When Larry Hogan ran for governor four years ago, he vowed to urgently address what he called Maryland’s “heroin epidemic.”
“It’s a major disaster,” the Republican said during an October 2014 debate. “In January, I will immediately declare a state of emergency.”
At the time, Maryland was approaching 888 opioid overdose deaths for the year, a then-record pace that Hogan was blaming on ineffective efforts by his Democratic predecessor, Gov. Martin O’Malley.
But upon taking office in January 2015, Hogan did not immediately declare a formal emergency. Instead, he set up a statewide task force that worked for a year to deliver 33 recommendations. As administration officials rolled out the strategies during 2016, opioid fatalities mounted to 1,856 people that year — a death count that ranked Maryland fourth among the 50 states for such per-capita drug fatalities.
In all, 6,139 Marylanders died of opioid-related overdoses from the start of Hogan’s term through June 2018, a period of three years and six months. That’s more than the 5,019 who died during O’Malley’s eight years in office.
“It’s been very frustrating,” Hogan said this month. “I don’t have a magic solution. We’ve tried everything.”
The task force recommendations called for such things as expanding treatment and curbing prescription abuse, but was criticized for lacking specifics on costs.
The governor’s current point man on the opioid crisis, Clay Stamp, acknowledges that the state’s initial strategy faltered as a surge in the use of deadly fentanyl — which was not a major concern four years ago — more than stripped away some progress achieved in reducing fatalities from prescription opioids and heroin. Fentanyl-related overdoses “continue to increase at an alarming pace,” the state said Friday, accounting for more than three quarters of Maryland’s 1,185 opioid deaths in the first six months of 2018.
“The task force came up with 33 recommendations. They implemented virtually all 33,” Stamp said. “The 33 didn’t seem to work.”
Hogan has continued to make fighting the problem a priority, Stamp said. In March 2017, the governor announced that state of emergency, committing to spend $10 million more per year over five years to expand prevention, treatment and law enforcement efforts. He also appointed Stamp, the former Maryland emergency management director, to head a new Opioid Operational Command Center. It is designed to cut red tape as state and local agencies work together to tackle the problem.
The additional money — which started flowing in the fiscal year that ended June 30 — has not impressed some experts.
"That’s a drop in the bucket,” said Caleb Alexander, a professor at the Johns Hopkins Bloomberg School of Public Health. “This is an epidemic that at a national level will take hundreds of billions of dollars over a decade or two.”
Advocates applaud several steps Hogan has taken, especially getting the federal government to let the Medicaid insurance program cover certain residential treatment. They’ve also praised state efforts to get hospital emergency rooms to screen for substance abuse and distribute the treatment drug buprenorphine.
But Alexander and others say Maryland needs to look to states such as Rhode Island, which has managed to reduce its overdose death rates, in part by allowing medication-assisted treatment in state prisons.
“I don’t think anyone is happy with the slow pace of progress” in Maryland, Alexander said. “When you have more people dying from overdoses than from motor vehicle accidents or homicides or at the peak of the AIDS crisis, we have a serious problem.”
Stamp made no excuses for failing to reverse the measurement that matters most: overdose deaths.
“No doubt, ultimately, the most important measurement is fatalities,” he said.
So what to do in a state where, according to a health department analysis, about 62,000 people over age 12 are in need of treatment for opioid use?
“We know that we have to expand our capacity for treatment and recovery,” Stamp said.
Narcan versus treatment
The governor proposed cuts to drug treatment before later putting additional money in the state budget. Critics question how it’s being spent.
Maryland spent about $135 million on drug abuse treatment during O’Malley’s final year in office, state officials say. In his first year of office Hogan proposed trimming that, but General Assembly leaders managed to get spending increased to $146 million. Hogan went on to increase funding to $171 million in the current fiscal year.
To date, the Hogan administration’s main drug of choice for addressing the crisis has been naloxone, the overdose-reversing drug also known as Narcan.
