While Carroll County, Maryland and the entire region have experienced a spike in opioid drug use and overdose deaths in recent years, local and state officials have also begun fighting back with new initiatives that offer a glimmer of hope and reasons for cautious optimism.
State government has been expanding civilian access to naloxone — an opioid and heroin overdose antidote — in the hope that more lives can be saved, and piloting new programs that could help more people get off drugs without winding up in prison.
In Carroll County, meanwhile, a close partnership between law enforcement and public health officials is fueling a shift toward a comprehensive response to substance abuse, one that emphasizes treatment when possible and in some ways is ahead of the state in such efforts.
There are signs that this might be beginning to push the needle back when it comes to the growth in overdose deaths: The 11 deaths recorded in Carroll through Nov. 30 in 2015 are on track for an improvement locally from the 15 overdose deaths in 2014, according to Carroll County Sheriff's Office data, which also show show seven deaths in 2013.
Statewide, though, opioid overdoses continue to rise in Maryland. There were 648 heroin and opioid drug-related deaths in the first half of 2015, according to the most recent Maryland Department of Health and Mental Hygiene, or DHMH, statistics available.
Overdose deaths from opioid drugs and heroin exploded in Maryland beginning in 2012, jumping to 732 deaths from 615 deaths the year before, according to DHMH statistics. In 2013, there were 838 such deaths and by July 2014, Maryland had seen 579 deaths. Heroin was responsible for 293 of those fatalities, prescription opioid drugs such as oxycodone claimed 172 lives, and a powerful synthetic opioid called fentanyl, often used to lace heroin, added another 114 deaths to the grim total.
The rising death toll by mid-2014 prompted then-Gov. Martin O'Malley to announce on June 27, 2014, the formation of an Overdose Prevention Council to coordinate a response to the overdose problem at the state level. The DHMH, meanwhile, began a large-scale media campaign promoting the Overdose Response Program, which trained both law enforcement and civilians — including users — in the use of naloxone, an opioid drug antidote.
Despite those efforts, by the end of 2014 the DHMH reported the statewide opioid and heroin death toll had piled up to 1,092, a 30 percent increase over 2013. Fentanyl deaths reached 185, nearly a 219 percent increase over the 58 deaths in 2013. And looking back one year further to 2012 and its 29 fentanyl-related deaths, 2014 represents a 538 percent increase.
Gov. Larry Hogan's administration has continued in much the same vein as its predecessor, with a few notable exceptions, beginning with the creation of state-level, interagency groups to study the overdose problem.
In February, Hogan announced the formation of both the Heroin and Opioid Emergency Task Force — a panel of top physicians, legal experts and law enforcement offices — and the Inter-Agency Coordinating Council, which brings together DHMH, the Maryland State Police, the Governor's Office of Crime Control and Prevention and other groups. The two bodies are both led by Lt. Gov. Boyd Rutherford and serve a function similar to that of O'Malley's Overdose Prevention Council, though with a wider focus, according to Shareese Churchill, Hogan's press secretary.
"O'Malley's council had a narrow focus and looked almost exclusively at overdose prevention," she said. "The mission of the lieutenant governor's council doesn't just look at overdose prevention, but also includes education, treatment, interdiction and recovery services."
The Heroin and Opioid Task Force published its final report on Dec. 1, making more than 30 recommendations for addressing the drug overdose problem, including providing better treatment to drug offenders in jail, better coordination between law enforcement and public health officials, and expanded access to naloxone and training in its use.
One new initiative Hogan has funded that breaks with the efforts of the past is the Medication Assisted Treatment program, which provides qualifying — and consenting — detention center and jail inmates with an addiction problem with injections of a non-narcotic, opioid blocker.
