The forgotten opioid epidemic of Baltimore – Vox

BALTIMORE – The last disaster of the deadly opioid epidemic, which is getting worse and worse, has been minimal: the 13-year-old addiction treatment van would not start.

The GMC white truck, which is open four times a week and parked in front of the city jail, is an attempt to fill a void in the troubled area of ​​the city. drug treatment system. But as ventilation has shown, even attempts to plug holes in the system sometimes have holes themselves. The van was out of order, so doctors and nurses took their own cars to see patients, some of whom were already skeptical about getting treatment.

The narrow van, funded by private foundations and managed by the Behavioral Health Leadership Institute, has a narrow hallway, a small kitchen and two desks so small that I could barely stretch out my arms. At the time of my visit, it was again operational and offered to the patient buprenorphine, one of the two drugs considered the standard par excellence for the treatment of opioid dependence.

Since November 2017, clients have been able to enter, be scheduled and begin treatment. The van does not need an ID card – a major obstacle, especially for homeless people – or any kind of insurance. The main objective is to have a person treated and then to connect to a long-term treatment in the more traditional health care system.

The van changed the life of Michael Rice. Without that, "I'll always be beating myself," Rice, 58, laughs nervously. He said that after 15 years of heroin use – a habit of $ 1,000 a week, he "was sick and tired of being sick and tired". Since he arrived at the van a year ago, he was recovering.

"This program works," he said. "I feel good, I keep money in my pockets." He pulled out dollar bills to prove it.

For Rice, the treatment seemed unattainable until he found the van. Treatment gaps exist throughout the United States. But the gap between Baltimore and its people has been magnified by enormous disparities in the economy and health care, making treatment inaccessible to the city's poor and black residents – while overdose deaths are breaking records .

"They need more of that," Rice said, pointing to the van.

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In the last two decades, The media generally focused on white victims of the opioid epidemic in the suburbs and rural areas, such as West Virginia and New Hampshire. And it is true that during the first years of the crisis, starting with opioid badgesics, whites were the first victims. But as the crisis spread to illicit drugs such as heroin and fentanyl, it has increasingly hit black and urban communities.

In 2011, the national overdose mortality rate among blacks was 8.3 per 100,000, compared with 14.9 per 100,000 for whites. In 2017, the black overdose mortality rate more than doubled – 19.8 per 100,000 population. The white overdose mortality rate increased to 24 per 100,000.

The drug overdose crisis in Baltimore has worsened. According to the Centers for Disease Control and Prevention, the city's overdose death rate was 22.7 per 100,000 population in 2011. It rose to 49.1 per 100,000 in 2015, which is comparable to current numbers. in West Virginia, the state where the rate of overdose deaths is highest in the country. In 2017, the rate in Baltimore reached 85.2 per 100,000 population. This is almost the equivalent of 0.1% of the city's population who dies from a drug overdose in one year.

According to the most recent figures, 2018 was probably worse. Blacks account for most overdose deaths in the city.

The Baltimore mayor's office forwarded issues related to the opioid epidemic to the city's health department, which declined requests for interviews.

For Baltimore activists, the increase in the overdose mortality rate is proof that city, state and federal officials are not doing enough to stem the epidemic of opioids. "People are not all on the bridge to stop this," said Natanya Robinowitz, executive director of Charm City Care Connection, which offers services to alleviate the dangers of drug use.

In addition to lack of access to treatment, the increase in the number of overdose deaths can be attributed to the powerful synthetic opioid fantanyl supplanting heroin. on the illicit market. Fentanyl can make a more predictable dose of heroin more deadly by making it difficult or impossible to measure the strength of the drug.

"People are scared," Rice said.

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Baltimore suffered decades of urban destruction, poor governance, and socio-economic and crime statistics that can compete with developing countries. There are great disparities in health from one neighborhood to another. The US Department of Justice concluded in 2016 that "[r]A substantially disparate impact is present at each stage of [the Baltimore Police Department]Coercive measures. "Armed violence is endemic, a local worker I met had to move his work to another block because of a shootout – an event treated as typical and inevitable, like a storm that forced people to go home.

Cities and state governments are taking steps – such as opening a stabilization center where people in crisis can be referred to addiction treatment and providing organizations with the antidote for opioid overdose, naloxone (often known as the brand name Narcan).

But Baltimore, which is already facing an increase in murders and major police scandals, and Maryland, focused on education, have limited resources. And the federal government, despite some increases here and there, has not committed the level of funding that experts and advocates have called for nationally to fight the opioid crisis.

As a result, treatment is still not accessible enough in Baltimore. People with addiction problems often do not have adequate health insurance, money for personal expenses, transportation, or even the necessary IDs to receive care. Baltimore treatment centers, because of their own rules or government regulations, often combine specific requirements with their services – such as invasive testing, group therapy, or strict zero tolerance rules. The stabilization center of the city, which is supposed to widen access to care, does not even allow visits without an appointment.

This is where the treatment van can help. It does not require appointments, identity or insurance. Clients who relapse are not excluded from care, as they are in other settings, and are offered support to help them get through the decline. There are no conditions for specific therapies; someone can take a prescription for buprenorphine and be on their way. Drug addiction experts describe this type of care as a "low threshold" – patients do not need to do much to get treatment.

"There are many high-threshold options, but not enough low-threshold options," said Robinowitz, of Charm City Care Connection, about Baltimore. "If you had a functional system, the threshold would be very low."

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Just in front of the vanI ran into Edward Kingwood, 56, smoking a cigarette. He testified that he was abused by his parents and escaped from his home – in Fort Lauderdale, Florida – in 1978, and since then has been largely homeless and unemployed. He started using heroin in 1986.

