Moving America Forward

Baltimore Explores a Bold Solution to Fight Heroin Addiction

September 1, 2016
Baltimore Explores a Bold Solution to Fight Heroin Addiction
As the leader of the country's oldest public health department, Dr. Leana S. Wen (at the podium) focuses much of her attention on the urgent issue of opioid addiction. Courtesy of Baltimore City Health Department
Health commissioner Dr. Leana S. Wen gives every single city resident access to medication that stops an overdose in its tracks.

In the emergency room at George Washington University (GW) Hospital, in D.C., Dr. Leana S. Wen administered anti-inflammatory meds to kids choking with asthma, rescued middle-aged dads from heart attacks and sewed up shooting victims. Unlike a primary care doctor, she knew almost nothing about the strangers wheeled into the frenzied space: their medical history, financial situation and neighborhood all mysteries.

The usual anonymity made it all the more surprising when she recognized a 24-year-old mother of two. Homeless and addicted to opioids, the woman would show up nearly every week, begging for treatment. Without fail, Wen delivered the disappointing news that the next available appointment was three weeks away. Inevitably, the young mom relapsed during that window. The last time Wen saw the young woman, she wasn’t breathing. Her family had discovered her unresponsive, killed by an overdose.

“I always think back to my patient now: she had come to us requesting help, not once, not twice, but over and over again, dozens of times,” says Wen. “Because we do not have the treatment capacity, the people looking to us for help fall through the cracks, overdose and die. Why has our system failed her, just as it is failing so many others who wish to get help for their addictions?”

Last January, at age 32, Wen took a new job as the city’s health commissioner. As the leader of the country’s oldest public health department (established in 1793), Wen devotes much of her attention to an urgent problem: addiction to opioids (a class of drugs that includes heroin, morphine and oxycodone) and prescription painkillers. In the seaside port city of 622,000 residents, two-thirds of them black, heroin addiction grips 20,000 people. Many more pop prescription drugs before turning to heroin, a drug that’s cheaper than ever and more socially acceptable since it can be snorted and not just injected.

Baltimore’s drug addiction is lethal: Last year, 393 residents died of overdoses, a staggering number that surpassed the city’s 344 murders in a year of record gun violence. Long past a criminal “war on drugs,” Wen is implementing a public health response to this medical crisis. Her three-part plan involves preventing overdoses, treating addiction and ending stigma against drug users. By treating addiction as a sickness, not a scourge, she’s now saving lives on a broader scale than any emergency room physician.

“It ties into every aspect of the city. I’ve spoken to kids who question why they have to go to school every morning when everyone in their family is addicted to drugs and doesn’t get up. If we have employees that are addicted or have criminal histories because of their addiction, then what does that mean for a healthy workforce?” asks Wen, a fast talker who regularly works 14-hour days. “This is absolutely something we need to address as a critical public health emergency.”

Tenacious even in childhood, Wen spent the first eight years of her life in post-Mao China, until the 1989 Tiananmen Square massacre forced her politically dissident parents to flee the country. They moved to Los Angeles’s gang-infested neighborhoods like Compton and East Los Angeles, scraping money together from jobs as a dishwasher and hotel maid. With money tight, Wen remembers her aunts choosing between prescription medications, food or bus passes. Never one to wait, Wen enrolled in classes at California State University, Los Angeles, when she was just 13 years old. By age 18, she finished her degree, graduating with the highest honors, and went on to earn her M.D. from Washington University School of Medicine in St. Louis.

Working as a public health professor at GW, Wen spearheaded campaigns to cut healthcare costs, remove lead from homes and design walkable neighborhoods with access to reasonably priced, nutritious food, which caught the attention of Baltimore Mayor Stephanie Rawlings-Blake and landed her a new job.

A key to Wen’s plan for fighting opioid addiction is the distribution of an antidote to reverse a life-threatening opioid overdose. Inhaled through a nasal spray or injected into the upper arm or thigh like an EpiPen, Naloxone instantly revives a person from an overdose with few, if any, serious side effects. During a heroin high, chemicals block pain and induce euphoria — dulling the body to such an extent that the lungs forget to breathe while sleeping or the heart fails to pump adequately. Essentially shaking the brain out of its high, Naloxone creates a 30 to 90 minute window in which medical treatment can be sought. “It truly is a miracle drug,” Baltimore County Fire Chief John Hohman tells the Baltimore Sun. “It takes someone from near-death to consciousness in a matter of seconds.”

