Tackling the opioid crisis and overdose epidemic in our nation is a task that involves partnerships among stakeholders at all levels: federal, state, and local governments and other organizations and health care systems in the community. The NIDA has been working with the Baltimore City Health Department (BCHD) on a comprehensive initiative to address the opioid crisis in that city, one that has involved innovative approaches to improving access to treatment for people with opioid use disorder. As these and other innovative programs and policies are implemented across the country, research will be critical for understanding what is most effective on the ground for fighting the opioid overdose epidemic.
Since it is also crucial for communities to share their experiences and learn lessons from one another, Mark L. O’Brien, Director of Opioid Overdose Prevention and Treatment, Baltimore City Health Department and Leana S. Wen MD, MSc, Baltimore City Health Commissioner were invited to guest blog about the initiative under way in their city.
Like much of the country, Baltimore City is facing an epidemic of opioid addiction and overdose. In 2015, 393 people died from drug and alcohol overdose in Baltimore—more than the number of people who died from homicide. And that number continues to rise. In the first three quarters of 2016, 481 overdose deaths occurred in Baltimore. Fentanyl has been a major driver of this increase. Since 2013, there has been more than a twentyfold increase in fentanyl-related overdose deaths, resulting in 267 deaths in January through September of 2016. In Baltimore, a city of 620,000 residents, nearly 25,000 people are estimated to have an opioid use disorder.
Even as we seek to reduce the harms associated with opioid misuse—disease transmission and overdose chief among these—through our Needle Exchange Program and naloxone distribution programs, the Baltimore City Health Department (BCHD) recognizes that the key to stemming this terrible tide is to ensure that every resident who needs it is able to access high-quality substance use disorder services when and where they are needed.
Since January 2015, we have trained nearly 20,000 people to respond to an overdose with naloxone, resulting in more than 640 lives saved, and we are simultaneously working to expand access to substance use disorder treatment in the following ways:
24/7 Phone Hotline for Behavioral Health Services
The first step to ensuring access to treatment is to make it easy for people to find services and get referrals to treatment. In Baltimore, residents previously had to navigate multiple phone lines to receive crisis services and behavioral health treatment referrals. In October 2015, we worked with partners to combine these lines into a single 24/7 hotline to create a more comprehensive resource for the community. This combined hotline enables callers to get screened and linked to the appropriate behavioral health services. The hotline receives more than 40,000 calls annually, and 12 percent generate a referral for direct crisis intervention by the city’s mobile crisis team.
24/7 Stabilization Center
The most common health concern of frequent users of emergency medical services in Baltimore City is substance use intoxication or mental illness. In fact, 32 percent of Maryland Medicaid enrollees with a substance use disorder visited the emergency department three or more times in a one-year period. We secured $3.6 million in capital funds to build a stabilization center, which will be the first step toward creating a 24/7 "ER" for behavioral health.
The center will provide voluntary care for adults who are intoxicated. In addition to first aid, medical monitoring, hydration, food, clothing, and showers, the Stabilization Center will provide Screening, Brief Intervention, and Referrals to Treatment (SBIRT) as well as case management for up to 30 days after a visit to ensure linkage to treatment, shelter, and health care.
Increasing Capacity for Medication-Assisted Treatment for Opioid Use Disorders
We have convened dozens of stakeholders ranging from city agencies to behavioral health service providers to develop a comprehensive opioid prevention and treatment framework that includes improving access to evidence-based treatment as a core pillar. We have engaged in a months-long strategic planning process with providers to identify strategies for increasing access to medication-assisted treatment for opioid use disorders with buprenorphine. BCHD has worked with our city’s hospital emergency departments to encourage buprenorphine induction and referrals to treatment. We plan to implement a mobile treatment capacity to bring treatment with buprenorphine to hard-to-serve patients who may not seek treatment in the traditional health care system. Similar to Vermont, we are developing a hub-and-spoke model to ensure that everyone who needs treatment has access to a flexible network of providers to meet his or her care needs.
BCHD is collaborating with the NIDA and other partners on a pilot to provide methadone through pharmacies in Baltimore City. This model will increase access to treatment in underserved parts of the city and further integrate medication-assisted addiction treatment into the health care system.
Improving Relations Between Treatment Providers and Communities
To address concerns that residents have about the presence of substance use disorder treatment centers in their communities and ensure access to care across the city, BCHD recently convened a work group of community and treatment system leaders to improve distribution of substance use treatment services in the city and encourage providers to adopt practices that make them good neighbors. The work group has held public meetings to seek input from city residents and will make recommendations and work with communities to address their concerns about the presence or absence of treatment services in their neighborhoods.
Baltimore is a city that cares about the health and well-being of every resident. BCHD has declared opioid addiction and overdose to be a public health emergency. As a city, we are striving to make medication-assisted treatment for opioid use disorders and other levels of addiction treatment available on demand to everyone who needs them. We have made great strides, yet we continue to see that opioids are ravaging our neighborhoods and families. We remain committed to fighting this scourge until we overcome it.