Terry DeMio

tdemio@enquirer.com

Lessons from Baltimore: The first in a four-part series.

BALTIMORE - This city is under an official public health emergency, and overdoses and drug use are the reasons. An epidemiologist has calculated 19,000 or 3 percent of its residents are addicted to heroin – important because here, officials just guess. Officials fight the epidemic with a multi-pronged, science-based approach that has specialists across the nation watching – and hoping.

"The city has a strong tradition of innovative approaches to dealing with heroin epidemic," said Dr. Adam Bisaga, professor of psychiatry at Columbia University Medical Center. "They have decades of experience building relationships with people who are using drugs," said Daniel Raymond, policy director for the national Harm Reduction Coalition in New York City.

Baltimore has been bold since last year in getting out the life-saving non-narcotic naloxone. It has a long track record of providing needle exchange programs to injection drug users. In addition, Baltimore was a pioneer in medication-assisted treatment, funding since 2003 medication buprenorphine, which quells cravings and stabilizes the brains of heroin and opioid users. Finally, the city health department supports the use of all FDA-approved medication for opioid and heroin use disorder.

Finding answers to heroin deaths a key to prevention

The efforts initially bore fruit. Baltimore saw a drop in overdoses for the first quarter of 2016, a year after the city adopted new programs and fortified those already in place to fight the drug. More recently, the numbers of overdose deaths are rising again. The city notes that fentanyl has hit hard, and in August, announced an initiative to fight those opioid deaths.

The city created a fentanyl task force that sends outreach teams to warn opioid users in high drug-use areas when the task force recognizes a fentanyl overdose spike. The task force also alerts treatment centers and other services that provide help to those addicted. Getting information to all stakeholders quickly is key to keeping people alive, the city's health department says.

The Enquirer visited Baltimore this summer to see its response to heroin. Here's what we found and how it compares with what's happening in the Cincinnati region.

1. Place a strong, identifiable leader with a medical background in charge.

In Baltimore, that's health commissioner Dr. Leana Wen.

Beyond declaring an emergency, Wen, an emergency room doctor, has stepped up existing efforts and initiated new ones that make medical sense to curbing overdoses and treating those addicted. Roughly a year ago, Wen issued a standing order enabling her to prescribe the opioid overdose-reversal drug naloxone to all of Baltimore's 620,000 residents.

Wen, 33, hasn't done it alone. Before the current emergency, the city had a history of funding addiction treatment. The city council is fully supportive of Wen's efforts to stop the plague. Finally, she has expert guidance and support from a robust cadre of private addiction clinicians.

"Dr. Wen's efforts in Baltimore are an example of the powerful impact local public health leaders can have when they implement these types of policies to help their communities,"Michael Botticelli, director of the Office of National Drug Control Policy, said in an email.

33-year-old doctor leads Baltimore's anti-heroin war

What's happening in Cincinnati

In 2014, a bewildered parent at a community meeting asked when the region would get a grasp on the epidemic and was told by Dr. Jeremy Engel, an anti-heroin advocate: "No one's in charge." It's not that progress isn't being made here. Task forces have formed and advocates continue to speak out. But there is no single person in Cincinnati or Northern Kentucky with the same kind of profile or power that Wen has.

2. Step up needle exchange.

Since 1994, Baltimore has provided needle exchange sites that provide other services including HIV and hepatitis C testing. After Wen became commissioner in 2015, the city expanded the exchange sites, which number at least 14 locations with a total of 24 to 26 sessions per week. Now, the service provides people with the number of needles they use, rather than requiring a one-for-one (used-for-new) exchange. This is an effort to further minimize infectious disease spread among users. Funding primarily comes from grants and the city's general fund.

Reducing the dying by embracing needle exchange

Baltimore's longstanding syringe exchange program has led to trust with people who inject drugs, Raymond said. That translates into healthcare for those drug users, and that means the city is safer from infectious diseases.

What's happening in Cincinnati

Needle exchange is not as available here. The Cincinnati Exchange Project has four locations, three Hamilton County neighborhoods and one in Middletown in Butler County. It is operated through the University of Cincinnati. Northern Kentucky Health Department has been pushing for needle exchange for more than a year; however, just one site in its district, in Grant County, has been approved and is operating. There's been pushback from politicians, who believe that providing syringes to heroin users is enabling their behavior. The needle exchange advocates say that it's a way to reach out to the addicted population, and eventually, help get them into treatment.

Kentucky and Ohio are plagued with increasing hepatitis C cases. The risk of HIV and hepatitis C is great among those who use injection drugs. Many who do so share needles if they do not have enough of their own, and the general public is at risk of contracting the infections from discarded needles. The national Centers for Disease Control and Prevention already has warned of the risk of HIV outbreaks for 54 Kentucky counties and 11 Ohio counties.

3. Train everybody to administer naloxone.

In Baltimore, the city provides education and training at DontDie.org. It has a sign-up calendar for training on naloxone through the health department. Under Wen's overdose-reversal initiative, more than 14,000 people have been trained to use naloxone. The simple goal: Stop the dying.

Going to the street to arm anti-heroin 'first responders'

The training includes every public official, all police officers, inmates before they are released from jail, drug court participants and injection drug users. That last step is particularly important, because national Harm Reduction Coalition research shows that most people saved with naloxone have been saved by someone who was with them at the time of the overdose – and that usually means other heroin users.