There’s only one catch: “You can’t give yourself this medication,” Wen explains. A person in the midst of an overdose often doesn’t have the wherewithal to inject the antidote. “That’s why we need every single person in our city to have access to it,” she adds, explaining that friends, family and community members have the ability to save a life.

In a controversial move, Wen issued a blanket prescription to the entire city last October — meaning anyone can buy the drug from a pharmacist. (For recipients of Medicaid, the price was reduced to $1 at a time when the drug’s price spiked drastically.) Wen sent training videos to jails and hospitals. Health department staffers visited areas notorious for open-air drug markets. Last year, the agency distributed 10,000 units of Naloxone and trained 12,500 residents how to administer it. That’s a big number for a program’s first year, but it’s still only half the number of active heroin users in Baltimore.

Outside of the roughly 30 recorded uses of Naloxone by police officers, there’s little hard evidence whether the drug has saved lives inside the city’s crack houses, parks and underpasses. Using data from Poison Control and other sources, Baltimore estimates Naloxone saved hundreds since 2015. “This remains a vastly underreported statistic,” says Sean Naron, a city spokesperson.

Critics claim that Naloxone encourages risky behavior and perpetuates the cycle of addiction because it removes the risk of death. “Naloxone does not truly save lives; it merely extends them until the next overdose,” Maine’s Gov. Paul LePage, wrote in April when he vetoed a bill that would have expanded access to Naloxone without a prescription. Suggestions like that make Wen balk. She calls them “specious,” “inhumane” and “ill-informed.” “That argument is based on stigma and not on science,” she responds. “You would never say to someone who is dying from a peanut allergy that you’re withholding their EpiPen to make them not eat peanuts.” Similarly for drug addiction, Wen believes there’s no use in talking about recovery tomorrow, if we don’t have the ability to stop a fatal overdose today.

Most in the medical community agree on the dire need for Naloxone. Experts caution, however, that it can’t be the sole response to this health crisis. Like most other cities, Baltimore is still trying to figure out how to effectively direct users whose lives were saved by Naloxone into long-term treatment programs, says Dr. Marc Fishman, medical director at Maryland Treatment Centers, a regional clinic. After reversing an overdose, an addict may “get dusted off and given a piece of paper with some phone numbers. They’re told to call this number today, tomorrow, next week. Maybe somebody will answer. Maybe they’ll take your insurance. Maybe they’ll see you next week or next month,” explains Fishman, who is also an addiction psychiatrist and faculty member at the Johns Hopkins School of Medicine.

Instead, Fishman suggests the medical system needs a “full continuum” from Naloxone administration to addiction treatment. It’s not unprecedented: just look to patients with heart issues, he says. They, too, receive lifesaving drugs to stabilize their ticker, but rather than being discharged immediately, a cardiac clinic assigns a care plan and prescribes maintenance medicines to patients.

Wen fully embraces the idea: she wants to see medication-assisted treatment that fools the brain into thinking it’s getting opioids without getting high or blocks an opioid high after shooting up, alongside housing and supportive social services. In the meantime, she’s set up a 24-hour hotline for users to get treatment option referrals. (Since October, it’s received 1,000 calls every month.) By next year, Wen wants to open a stabilization center where a person can drop in for several days to get sober.

It’s far from the perfect solution, Wen acknowledges. But at the moment, she’s constantly iterating new approaches. Last year, at a meeting of the Mayor’s Task Force on Heroin, Wen asked her colleagues to think of what they could do immediately that wouldn’t need further funding or manpower. That type of thinking fits with the approach she learned from life-or-death decisions in the emergency room: it’s better to act quickly now with what’s available than to wait for an instrument that might never come.

“Everybody is working hard and trying stuff. Some things are succeeding, and some are failing,” Fishman says. “I get a sense of dynamic enthusiasm. People are rolling up their shirtsleeves. I’m sorry that white kids from the suburbs had to start dying before anybody started paying attention, but it’s better late than never.”

Despite Wen’s tireless efforts, overdoses continue to rise in Baltimore. Last year, 260 heroin users overdosed, tripling the 76 intoxication deaths in 2011. Why are people still dying? Wen returns to the idea that a heroin user, on the brink of an overdose, can’t save himself; the rest of the city needs to be on the lookout, which isn’t always the case.

Baltimore’s response to this crisis has the ability to end an epidemic and to unite an ailing community. Wen, who says she’s an optimist by nature, might just find a way to cure a hurting American city after all.

Homepage photo by Spencer Platt/Getty Images

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