In the war on heroin, Baltimore drug programs face an uncertain future

In 2015, Baltimore wrote a city-wide prescription for a heroin antidote. Two years later, as the city tries to expand access to addiction treatment, will the White House support its mission?

With a black plastic bag in hand, Gerald Young ducked into the needle exchange van parked across the street from Baltimore’s Saint Paul Freewill Baptist Church. A cold January rain drizzled outside.

Young shuffled to a small table and sat down, untying and overturning his half-knotted bag. Three bundles of used needles tumbled into a red medical waste bin.

Across from Young, John Harris opened a new box of clean hypodermic needles and restored Young’s supply. Harris, a Baltimore public health worker, also gave him a new kit of naloxone, an opioid antidote that stops a potentially fatal overdose in moments. Young, a 61-year-old homeless Baltimore native, rose to leave the van and wander around his hometown.

On that same van, outgoing U.S. drug czar Michael Botticelli, whose strategies targeted substance abuse and addiction treatment for the White House Office of National Drug Control Policy, stood off to the corner, asking workers what they’d been seeing. Botticelli had traveled to Baltimore to praise the city’s fight against the opioid epidemic. On the eve of President Donald Trump’s inauguration, he wondered how his work would carry forward.

Over the last five years, the nation’s opioid crisis has gained momentum, despite federal, state and local officials’ attempts to control it. The most recent government data shows more than 33,000 Americans died from opioid overdoses in 2015 alone. Those deaths have quadrupled since 1999, according to the Centers for Disease Control and Prevention. And in Maryland, which ranked 14th in drug overdose death rate nationwide in 2015, that rate rose 20 percent over the previous year. By September 2016, 70 percent of the state’s 918 fatal heroin overdoses happened in and around Baltimore, state records show.

Policymakers have targeted opioid deaths with new programs in recent years. All states except Missouri use real-time electronic records to monitor how often doctors prescribe and pharmacists dispense drugs. When Congress approved and President Barack Obama signed the 21st Century Cures Act last year, states secured $1 billion to fund substance abuse treatment targeting heroin and opioid users. And a growing number of cities and states have expanded access to naloxone; Baltimore was one of the nation’s earliest adopters.

Without these strategies, Botticelli told the NewsHour, “I don’t know where we’d be in terms of overdose deaths.”

As the nation sees a historic rise in fatal drug overdoses, and a new president steps into the White House, the future of those programs are unclear. The national drug control policy office, created by President Ronald Reagan nearly three decades ago, has faced political threats before. While advocates have praised the office’s ability to coordinate anti-addiction efforts across federal, state and local offices, critics say billions in spending hasn’t stopped drug use from rising.

In October, Trump pointed to then-running mate Gov. Mike Pence’s work in Indiana, where he “increased the mandatory minimum sentences for the most serious drug offenders, while expanding access to treatment and prevention options for those struggling with addiction,” Trump said. “We must make similar efforts a priority for the nation,”he added.

The Obama administration praised Baltimore’s efforts to combat the opioid epidemic. Under the Trump administration, it is unclear how the nation will face this public health crisis. Photo by Frank Carlson/NewsHour

But a month after Botticelli’s visit, the New York Times reported the Trump administration planned to ax the national drug control policy office. Trump has yet to nominate someone to take Botticelli’s place. His team also hasn’t spoken publicly about dissolving the office. Last week, advocacy groups submitted a letter to the White House, making the case for why the office needs to stay. A day earlier, the Fraternal Order of Police sent its own letter urging the Trump administration “to reject any notion or proposal to eliminate” the office, saying it “plays a vital role in coordinating a national strategy to fight drug trafficking and reduce illegal drug use.”

When reached Thursday, a White House spokesperson told NewsHour in a written statement that it’s “premature to comment,” adding: “The President and his cabinet are working collaboratively to create a leaner, more efficient government that does more with less of taxpayers’ hard-earned dollars.”

The Obama administration held up Baltimore as an example of how a cash-strapped city can forge partnerships at all levels of government and develop new ways to prevent drug overdose deaths, expand treatment access and nurture greater recovery, but the opioid problem is not yet solved. In Charm City, people are dying for answers.

***

The Saturday night after Trump’s inauguration was bitterly cold in Baltimore. People huddled around the city’s needle exchange van at Harford Road and 25th Street; a few people asked Harris if they could come inside to warm up. He obliged.

At least 15 people asked Harris: “Y’all have that medicine that brings people back?”

He did. That night, Harris trained people to use naloxone. He told them if they saw someone with no signs of life — at church or a bus stop, in a restaurant bathroom or their own home — they should release the nasal spray antidote and call 9-1-1. Within moments, naloxone stops the overdose and sends the person into withdrawal, a preferred side effect if the only other option is death.