The drug, naltrexone, or brand name Vivitrol, is given on a monthly basis, first in jail, and then by a local health department after the person's release from detention, according to Chris Shank, executive director of the Governor's Office of Crime Control and Prevention. That office has made $500,000 in federal funding available to more than eight counties, including Carroll, to cover the cost of the Vivitrol injections. Shank, a former Washington County state senator, said a pilot program there had convinced Gov. Hogan the program should be expanded.
"Our [Washington County] health department had done a lot with this program. We had gotten some really great results, with upward of 90 percent of [participating offenders] not recidivating," Shank said. "It was something the governor and lieutenant governor wanted to give a shot to. They were concerned with the revolving door with addiction — if you don't do something about re-entry, that's when you sometimes see the deadly overdoses, where people have not been using in a while."
The Carroll County Health Department received $54,272 for the program in June, and if it proves successful in Carroll and other trial counties, Shank said, the program could be expanded and permanently funded.
Thus far, the health department has provided Vivitrol injections for 16 inmates at the Carroll County Detention Center, and several of those people have since continued to receive the shot for three or more months once they have returned to the community, according to Sue Doyle, of the Carroll County Health Department.
DHMH is also continuing to use the state's Prescription Drug Monitoring Program and direct outreach to doctors and insurers to reduce the amount of prescription opioid medications that find their way to the street, according to Mitchell.
Even as heroin has become resurgent, many public health officials, such as Doyle, point to prescription opioid medications as the ground zero of the current overdose explosion.
"This latest epidemic is directly related to the increase in the abuse of prescription pain medications," said Doyle, the health department's director of the bureau of prevention, wellness and recovery. "As more and more doctors prescribed and then refilled ongoing [prescriptions] for pain medication, more and more people had access."
Many of those people, initially prescribed the drugs for a real medical need, later became addicted, Doyle said, after which a combination of less access — as doctors wised up to people seeking a high over help — and the lower cost of heroin relative to prescription pills drove the resurgence of heroin.
"On the street we know that generally prescription medication cost $1 per milligram. So a 40-milligram tablet of OxyContin would cost $40. If you need 160 milligrams each day you need $160 a day," she said. "The cost of heroin has decreased significantly, while the purity has increased … So $20 to $40 in heroin will do the same thing as $160 of pills. Simple economics."
Front lines in Carroll County
In some ways, local jurisdictions like Carroll County have an advantage over state-level organizations, in that they are more nimble and closer to the situation on the ground.
When it comes to responding to the problem of prescription opioid drugs, for instance, Mitchell said DHMH is exploring pilot programs that would install safe drug dropoff boxes in some Maryland counties where people could dispose of unused opioid medications. Carroll, meanwhile, has eight such locations already active across the county.
Opioid drug deaths ballooned in Carroll in 2012, when deaths from prescription opioid drugs jumped to 17 from five in 2011. Heroin deaths jumped from two to 13 in that same period, according to DHMH data.
The Carroll County Health Department responded by increasing community education efforts about opioids, according to Doyle, as well as reaching out to doctors and dentists concerning the perils of writing prescriptions to people who might be "doctor shopping," or going from provider to provider to find one that will prescribe them their drug of choice.
The health department also reached out to law enforcement and medical officials to create a fatality review board that would look at the circumstances of each drug-related death in the county.
As part of the O'Malley administration's efforts in 2014, the county health department received special funding to focus on overdose prevention efforts and was required to write an Opioid Misuse Prevention Plan, a component of which was the creation of a county-level overdose prevention council, which Doyle credits as being an important change.
"The new overdose prevention efforts allowed us to … get more partners at the table to address this in a comprehensive manner, which in my opinion, the most helpful change [was] the sharing of data," she said. "The Sheriff's Office agreed to be the conduit to collect data on overdose calls throughout the county and compile the data so that the group has clear data to look at [to] identify [and] address the issues."
The Sheriff's Office began tracking both nonfatal and fatal overdoses in 2013 — DHMH tracks only fatal overdoses — illuminating some interesting trends in the county. (It should be noted that DHMH county data and those of the Sheriff's Office sometimes don't match.)
