the lockdowns last year.
“It helped tremendously because we were in a group form again,” Smith said. “With no more outside meetings and everything ... it really played a significant part.”
However, while officials touted their successes in adapting to delivering their services through telehealth, they’re also worried about what goes by the wayside now that Hogan’s emergency orders have expired.
One order that allowed for treatment programs to provide intensive outpatient services via telehealth expired Aug. 15. According to Michael Ricci, Hogan’s spokesman, it was one of several orders extended past the original end of July 1 as a grace period. He did not respond to a question about whether Hogan considered a further extension.
Blalock said she had wanted Hogan to extend the order, as it allowed for treatment programs to reach clients in more remote areas. She added that while people in northern Anne Arundel County and Baltimore City “can jump on a bus to get to an outpatient clinic,” services are more limited in southern Anne Arundel County, which is more rural.
“While the pandemic has gotten better, it hasn’t gone away,” she said.
This story has been updated to reflect the correct name for Dr. Gary Pushkin.