BALTIMORE – The last disaster in the deadly and worsening opiate epidemic in Baltimore was small: the dependency treatment van, now 13, would not start.
The GMC's white truck, open four mornings a week and parked outside the city jail, is an attempt to close a breach in the city's struggle. system of addiction treatment. But as the collapse showed, even attempts to plug holes in the system sometimes have holes. With the van out of service, doctors and nurses drove to their own cars to see patients, some of them already skeptical of the treatment.
The tight van, funded by private foundations and run by the Behavioral Health Leadership Institute, has a narrow aisle, a small kitchen and two offices so small that I could barely stretch my arms. He was back and running the moment I visited, offering buprenorphine, one of the two drugs considered the gold standard for opioid dependence treatment, to patients.
Since November 2017, customers have been able to enter, not schedule and begin treatment. The van does not require identification – a great barrier, especially for people experiencing homelessness – or any type of insurance. The main goal is to put someone under treatment and then connect you to a long-term treatment in the more traditional health system.
The van changed the life of Michael Rice. Without that, "I'd still be getting stoned," Rice, 58, she told me, laughing nervously. He said that after 15 years using heroin – a habit of $ 1,000 a week, he said – "got sick and tired of being sick and tired." Since coming to the van a year ago, it is in recovery.
"This program works," he said. "I feel good.I keep money in my pocket.He took dollar bills to prove it.
For Rice, the treatment seemed inaccessible until she found the van. Gaps in treatment exist throughout the US. But the gaps in Baltimore have been amplified by huge economic and health disparities, leaving treatment inaccessible to the city's poor and often black residents – as overdose deaths rise to record highs.
"They need more of that," Rice said, pointing to the van.
In the last two decades, News media has focused on white victims of the opiate epidemic in suburban and rural areas, such as in West Virginia and New Hampshire. And it is true that during the early years of the crisis, starting with opioid analgesics, white people were the main victims. But as the crisis escalated to include illicit drugs like heroin and fentanyl, it has hit black and urban communities more and more.
In 2011, the national overdose death rate for black people was 8.3 per 100,000, compared to 14.9 per 100,000 for white people. By 2017, the death rate from overdose of blacks had more than doubled – to 19.8 per 100,000. The white overdose mortality rate rose to 24 per 100,000.
In that period, the drug overdose crisis in Baltimore skyrocketed. According to the Centers for Disease Control and Prevention, the city's overdose mortality rate was 22.7 per 100,000 people in 2011. It rose to 49.1 per 100,000 in 2015 – comparable to the current numbers in West Virginia, the state with the highest rate of overdose deaths in the country. By 2017, the Baltimore rate was 85.2 per 100,000. That's almost equivalent to 0.1% of the city's population dying of drug overdose in a year.
Based on the most recent figures, 2018 was probably worse. Blacks make up the majority of overdose deaths in the city.
The mayor's office in Baltimore asked questions about the opiate epidemic for the city's health department, which declined requests for an interview.
For Baltimore activists, the rising rate of overdose deaths is proof that city, state, and federal officials are not doing enough to contain the opiate epidemic. "People are not all on deck to prevent this," said Natanya Robinowitz, chief executive of Charm City Care Connection, which offers services to reduce the dangers of drug use.
In addition to the lack of access to treatment, the increase in overdose deaths can be attributed to the powerful synthetic opiate fentanyl supplanting heroin in the illicit market. Fentanyl may make a more predictable dose of heroin more dangerous, making it difficult or impossible to assess the strength of the drug.
"People are scared," Rice said.
Baltimore suffered decades of urban decay, poor governance, and criminal and socioeconomic statistics that can rival developing countries. There are vast disparities in health from neighborhood to neighborhood. The US Department of Justice concluded in 2016 that "[r]A particularly unequal impact is present at all stages of the process. [the Baltimore Police Department]A recovery worker I met had to move his job to another block because there was a shooting-an event that was treated as typical and inevitable, like a storm that forced people into House.
The city and state governments are taking some steps – such as opening a stabilization center where people in crisis can be referred for drug treatment, and supplying organizations with the naloxone opioid overdose antidote (known to the brand Narcan).
But Baltimore, which is already dealing with the increase in murders and major policing scandals, and Maryland, with a focus on education, has limited resources. And the federal government, despite some increases here and there, has not compromised the level of funding that experts and advocates have asked across the country to counter the opiate crisis.
The result: treatment is not yet affordable enough in Baltimore. People who struggle with addiction often do not have adequate health insurance, money for expenses paid, means of transportation or even identifications needed to go into treatment. Treatment centers in Baltimore, due to their own rules or government regulations, often link specific requirements to their services – such as invasive testing, group therapy, or zero tolerance rules. The city's stabilization center, which supposedly expands access to care, does not even allow visitors.
That's where the treatment van can help. It does not require a commitment, ID or insurance. Recurrent clients are not expelled, as is the case in other configurations, and are supported to overcome setback. There are no requirements for specific therapies; someone can get a buprenorphine prescription and be on the way. Dependency specialists call this kind of "low threshold" care – patients do not have to do much to get into treatment.
"There are lots of high limit options, but not enough low limit options," said Robinowitz of the Charm City Care Connection over Baltimore. "If you had a system up and running, it would be very low threshold."