Along with the seven deaths in 2013 due to opioids of any kind, there were 84 nonfatal opioid overdoses, according to the Sheriff's Office data. Those numbers jumped to 15 deaths and 154 nonfatal opioid overdoses in 2014, and in addition to the 11 fatalities recorded through the end of November of 2015, there have also been 145 nonfatal overdoses.
"The only thing to explain the nonfatal overdoses is the implementation of naloxone," Doyle said.
The health department also spearheaded a number of other initiatives, though the results are difficult to track. Linda Auerback, the health department's substance abuse prevention supervisor, worked with the U.S. Drug Enforcement Administration and a local theater group to create a series of PSAs on the dangers of opioids and heroin, and to hold numerous public meetings on the topic, including the county's first Drug and Violence Expo held at the Carroll County Agriculture Center in May.
The health department has also worked closely with Carroll Hospital to help identify people with substance abuse issues who turn up at the emergency department, according to Doyle, and the health department has implemented a peer support system, through which former addicts in recovery mentor those who are just beginning to look for help.
It's part of a shift in approach that would not be possible without close partnerships between public health and law enforcement.
Police, prosecutors push for treatment over jail
A shift in attitudes about addiction under Sheriff Jim DeWees and State's Attorney Brian DeLeonardo has brought about programs and initiatives to try to distinguish the drug users who need treatment from the drug users who deserve jail time.
DeLeonardo said he participated in the law enforcement subcommittee on the Heroin and Opioid Overdose Prevention Task Force and was pleased to see that many of the recommendations made by the Task Force included initiatives Carroll County had already begun, such as diverting low-level offenders into treatment.
Along with the Carroll County Drug Task Force, which is composed of Maryland State Police troopers, deputies and a Westminster Police Department officer, DeWees said he has increased efforts to address quality-of-life issues that can lead to drug arrests.
Because thefts are often an indicator of a drug problem — individuals stealing to subsidize a habit — DeWees said being proactive in monitoring pawn databases and responding to neighborhood complaints of suspicious activity has led to individuals in need of treatment.
Once the drug user is in the system, he or she can be connected to resources and even court-ordered to use them.
DeLeonardo said his office is trying to identify drug users early and connect them to treatment resources before they have a lengthy criminal record. A first conviction for theft will no longer mean probation before judgment and release, but instead will get the offender into meetings with mentors and other recovery resources.
"A lot of this battle, I believe, is going to be on the local level," he said.
Funding from the Carroll County Board of Commissioners in fiscal year 2016 allowed DeLeonardo to hire an additional investigator for drug crimes, a new prosecutor, and Tim Weber, a recovering addict and owner of Weber Sober Homes who is now serving as the drug treatment and education liaison for the State's Attorney's Office.
"I think we're in a very good position moving forward to make a real difference," he said.
DeWees said he hopes that law enforcement is slowing the overdose numbers and expects to see the problem get better over the next few years, though it will never go away.
"I can't keep folks from putting needles in their arms," he said.
Poised to make a difference
The commitment from county leaders and the new and closer cooperation between agencies in Carroll County on the issue of drug overdoses is something Doyle said she is optimistic about. Even as the overdose numbers continue to climb, she believes these changes will put the county in a position to leverage some real downward pressure in the current fiscal year.
"Carroll is in a better spot than we were one year ago based on the fact that multiple agencies have come together to partner and work on this issue," said Doyle, of the health department. "There is an approach in place where all the players are at the table and we all know what each partner is doing, looking at the data together, addressing in a comprehensive manner, pulling information and data together so that we have a better view of what is really going."
This is a relatively unique approach among Maryland jurisdictions, one that has garnered attention throughout the state.
"Carroll County, I want to be very clear, really stands really tall in terms of its efforts on this issue," said Shank, of the Governor's Office of Crime Control and Prevention. "I am really impressed with your elected officials and leadership … They are very open-minded and realize this is a problem."