Funding to get the life-saving drug into the hands of police, fire and emergency medical personnel has increased from $856,000 in fiscal year 2016 to $3.6 million in fiscal year 2018, which ended June 30. The number of naloxone doses dispensed increased from nearly 29,000 to nearly 43,000.
Stamp said while all fatalities are tragic, “we also have to remember that in the last two years upwards of 20,000 have been saved just by EMS administering naloxone.”
“When you talk about what treatment works, that works,” he added.
“People come back and say you’re wasting your money. Human life is not a waste of money,” Stamp said. “You don’t get a second chance unless you save the life the first time.”
Experts say naloxone is important but does not treat addiction. What’s needed, they say, are residential and outpatient recovery programs and medications such as buprenorphine, methadone and naltrexone.
“They put their money into Narcan instead of treatment,” said Mike Gimbel, an addiction treatment specialist who for many years served as Baltimore County’s “drug czar.”
Narcan’s “wonderful,” Gimbel said, “but if you don’t get [addicts] into treatment, they will use again and they will die — and that’s what happened. The numbers keep getting worse.
“We don’t have much more treatment than we did before,” Gimbel added. “Maybe a little but not much.”
Increases in treatment opportunities stem, in part, from the state’s successful push to get the federal government to provide new funding through the Medicaid program to cover residential drug treatment at small community facilities and at private institutions, such as Sheppard Pratt in Towson. Congress last month approved a sweeping opioid-fighting bill that incorporates that same measure across the nation and one that Hogan testified about in March to tighten mail shipments of fentanyl.
State officials say there are 3,354 licensed substance use disorder treatment beds in Maryland. That’s an increase from the 1,484 beds recorded as available in January 2017.
But local health officials say they see only a small increase in the number of treatment beds, which they attribute to the Medicaid funding creating a demand for organizations to create them.
Raymond Crowel, chief of Montgomery County’s behavioral health and crisis services agency, said the availability of Medicaid coverage is beginning to expand access to residential, outpatient and medication treatments, but that many more beds are needed.
“There is still a shortage of treatment beds,” Crowel said. “We are nowhere near treatment on demand.
“We spend a lot of time on prevention and getting Narcan out there and educating the community,” he said. “Expanding treatment capacity is lagging.”
Adrienne Breidenstine, a spokeswoman for Behavioral Health System Baltimore, which administers drug treatment spending in the city, agreed with Crowel’s assessment.
“Having this service be billable under Medicaid should expand access to this type of treatment for more people,” she said, but she still thinks the state should do more to add treatment beds.
Hogan’s administration has worked to expand the number of medical practitioners authorized to prescribe buprenorphine, a medication that relieves withdrawal symptoms. But critics fault the administration for not providing “bupe” — or other medical treatment for addiction — to thousands of addicted inmates within Maryland’s prison system.
The number of doctors, physician assistants and nurse practitioners in Maryland eligible to prescribe buprenorphine, most commonly known by its Suboxone brand name, has increased from about 725 in 2014 to nearly 1,900 this year, federal data show.
And prescriptions for buprenorphine for substance abuse treatment have increased 15 percent since Hogan took office, from 188,298 in 2014 to 217,846 in 2017, state data show.
The administration also has been working to get more hospitals to provide Suboxone and other medications that lessen withdrawal symptoms.
Today, 12 of the state’s 45 emergency departments initiate the use of buprenorphine. Ten of those started under a program initiated by Baltimore’s health department.
“The state has worked with all of the ERs in the hospitals to engage the doctors so they can prescribe and dispense buprenorphine right away when they’re in those critical situations,” said Dr. Howard Haft, Maryland’s deputy health secretary for public health. “The state is leading the country in that regard.”
All of Maryland’s emergency rooms dispense naloxone.
Anita Braden Ivey’s son was saved by naloxone and Suboxone — for a while, at least — after he admitted to his parents in 2010 that he was addicted to Oxycontin and heroin. But when 18-year-old Matthew entered a month-long treatment program, the rehabilitation center required him to go off the bupe, Ivey said. He relapsed almost immediately after his stay and quickly overdosed.
