Baltimore City's real solution to the opioid epidemic
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In Baltimore, we spend a lot of time training people to use naloxone, the antidote medication that reverses an opioid overdose. At these trainings, we talk about the opioid epidemic — what caused it and how it escalated so quickly. These explanations are often unnecessary. Our city’s residents know the opioid epidemic. It has taken people they loved.
At each training, we talk about what our city is doing to reverse the tide of overdose deaths. We talk about the “standing order” — the blanket prescription for naloxone that makes it available without a prescription to all 620,000 residents.

We talk about how everyday residents have saved nearly 1,800 lives in the last two years. We talk about our city’s work to increase medical services to people with the disease of addiction: setting up a 24/7 hotline; offering individuals arrested for low-level drug offenses the choice of treatment instead of prosecution; and making on-demand treatment available in our emergency departments.

We do not talk about how these initiatives have led to a reduction in total overdose deaths, because they haven’t. Every day, we hear anecdotes from people who have their lives back because of our interventions, but our dedicated outreach workers cannot keep up with the rise of fentanyl and the toll of addiction. In 2014, our city had 305 overdose deaths. In 2015, we jumped to 393. In 2016, to 694. When the final number for 2017 comes in, it will be higher still.

It was in this context that we listened to President Trump announce his new opioid strategy last month. Its apparent centerpiece, in response to all this death, was more death: the death penalty for people who distribute drugs. This “eye for an eye” proposal does not take into account the myriad of studies showing that tougher penalties for drug distribution do not make drugs harder to get and that the so-called “war on drugs” has not curbed drug use but has contributed to the mass incarceration that decimated communities like ours in Baltimore.

We did not take issue with all of the president’s proposals. His strategy includes cutting back on the prescribing of opioid painkillers, although it does not explain how. It also proposes expanding access to evidence-based addiction treatment, but, again, without explaining how.

Perhaps the explanations were missing because they depend on something else that was missing: a sustained commitment of resources.

Addiction is a disease. Treatment for that disease exists and it works. When people are dying from overdose, naloxone will save their lives. Despite broad availability through Baltimore’s blanket prescription, we have to ration naloxone because we simply don’t have resources to purchase enough for all who need it. Long-term treatment is even harder to come by. Research shows that treatment with medications like methadone and buprenorphine cut mortality by more than half.

Many people require this treatment for years, just as patients with diabetes require insulin. However, the infrastructure needed to treat addiction as the chronic ailment that it is does not exist. A 2016 Surgeon General’s report found that only 1 in 10 people with addiction are able to receive treatment for it. According to the president’s own opioid commission, 85 percent of counties have no specialty addiction treatment center and 47 percent have not a single doctor who can treat addiction with buprenorphine.
Building this infrastructure will require bold policy changes, like requiring that all doctors who prescribe opioids to be trained to treat patients with addiction. More than anything, what is required in this purported state of emergency is a sustained investment of resources.

The president had called for several billion dollars in his proposed budget and the funding package that Congress recently passed adds $3.3 billion. These funds are a stopgap measure. They will fund some important programs and perhaps provide cities and counties with much-needed naloxone. However, our country cannot build a treatment infrastructure with a few billion dollars spent a year or two at a time.
Nearly thirty years ago, at the height of the HIV/AIDS epidemic, our country made a bold choice. To stop Americans from dying from a preventable disease, our leaders recognized that we needed a comprehensive and permanent treatment safety net, one that funded both medical care and the broader system of social supports that would allow that medical care to be effective.

The Ryan White HIV/AIDS program was born; it provided — and continues to provide — billions of dollars in funding each year and our response to that epidemic improved dramatically as a result.

Today, Sen. Elizabeth Warren (D-Mass.) and Rep. Elijah Cummings (D-Md.) will introduce a bill that would create what we so desperately need: a Ryan White program for the opioid epidemic. The bill — the Comprehensive Addiction Resources Emergency Act (CARE Act) — would direct $100 billion to the opioid epidemic over ten years, including funding for local jurisdictions that the epidemic has hit hardest. There are no silver bullets here. But this is, finally, a proposal that stands a chance of making difference. We celebrate Senator Warren’s and Congressman Cummings’ leadership and we call on their colleagues to support their bill.

Five days after the president announced his opioid strategy and three days after Congress celebrated their stopgap contribution to the nation’s response to the epidemic, we received preliminary overdose numbers for the first months of 2018. In Baltimore, they are, once again, rising. We will continue to train our residents to use naloxone.

We will continue to expand access to treatment in whatever way our shoestring budget allows. But we will continue to watch our loved ones die. What we need, urgently, is sustained funding, in an amount commensurate with the scope of the disease, directly to areas hardest hit by addiction and overdose. This is precisely what the CARE Act would provide. Without it — without the money to scale up what we already know works — we will be having the same conversation years from now, wondering why we didn’t stop this epidemic when we had the ability, the will and the resources to do so.

Evan Behrle is the special advisor for opioid policy at the Baltimore City Health Department. Dr. Leana S. Wen is the health commissioner of Baltimore City. You can find her on Twitter: @DrLeanaWen.

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