But what Harris has seen disturbs him. People shoot up or snort forms of synthetic heroin called fentanyl and carfentanil, which is 10,000 times stronger than morphine and used as an elephant tranquilizer — aiming for a more potent high at the risk of losing it all. And with the price of heroin as low as $3, Harris said it’s more accessible than ever. By his count, 43 people overdosed in Baltimore that January weekend.

“The trauma [of being] there, to see someone drop and die in your presence, can leave a scar forever,” he said. “It’s in your neighborhood. It’s everywhere. I’m just glad to be a part of the solution as opposed to the problem.”

Harris lives in the same Coppin Heights home where he was born. But the neighborhood where his father and his mother raised 13 children changed long before the opioid crisis captured national attention. Down the red-brick street, a drug market openly thrives. The sounds of children laughing and playing no longer bounce off the brick rowhouses with white trim. It’s not safe anymore, said his niece, Rhonda Harris. Instead, ambulance sirens start wailing after lunchtime and go all night long, occasionally punctuated by gunshots, John Harris said.

Harris, 59, knows the ghosts of addiction who haunt his street all too well. He was once one of them.

Part of the solution — Baltimore public health outreach worker John Harris stands on the porch of his Coppin Heights home, the same house where he was born and where his parents raised 13 children. In long-term recovery from his own addiction to heroin, Harris trains the public to use an overdose antidote called naloxone, writes treatment referrals for people ready to confront their addiction and attends weekly Narcotics Anonymous meetings. Photos by Frank Carlson/NewsHour

Harris was captain of his high school wrestling team; he also played basketball and ran track. But he was shy to talk to girls or speak up in class. To take the edge off, he smoked marijuana and sipped cough syrup. When he first snorted heroin, Harris said it made him feel “real smooth.” He remembered competing in wrestling meets while high on heroin and thought he hid it well.

For more than a decade, addiction tightened its grip on him. He spent less money on haircuts, new clothes and movie tickets. Instead, it went to heroin. He injected heroin, puncturing his arms with dirty needles. He lost his job, his friends, his family, his home, his health. He picked up and dropped off drugs, taking a cut for himself when he couldn’t afford to buy them outright. He overdosed. He broke his parents’ hearts. Finally, in 1989, when Harris found out his girlfriend was pregnant, he panicked and said he couldn’t get high with a baby on the way.

A short time later, a high school friend who worked at a drug treatment facility found Harris sitting on the street in a gutter. He told Harris to come to treatment.“‘If you don’t like what you see in 28 days,” the friend said, “you can go back and do what you was doing because it’s waiting for you.’”

That made sense to Harris. For more than a month, he completed in-patient substance abuse treatment at Wyman Park and the Tuerk House in Baltimore. Harris emerged from treatment clean, in time to see his son born.

But he was scared to come home.

Harris tried to apologize to his father, his lifelong hero, who for more than 30 years worked two jobs as a postal worker and union leader to provide for his family. His father told him: “‘Don’t come telling me what you’re gonna do. You show me.’”

Baltimore public health outreach worker John Harris, right, stands at a Penn-North neighborhood bus stop in Baltimore and trains a man to use Narcan, also called naloxone, an antidote that can reverse an opioid overdose within minutes. Photo by Matt Ehrichs/NewsHour

His father’s command lit a fire inside of him that still burns. He took classes at Baltimore City Community College to learn how to counsel others battling addiction. He attends Narcotics Anonymous group sessions at least twice a week and says those conversations keep him in line. And he began working on the needle exchange vans that roll six days a week to meet the challenge of substance abuse in Baltimore.

He is encouraged that people talk more openly about substance abuse and addiction as families, communities and the country are confronted with a mounting opioid epidemic. He works to remove addiction’s stigma, seeing people come to him “from all walks of life.”

“They’re not bad people,” Harris said. “They’re human beings who have made some unhealthy decisions, who have put their lives in a dangerous place, and they need help.”

***
Since she was appointed in January 2015, Baltimore Public Health Commissioner Leana Wen has tried to figure out how the city would navigate the opioid crisis. In October 2015, Wen, an emergency room physician, wrote the city’s 620,000 residents a standing prescription for naloxone, also called Narcan, after she used the antidote on hundreds of patients herself.

“I’ve seen that, [if there’s] someone who’s overdosing who has minutes to live, I can literally save their life by nasal injection or by injecting something that’s similar to an epipen into them,” Wen told the NewsHour.

Since then, more than 17,000 people have received naloxone training in jails, at bus stops, at churches around Baltimore. After Wen became commissioner, naloxone has saved more than 800 lives in Baltimore. But as with EpiPen, the antidote’s price for some people is on the rise. So is the demand, at a time when nearly 25,000 city residents are estimated to have an opioid disorder.

kaléo, a Richmond, Virginia-based pharmaceutical company, makes auto-injectors that allow anyone to administer naloxone. A twin-pack of EVZIO auto-injectors that cost $575 in 2014 now costs more than $4,000, Kaiser Health News reported. The company argues that for 200 million people with commercial insurance and a prescription, the auto-injectors are now available free of charge.