“A police officer came to our house and gave him Narcan,” she said.
The Ellicott City man went back on bupe, entered college at the University of North Carolina, Wilmington, and got his life back on track for nearly five years. Ivey and her husband worried when Matthew, at 23, decided to go off Suboxone under a doctor’s supervision, but “thought he was doing fine.”
Then, on Jan. 7, 2015, the morning he was set to return to North Carolina for his last semester, Matthew overdosed and died in his parents’ basement. Ivey found him when she went to wake him for his ride back to school.
“I wish he had never gone off Suboxone,” she said.
Meanwhile, treatment advocates have been pleading for years to get bupe into a place they say it is desperately needed: prisons.
About 60 percent of the population in Maryland’s corrections system is estimated to have a substance use disorder. Upon release, former prisoners are more susceptible to a fatal overdose because they have a lower tolerance for the drugs they once abused.
Yet Maryland, like most states, focuses primarily on abstinence-based programs and provides virtually no medical treatment for most prisoners suffering from substance abuse, state officials acknowledge. Methadone maintenance is provided in Baltimore’s state-run pretrial detention center, which has received federal money to initiate treatment in the facility, according to a Public Safety and Correctional Services Department report to the General Assembly.
Stamp said Hogan is committed to expanding “treatment on demand” with medication and abstinence programs across the state, including in prisons.
“There is much work to be done, but the commitment is there,” he said.
County jails are doing more in this regard, using state aid. Supplemental funding approved by the governor and the General Assembly last year provided $985,000 to increase access to medications at six correctional facilities in Anne Arundel, Calvert, Cecil, Dorchester, Howard and Washington counties.
Stephen Moyer, the state secretary of public safety and correctional services, said in a statement that his agency is wary of buprenorphine because of “documented instances showing the misuse of Suboxone and its effect on the safety and security of our prison system.”
But Moyer’s department is evaluating alternatives for providing treatment, including a pilot program to give 250 inmates a shot of the long-acting anti-abuse drug naltrexone prior to release and track them for six months.
Recent evidence has shown that offering medication treatment to addicts in prison can reduce overdose deaths overall.
Rhode Island — which has had one of the worst per-capita rates of overdose deaths — in 2016 began the first and still only program in the nation to screen all inmates for opioid use disorder and provide medications for addiction treatment such as buprenorphine.
A Brown University analysis of the program showed a 61 percent decrease in overdose deaths after people left prison. The decline “contributed to an overall 12 percent reduction in overdose deaths in the state’s general population,” the study reported.
Providing such treatment in prison, “with linkage to treatment in the community after release, is a promising strategy for rapidly addressing the opioid epidemic nationwide,” the researchers wrote in February.
Massachusetts lawmakers are considering a similar law as federal prosecutors there have begun an investigation into whether that state is violating the Americans with Disabilities Act by prohibiting inmates with opioid addictions from receiving buprenorphine or methadone behind bars.
Rhode Island’s health director, Dr. Nicole Alexander-Scott, said allowing buprenorphine, methadone and naltrexone into prisons was one of the most important steps her state has taken to combat the crisis.
“That was a game changer,” Scott said.
Prescription monitoring, to a point
Democrats and Republicans have praised Hogan’s administration for requiring pharmacies and medical practitioners to use a prescription drug monitoring program, which collects and stores information on drugs dispensed that contain certain controlled dangerous substances. Such access allows doctors and pharmacists, for example, to determine whether patients are exhibiting addictive behavior by obtaining too many pills.
But critics say the system should alert licensing boards and law enforcement when prescribing practices appear to be inappropriate or illegal — as when a so-called “pill mill” is dispensing large quantities to a single address.
The current system allows law enforcement to access that information only with a subpoena as part of an investigation.