Right outside the vanI met Edward Kingwood, 56, smoking a cigarette. He said he was abused by his parents, so he ran away from home – in Fort Lauderdale, Florida – in 1978, and has since been homeless and unemployed. He started using heroin in 1986.
"It's so difficult," he said.
Kingwood, who has been on the vans program since January, was recently arrested for an armed robbery. He complained that the city and state did little to connect him to social services: the arrest did not provide treatment and released him without doing anything to deal with his lack of housing or drug use, which contributed to his crime. When he left, he went back to using heroin.
In the middle of the interview, Kingwood apologized, running in front of the van and vomiting on the side of the street. It was withdrawn. "I'm sick," Kingwood said, apologizing repeatedly, his eyes low and tearful. He squeezed a rubber ball in his left hand – a stress reliever, he explained.
This disease is what causes many people to continue using heroin and other opioids. Abstinence is commonly described as a mixture of the worst stomach flu and overwhelming and disabling anxiety. For this to stop, people often go for any opioid they may encounter.
This is one reason why medications such as methadone and buprenorphine are so successful. As opiates themselves, they may be prescribed for people with opiate dependence to avoid complete withdrawal. Once patients are stabilized in a dose, medications do not produce a high and instead help someone feel normal – "stay ahead" – without resorting to dangerous drugs. Decades of research show that drugs work, with studies discovering that they reduce the all-cause mortality rate among patients with opiate dependence by half or more and do a much better job of keeping people on treatment than non-opiate approaches. medicines.
Still, the stigma remains. A Baltimore methadone patient, Ricky Morris, 52, told me that his primary care physician told him to stop the medication, arguing, "You're killing yourself." Despite scientific evidence of the benefits of methadone and buprenorphine, there is a widespread misconception that drugs, such as opiates, are "replacing one drug with another" – even if the remedies, when taken as prescribed, are simply much more safe than heroin or fentanyl and reduce cravings and withdrawal.
In response to the rise in overdose deaths in the 1990s, Maryland and Baltimore expanded access to treatment with methadone and buprenorphine. This led to a drop in overdose deaths in the late 2000s, according to a study American Journal of Public Health. But once fentanyl arrived in mid-2010, overdose deaths started firing again – and the remaining gaps in the treatment were exposed.
For Kingwood, the van is an opportunity to avoid withdrawal in the future – in a cool way. "I'm not going to break the law anymore to be okay," he said.
He just wants to have the opportunity sooner.
"I would like to live in a house, I would like to eat food, I would like to have a job," Kingwood said.
Barriers to treatment are a problem nationwide – one reason the US surgeon concluded in 2016, because only one in 10 people with substance abuse receive specialized treatment. Even in places that have received wide national attention, such as West Virginia and New Hampshire, people suffering from addiction may still face waiting periods of weeks or months for treatment.
But such barriers are especially acute in Baltimore, where historical divestment and segregation have led to high poverty rates and huge racial disparities in wealth, income, and education.
"We are neglected," Darrell Hodge, a peer recovery specialist and former patient at the REACH treatment clinic in Baltimore, told me. "Many people in Baltimore feel private, like second-class citizens."
There is common wisdom in Baltimore about why overdose drug deaths have been allowed to increase dramatically in recent years with little external attention.
"Racism always has a part in it," Christian Diamond, a community welfare worker at Charm City Care Connection, told me. "We're trying to tell people that this is a disease for years, but no one was listening" – until the face of drug addiction became white and richer, he explained.
Keith Humphreys, a Stanford drug policy expert, acknowledged that racism is "undoubtedly" a factor in the lack of attention to the opiate epidemic in Baltimore and other mostly black communities. But he also pointed to the role of the class: a methamphetamine epidemic in the early 2000s, which disproportionately hit the poorest white communities in the United States, received little media attention and was generally framed as a crime, not a health issue public.
The opiate crisis has received much national attention, in part because it affects white people, rich and powerful – not just the black, the poor and the oppressed.
That's why New Jersey's former governor Chris Christie could make a moving speech that had more than 15 million views on Facebook about his high school buddy dying after years fighting addiction: it happened to someone he knew. This personal connection made the crisis more visible to the people in power and forced them to react more sympathetically – to family, friends and neighbors – in contrast to the punitive and criminal justice approach that dominated reactions to previous drug epidemics .
Bmore POWER is among the trying to fill the gaps in Baltimore. I scored with them in West Baltimore as they provided naloxone and fentanyl test strips to people who use drugs.
Ideally, people who use drugs would receive treatment. But Bmore and POWER groups like him try to ensure that people who use drugs do not overdose and die first. Ricky Morris, who now works with Bmore POWER, described the group's harm reduction philosophy: "You need to be here the next day to change your mind."
Morris was parked along Pennsylvania Avenue near the CVS that was set on fire during the Freddie Gray riots in 2015. Several police cars were nearby. But there seems to be no effort to stop drug trafficking; I saw money and exchanged goods several times in the two hours I was there.
In fact, that's why Bmore POWER was here: the group hoped to get people before they used drugs, giving them tools and instructions to reduce the risk of overdose and death.
"We expect people to see us as they are cheating," Ro Johnson, of Bmore POWER told me. She saw the damage from drug addiction personally, including with siblings and cousins.
As we talked, a medical emergency across the street attracted an ambulance and a fire truck. Johnson said he would not be surprised if it was an overdose.
She added, "I just hope she's not my sister."