"It's so hard," he says.

Kingwood, who has been involved in the van program since January, was recently jailed for an armed robbery. He complains that the city and the state have done little to put him in touch with social services: the prison did not treat him and released him without doing anything to remedy his situation. homelessness or drug use, two factors that contributed to his crime. When he came out, he started using heroin again.

In the middle of the interview, Kingwood excused himself, rushing to the van and vomiting on the edge of the street. That was the withdrawal. "I'm sick," said Kingwood, apologizing several times, his eyes lowered lightening. He squeezed a rubber ball in his left hand – an anti-stress, he explained.

This disease is what drives many people to continue to consume heroin and other opioids. Weaning is usually described as a mixture of the worst stomach flu and an overwhelming and disabling anxiety. To stop it, people often go to the opioid that they find.

This is one of the reasons why drugs like methadone and buprenorphine are so successful. As opioids themselves, they can be prescribed to people with opioid dependence in order to avoid complete withdrawal. Once patients are stabilized at one dose, the medications do not produce a high effect, rather they help a person feel normal – "go right" – without the use of dangerous drugs. Decades of research show that drugs work, with studies showing that they reduce the all-cause mortality rate by half or more in opioid-dependent patients and do much better at keeping patients on treatment than non-drug approaches.

However, the stigma remains. Ricky Morris, a 52-year-old Methadone patient in Baltimore, said his former health care doctor had told him to stop taking medication, saying, "You're killing yourself." Despite the evidence scientists attesting the benefits of methadone and buprenorphine, a common misconception that medications, as "opioids," replace one drug with another "- even if they are taken as prescribed, they are simply a lot safer than heroin or fentanyl and reduce cravings and weaning.

In response to the increased number of overdose deaths in the 1990s, Maryland and Baltimore have expanded access to methadone and buprenorphine treatment. This led to a decrease in the number of overdose deaths in the late 2000s, according to a study published in the American Journal of Public Health. But once fentanyl arrived in the mid-2010s, overdose deaths began to skyrocket again – and the remaining treatment gaps were updated.

Gabriella Demczuk for Vox

For Kingwood, the van is an opportunity to avoid withdrawal in the future – in a legal manner. "I will not break the law to recover," he said.

He just wants to have the opportunity sooner.

"I'd like to live in a house. I would like to eat food. I would like to have a job, "Kingwood said. "Give a guy a chance."

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Barriers to treatment are a problem nationwide – one of the reasons, concluded the surgeon general of the United States in 2016, according to which only one in 10 addicts receives specialized treatment. Even in places that have attracted national attention, such as in West Virginia and New Hampshire, people with addictions may still face periods of treatment waiting several weeks or weeks. several months.

But these obstacles are particularly acute in Baltimore, where historical disinvestment and segregation have led to high rates of poverty and huge racial disparities in wealth, income and education.

"We are being neglected," said Darrell Hodge, a peer recovery specialist and former patient at the Baltimore REACH treatment clinic. "Many people in Baltimore feel helpless, like second-clbad citizens."

Gabriella Demczuk for Vox

In Baltimore, there is general agreement that drug overdose deaths have been allowed to increase dramatically in recent years without attracting too much outside attention.

"Racism still has a role to play in this case," said Christian Diamond, a Community Wellness Officer with Charm City Care Connection. "We try to tell people that it's been an illness for years, but no one listened to it" – until the face of addiction became white and richer, he explained.

Keith Humphreys, a Stanford drug policy expert, acknowledged that racism is "without a doubt" a factor in the lack of attention paid to the opioid epidemic in Baltimore and in the US. other essentially black communities. But he also stressed the role of the clbad: a methamphetamine epidemic in the early 2000s, which disproportionately hit the poorest white communities across the United States, drew little attention from the media and was generally described as a crime, not public health.

The opioid crisis has attracted a lot of attention at the national level, in part because it affects white, rich and powerful people – not just black, poor and oppressed people.

That's why former New Jersey governor, Chris Christie, was able to deliver a moving speech, which received more than 15 million views on Facebook, about the death of his high school friend after years Drug addiction: This happened to someone he knew. This personal connection made the crisis more visible to those in power and prompted them to respond with greater sympathy – to their family, friends and neighbors – contrary to the punitive approach focused on criminal justice that dominated reactions to previous drug epidemics.

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Bmore POWER is among the groups trying to fill the gaps in Baltimore. I followed them to West Baltimore, where they provided naloxone and fentanyl test strips to drug users.

Ideally, people who use drugs could get treatment. But Bmore POWER and groups like this are trying to make sure that people who use drugs do not overdose and die first. Ricky Morris, who is now working with Bmore POWER, described the group's harm reduction philosophy: "You must be here the next day to change your mind."

Morris was parked along Pennsylvania Avenue, near the CVS set on fire during the Freddie Gray riots in 2015. Several police cars were hanging around. But there did not seem to be any effort to stop drug trafficking; I've seen money and merchandise swap hands many times over the past two hours there.

In fact, that's why Bmore POWER was here: the group was hoping to catch people just before taking drugs, giving them tools and instructions to reduce the risk of overdose and death.

"We hope people will see how they get rid of shit," said Ro Johnson, with Bmore POWER. She saw the misdeeds of addiction personally, including with her siblings and cousins.

While we were talking, a medical emergency on the other side of the street attracted an ambulance and a fire truck. Johnson said that she would not be surprised if it was an overdose.

She added: "I just hope it's not my sister."