In a written statement to the NewsHour, Spencer Williamson, chief executive at kaléo, said the company has donated nearly 200,000 auto-injectors since October 2014 to “public health departments, first responders and non-profits serving patients in need, free of charge.” Those free injectors make up about 40 percent of all auto-injectors shipped as of December, he said. The company plans to donate 100,000 more auto-injectors this year.

“We’ve received reports of more than 3,000 lives saved by EVZIO,” Williamson said. “That’s an average of more than 25 a week since the start of the program.”

The antidote is important, but if that’s the public’s only defense against opioid addiction, then “we’re just on this treadmill,” Wen told the NewsHour. Out of an estimated 20 million people who abuse substances nationwide, 11 percent seek treatment. That’s why she secured $3.6 million to build a stabilization center that offers round-the-clock behavioral health treatment. And as of Feb. 6, the city’s police officers can send minor drug offenders to treatment, rather than jail, in a move championed by law enforcement and Wen’s office.

After Trump won the presidential election, Wen, along with 10 other public health commissioners of major U.S. cities, wrote a letter to his transition team, asking that they “prioritize combating opioid addiction and overdose in the first 100 days,” and appoint a drug czar “with experience in public health and addiction treatment to ensure that addiction is addressed as the disease that it is.”

Mike Gimbel, of the Maryland Addiction Recovery Center, agrees with Wen’s belief that when communities treat addiction like a disease rather than a moral failing (“treat people rather than put them in prison”), they will produce better outcomes. But he said the city emphasizes naloxone too much and should do more to steer people battling addiction into treatment.

Gimbel, a recovering heroin addict, says he has been clean for 44 years. He scoffs at the way people talk about addiction in the United States today, compared to the searing rhetoric of the drug war of the past. Now that heroin is a middle-class issue, governments want to treat addiction “like it’s every other disease,” he says.

“The inner cities have been dealing with heroin addiction for over 50 years,” he said. “Suburbs have just begun to come to terms with the fact that there’s a heroin problem in white middle class America.”

In October 2015, Baltimore City Public Health Commissioner Leana Wen wrote a standing order for naloxone, an opioid overdose antidote, for all 620,000 residents. Photo by Frank Carlson/NewsHour

But he thinks a standing citywide order for naloxone makes it too easy for people with substance addiction to escape hospital care and treatment. Instead, he says public health officials should invest more resources in long-term treatment facilities and design policies that route people into those facilities. That was the only thing that broke heroin’s hold on him, Gimbel said.

“It takes over your body. It takes over your mind. It takes over your soul. Heroin is literally the devil,” he said. “Middle-class America has never had to confront this.”

Pharmacist Dwayne Weaver began filling prescriptions at his Penn North neighborhood shop two decades ago. Nowadays, clients step up to his pharmacy’s bulletproof glass window once or twice a week, asking for more naloxone under Wen’s citywide prescription. The antidote’s potential is huge, Weaver said. As more people become addicted to opiates, like oxycontin, “the marketplace has turned to heroin for a cheaper high.”

But Weaver holds the medical community partially responsible for its role in the epidemic.

Public health officials “seem to be finally educating doctors on more prudent prescribing of opiates,” Weaver said.

And it’s not just doctor’s prescriptions. A few blocks from Weaver’s store, drug dealers stand shoulder-to-shoulder next to a red brick wall in an open market. A police helicopter circled overhead, and officers patrolled around the corner, but business never slowed down on a chilly Wednesday afternoon.

***
Back on the van, on Michael Botticelli’s final day as the drug czar, he asked public health workers like John Harris what they thought the nation needed to more fully combat the opioid epidemic.

Mental health problems and addiction are often tightly intertwined, Harris told Botticelli, and people feel isolated in poverty and violence. Cities like Baltimore need more treatment centers that integrate psychological disorders and substance abuse, he said. Otherwise, said Thomas Clemons, another city health educator who works alongside Harris on the van, “you’re gonna come right back to the same problem.”

Several outreach workers who spoke to Botticelli that day had served on the frontlines of Baltimore’s opioid crisis for roughly a decade. They told him a sense of mission and compassion kept them coming back.

Nationwide, “that’s what we need in the middle of this epidemic,” Botticelli said.

Despite the concern that echoes around him, Harris said he remains optimistic the new president will support his city’s efforts to fight a public health crisis. Officials in Baltimore and other cities across the country are waiting to see how the new administration chooses to tackle this epidemic. Until then, he’ll hand out clean needles, write up treatment referrals and train people to trick death while working to loosen addiction’s hold on his hometown.