Wen's high-profile role in the opioid and heroin response in her city, combined with the city's dedication to gaining the trust of injection drug users, made for the perfect jumping point to get naloxone into the hands of the addicted population. "They had this whole platform in place," Raymond said. "You need to mobilize the response."

What's happening in Cincinnati

Northern Kentucky and Southwest Ohio have significantly stepped up naloxone training in the past year. After getting bombarded with an unprecedented number of opioid overdoses from Aug. 19-24, the city of Cincinnati plans to offer training for neighborhood residents. The Northern Kentucky Health Department is planning community sessions for its counties, Boone, Campbell, Kenton and Grant. St. Elizabeth Healthcare provides police with naloxone; however, several police departments still do not carry the medication.

Dr. Shannon Miller of the Cincinnati Veterans Affairs Medical Center, said it is important to get naloxone into the hands of those using injection drugs, their families, and people who are prescribed opioid medications. The Cincinnati VA center has been a leader nationally in doing so. "Many of our kits were used by our veterans, not only on veterans, but also on nonveterans," noted Miller, director of addiction-related services at the Cincinnati VA.

The local VA was fifth in the nation to deploy an opioid overdose education and naloxone distribution program and at one point was first in the VA nationally in opioid overdose reversals, Miller said. The program started in 2014, and in 2015, Cincinnati VA expanded it to include its pain clinic patients.

4. Make medication-assisted treatment the rule.

Baltimore drug courts, public health treatment centers and the health commissioner espouse the standard treatment for heroin and opioid disorder, encouraging FDA-approved medications, buprenorphine, methadone or injectable naltrexone. The city has provided funding that helps with medication assisted treatment costs. The treatment is supported by the private medical community that espouses scientific, evidence-based solutions for people using heroin and opioids. It is just part of treatment, which also includes counseling.

To further encourage the use of buprenorphine, Behavioral Health System Baltimore provides the training for it to private doctors' offices. The organization, which allocates funds for substance use disorder and mental health services, is seeking new ways to provide easy access to buprenorphine for people who are addicted. Now the organization is exploring the feasibility of mobile buprenorphine clinics to get the services to the people who need them, and not the other way around.

Bisaga said the evidence-based approach to treating opioid and heroin addiction is the way to reducing overdoses.

"You need to make a medication widely available and inexpensive," he said. "It needs to be de-stigmatized. Unfortunately, not everyone can be delivered this treatment safely; therefore, efforts should be made to train providers."

Science leads the way to combat addiction, death

What's happening in Cincinnati

Medication-assisted treatment is making strides in Greater Cincinnati and Northern Kentucky, yet some medications are more likely to be used than others. For example, inmates leaving Kenton County jail may qualify for injectable naltrexone, or Vivitrol, upon release and are funneled to providers to continue the treatment.

Warren County Common Pleas Judge Robert Peeler has pioneered a Vivitrol program for heroin-addicted drug court participants. Once accepted into the program, the participants receive their first Vivitrol injection in the jail. "We only use Vivitrol because we have not reached the point where Suboxone or methadone can be used in the jail," Peeler said.

Some of Hamilton County's drug court participants are provided with medication, as well as counseling and other program services, for their addiction. And some Northern Kentucky drug courts allow for Vivitrol, a non-narcotic medication that blocks the effects of heroin or opioids.

Still, Kimberly Wright and Charlotte Wethington, two leading Northern Kentucky advocates for treatment on demand, say that most of those addicted are getting abstinence-based treatment based on their contact with hundreds of parents of heroin users.

5. Keep innovating and make sure you have funding to do so.

Baltimore has plans and $3.6 million in state funding to create a "no-wrong-door" center for those with addiction. People will be offered detox and get referrals to treatment. They will be provided support services to help them improve their lives. This not only serves people with addiction but reduces stress on jails, police, emergency responders and hospitals, where people are often taken when they are intoxicated.

The initiative is a "hub-and-spokes" approach: a center that can stabilize patients and start treatment. The patients then get moved to community providers or other "spokes" for treatment. The American Society of Addiction Medicine says such a method fills in system gaps and guides clients through a continuum of treatment.

What's the situation in Cincinnati

The disease of addiction sometimes is seen as a moral failure; harm reduction programs such as needle exchange and anti-addiction treatments are seen as enabling the addicted.

"Stigma is still there," said Linda Gallagher, vice president of mental health and addiction services for the Hamilton County Mental Health and Recovery Services Board.

Needle exchange continues to be viewed negatively by many, including politicians who must approve the syringe access programs. The Northern Kentucky health department can't expand services because of push-back.

The biggest problem in Greater Cincinnati and Northern Kentucky might be money. Needle exchange is one example. In Northern Kentucky, syringe exchange efforts are paid for with $250,000 in grant funding from the R.C. Durr Foundation. The health department, however, provides staff for the exchange and says the existing staff doesn't get paid additionally for the work. Hamilton County Public Health so far has not contributed to needle exchange efforts. In Baltimore, city funds cover some of the costs.

Ohio and Kentucky are putting increasing funding behind their fight against heroin. The states provide money for prevention, education, naloxone and its training, treatment and more, but the funding isn't as far-reaching as in Baltimore. Here's one example: In Baltimore, methadone is paid for with Medicaid dollars, whereas Kentucky has balked at that.

People in the Cincinnati medical community and those in recovery locally routinely hear of people in recovery who say they are unable to pay the costs of their treatment, leaving them at risk for relapse and overdose.