Opi­oid deaths con­tinue to haunt of­fi­cials

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OPI­OIDS, ties 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 med­i­ca­tionas­sisted 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. Clay Stamp

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 treat­ment pro­gram, the re­ha­bil­i­ta­tion cen­ter re­quired him to go off the bupe, Ivey said. He re­lapsed al­most im­me­di­ately af­ter his stay and 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, Over­dose deaths in Mary­land from il­le­gal opi­oids, driven pri­mar­ily by fen­tanyl, have soared. Two bright spots: From 2016 to 2017, heroin deaths de­clined 11 per­cent from 1,212 to 1,078 and pre­scribed opi­oid fa­tal­i­ties dipped 1 per­cent from 418 to 413. Gov. Larry Ho­gan em­pha­sized dis­tri­bu­tion of nalox­one, the over­dose-re­vers­ing drug also known as Nar­can. Spend­ing on the pro­gram has in­creased from $856,000 in fis­cal year 2016 to $3.8 mil­lion this year. Spend­ing on drug abuse treat­ment has in­creased over the past five years, from $146 mil­lion to $171 mil­lion this year, but ad­vo­cates say more is needed. 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. 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.

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.

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.

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 ddono­van@balt­sun.com twit­ter.com/doug­dono­van

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