By Robert P. Schwartz, The Baltimore Sun
Once largely relegated to Baltimore City, heroin use and its related adverse consequences are spreading to every part of the state, and an increasing number of Maryland's citizens are dying of heroin overdoses. This shift reflects national trends showing a 74 percent increase in heroin use from 2009 to 2012 and a doubling of heroin overdose rates in 28 states sampled by the Centers for Disease Control. After a sharp reduction in heroin overdose deaths from 2007 to 2010, Maryland heroin deaths have risen to mirror these increases, reaching 464 deaths in 2013. In Baltimore City, conversely, the number of heroin overdose deaths had declined from its peak in 1999 to a low of 76 in 2011 and has not risen as sharply as it has in other parts of the state. This recent state-wide rise in overdose deaths appears to be driven by two factors: changes in the availability of prescription opioids and a decreasing price for heroin. After more than a decade of increasing misuse of prescription opioid analgesics, the supply of such medications is being reduced by law enforcement actions and by prescription monitoring programs, which alert physicians of patients who are "doctor shopping" for multiple prescriptions. As the availability of these medications is reduced, some individuals with a proclivity to misuse opiates will move toward heroin, which has declined in price in the past few years. The combination of relatively cheap heroin (which is sometimes laced with fentanyl—an opiate 100 times more potent than morphine) and a group of individuals with prescription opiate dependence who can no longer afford to obtain these medications is a recipe for increased overdose deaths.
The response to this increase in overdose deaths must be multi-faceted and include local prevention messaging, physician training on proper prescribing of opioid medications, federal and state law enforcement to reduce large-scale heroin trafficking, and efforts to increase the availability of treatment for those in need.
Fortunately, there are a number of treatments that can be brought to bear. Two effective medications, methadone and buprenorphine, are approved by the FDA to treat opioid addiction. These medications, when taken at the proper dose as part of treatment, help patients feel normal (not "high"), block the effects of heroin, free patients from the daily grind of heroin use and permit them to function in society. A third effective medication, called naltrexone, is FDA-approved to prevent relapse. It is a pure opioid blocker that can be taken daily by mouth or monthly by injection. No single treatment is right for everyone, and therefore these effective treatments must be available in the community and in local jails to anyone who needs and wants them.
Importantly, there is also an FDA-approved medication called naloxone (Narcan) that is an antidote to opioid overdose. This medication is a short-acting opioid blocker that can revive an individual who has overdosed on opioids. While typically used by paramedics and emergency room staff, increasingly naloxone is being made available to non-medical personnel to save lives in the community because typically overdoses are witnessed by someone who could intervene effectively.
To date, Maryland's response to heroin-related problems has been robust. In June, the governor issued an executive order to create a state-wide Overdose Prevention Council which has brought together key state agencies to coordinate the Maryland's response. The health department has ramped up its prescription monitoring drug program and increased the availability of the heroin-antidote naloxone, which is being used by law enforcement, first responders, and peers and family in Baltimore City. A new Good Samaritan law passed this year protects from prosecution individuals who try to assist those who have overdosed. Drug abuse treatment is increasingly available to indigent patients through the state's expansion of Medicaid, and long-standing waiting lists for methadone treatment have all but disappeared. Finally, the state's prisons and the Baltimore City Detention Center have significantly increased the availability of drug abuse treatment.
While governors do not control every factor in their states that might influence the availability of heroin and prescription opiates and their related consequences, they can make a difference. It will be critical for Governor-elect Larry Hogan to continue the efforts that are already underway in Maryland and to react quickly to changing conditions.