Del. Erek Barron, a Prince George’s County Democrat, notes that a bill he introduced this year in the General Assembly — with Hogan’s support — would have allowed health officials to flag for law enforcement signs of potentially illegal prescribing. It was defeated amid strong opposition by the Maryland State Medical Society, which argued health officials lacked the experience to make such reports.
An October 2017 report, The Opioid Epidemic, by the Bloomberg School of Public Health and the Clinton Foundation, says states should use the monitoring databases to proactively alert “licensing boards and law enforcement” to possibly illegal prescription-writing.
Still, mandatory use of the database is expected to continue what state officials see as a positive trend.
Haft said educating medical professionals about the dangers of prescription opioids and use of the prescription drug monitoring database has helped lead to a 16 percent decline in the number of opioid prescriptions in Maryland — from 3 million in 2015 to 2.5 million last year.
Deaths associated with prescribed opiates have declined 1 percent as a result, state officials say, though overall opioid deaths continue to rise.
Real-time data needed
One of the biggest missing pieces to reducing Maryland’s high death rate is a real-time data system that shows where nonfatal overdoses are occurring, indicating a potentially deadly batch of opioids, many experts say. Such information would allow the state and its local partners to rapidly deploy resources such as more naloxone and investigators to warn users and identify the problem.
The local and regional “Opioid Intervention Teams” funded and established in all of the state’s 24 jurisdictions still do not have such data, which public health officials see as critical for an effective response, said Baltimore’s departing health commissioner, Dr. Leana Wen.
“We’re talking about a public health emergency and crisis,” Wen said. “And we need real-time data to identify patterns.”
Crowel of Montgomery County agreed.
“Data has always lagged by as much as a year” from the state, he said. That has improved over the past year, he said, but the wait is still three months.
Crowel said Montgomery County police and health officials set up their own system of informal reports of fatal and nonfatal overdoses.
“That gives us more real-time data in terms of what we’re doing locally and where we want to put our resources if we see an uptick,” he said. “We’ve done those things at the local level.”
The state has begun to address the issue, earmarking $75,000 to “implement an information-sharing system to map and track statewide EMS overdose responses for the purpose of improving the public health response,” states an August letter from Health Secretary Robert R. Neall to legislative leaders.
The General Assembly this year approved Hogan’s Overdose Data Reporting Act, which went into effect three months ago. It authorizes state emergency management officials to share within days data they’ve received from EMS responders about opioid overdoses. The EMS data is stripped of personal information and feeds into an “OD map” managed by a federally run program known as High Intensity Drug Trafficking Areas, which can email and text local agencies when spikes in deaths are spotted.
Rhode Island’s data-sharing effort is still considered the model worth following.
Unlike in Maryland, Rhode Island requires hospitals to report all overdoses within 48 hours, allowing state officials to alert local emergency responders about spikes in deaths. When those alerts go out via email and text, the state directs more resources such as naloxone and investigators to determine whether a bad batch of street drugs is driving the overdoses.
“It’s an example of real-time public health having a real-time impact," said Scott, Rhode Island’s health director. “We have gone from not only collecting data but collecting it in almost real time and responding to it.”
State officials also meet every Tuesday at 3 p.m. to examine nonfatal overdose data, said Dr. James McDonald, medical director of Rhode Island’s drug overdose prevention program.
Lorece Edwards, a public health professor at Morgan State University, is director of the federally funded Get Smart West Baltimore Drug Free Community Coalition. She said her work in the region has shown her that too few people know about the ongoing severity of the epidemic and the state’s efforts to combat it.
And the opioid problem gets worse every day, she added. Through June — the most recent data available — 1,185 people had died this year of opioid-related overdoses, 15 percent more than in the same period last year.
“It’s out of control,” Edwards said. “Right now, it looks like we’re walking backwards.”
To find a GRASP support group for people grieving the death of a family member or friend to overdose, visit Grasphelp.org
To find addiction services across the state, visit beforeitstoolate.maryland.gov