The rate of death, caused by heroin cut with the lethal synthetic opioid fentanyl, is comparable to the opioid epidemic’s worst ravages in rural and suburban parts of the United States. More people died of opioid overdoses than homicides last year in the District.

But the city’s overdose victims are different from those in areas of the country more commonly associated with opioid abuse. Many are black men who have been addicted to heroin for decades. And unlike drug users elsewhere, they have often been left by their government without basic help.

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The District has consistently fallen short in its response to mounting opioid casualties, misspending millions of federal grant dollars and ignoring lifesaving strategies that have been widely adopted elsewhere, a Washington Post investigation found.

D.C. officials distributed naloxone — an overdose antidote that laypeople can use to prevent deaths — at a far lower rate than other cities with comparable opioid problems. As fatal overdoses peaked last year, Baltimore handed out more than four times as many naloxone kits per capita as the District; and Philadelphia, more than three times as many, according to city data. Officials at the nonprofit groups that collaborated with the District on its naloxone campaign called it “woefully inadequate” and “disastrous.”

The city has also faltered in carrying out a federally sponsored initiative to connect long-term heroin users with treatment. Although D.C. officials in 2017 began receiving what will ultimately total $4 million over two years from the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA), many programs the city said it would launch never materialized. Officials at the clinic contracted by the District with most of its federal funds said not a single patient has been referred to them for addiction treatment.

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“It’s just pure incompetence,” said Larry Gourdine of Medical Home Development Group (MHDG), which received nearly $1.5 million of the city’s grant money. “This is not that difficult. I mean, this is straight-up health-care delivery.”

In a city where growing prosperity conceals profound divides of race and class, the damage done by heroin and fentanyl has fallen squarely on African Americans. Of the 860 people known to have died of opioid overdoses since 2014, 4 in 5 were black, according to the chief medical examiner. In 2017 — the most recent year of data from the Centers for Disease Control and Prevention — the rate of fatal drug overdoses among African Americans in the District was higher than that of whites in West Virginia, Ohio or New Hampshire.

Yet those deaths, concentrated in the historically black neighborhoods of Southeast and Northeast Washington, have been unnoticed by many residents of the nation’s capital. Few elected officials have taken prompt action to address the crisis. Frustrated advocates and medical professionals say the District’s lackluster response would never have been tolerated in whiter and more affluent neighborhoods.

“People discount the severity of our opioid epidemic because it’s mainly older, African American men who have used heroin long-term who are dying,” said Kaitlyn Boecker, who works in the D.C. office of the Drug Policy Alliance, a national organization that works to change drug laws. “There just seems to be no urgency in addressing the crisis.”

D.C. officials defended their response to surging opioid deaths, saying the past several years have been a learning period. Looking ahead, they said they are planning a comprehensive response to the epidemic, with the help of $21 million in new funding for opioid programs that the District is scheduled to receive from the federal government.

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Mayor Muriel E. Bowser (D) declined repeated requests for an interview for this article. In a written statement, Bowser said the District’s strategies “are working and saving lives.” She noted that more than 700 overdose reversals have been reported using naloxone distributed by the city.

“We will remain relentless in seeking the best possible tools and data to stop preventable overdose and death,” Bowser said in the statement.

There are bright spots in the city’s opioid response. Beginning late last year, the District gave out $1.7 million in local grants to increase the number of doctors and nurses trained to treat addiction. But there has been no corresponding spike in the number of patients signing up for treatment, according to city and federal data.

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After three straight years of increases, opioid deaths are on track to drop this year — although the number of projected fatalities will still be twice as many as in 2014, according to the District’s chief medical examiner. Some city officials say the decline results from their prevention efforts.

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But some medical experts think the trend — which mirrors a decline in fatal opioid overdoses seen in other cities and states — could have other causes. One theory holds that chronic users are beginning to adapt to fentanyl-tainted heroin, using it more carefully and in smaller doses.

Another is that four years into the District’s opioid crisis, many of the addicts most at risk are already dead.

'The only tools we have'

Maurice Abbey-Bey stepped out of a minivan at the D.C. General shelter for homeless families, opened the trunk and announced his wares — free syringes, condoms and Narcan, a brand of naloxone nasal inhaler — in a hoarse shout. Among the dozens who lined up was Renee Jones-Collins, a resident of Southeast Washington.

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Jones-Collins said she no longer uses heroin but has friends who do. The previous month, she said, she had used Narcan to revive one who had “fallen out,” or overdosed. She said that while fentanyl-laced heroin was “all over the place” in the District, naloxone was comparably scarce.

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“It’s not enough,” she said.

Abbey-Bey was selective with his 30 Narcan kits but quickly ran out. Soon he was driving back to the nonprofit Helping Individual Prostitutes Survive (HIPS), where naloxone provided by the city was carefully rationed.

“I don’t want to hold on to this stuff like it’s dear life,” he said. “But that’s what I’m doing.”

The D.C. Department of Health began its campaign to saturate overdose-heavy neighborhoods with Narcan in the spring of 2016. The department partnered with HIPS and Family and Medical Counseling Service (FMCS), another nonprofit that provides needle-exchange services, giving the organizations city-purchased Narcan to distribute.

The city’s management of the program has been “disastrous,” said Diane Jones, a social worker who oversaw the initiative at FMCS. In an interview in May, she estimated that the approximately 150 kits FMCS was receiving from the city each month were half of what was needed. She said her organization routinely faced agonizing decisions about which clients are most deserving of the medicine.

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“These, at this point, are the only tools we have in this crisis,” Jones said. “And we’re having to ration them out.”

Similar complaints date to the earliest days of the city’s naloxone initiative. On July 12, 2016 — approximately two months after the program got underway — then-HIPS employee Andrew Bell warned top health department officials that the group’s Narcan supply was exhausted and it was unable to meet demand for the medicine.

“Not a day goes by that we don’t have clients asking for naloxone,” Bell said in an email.

The health department ultimately increased HIPS’s Narcan supply. But the nonprofit organization continued to face shortages. In May of this year, HIPS launched an online donation drive when it was on the verge of running out of Narcan and the city refused to allow it to restock nine days early.

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“We’re tired of the city’s woefully inadequate response to fatal overdoses in D.C.,” the group wrote in its appeal. “Please donate today and help HIPS purchase our OWN supplies so we can do the city’s job for them.”

HIPS Executive Director Cyndee Clay said other local governments were more aggressive in making sure naloxone reached drug users.

“There are places where this is done well,” she said. “D.C. is just not one of them.”

Other municipalities have launched far more robust Narcan distribution campaigns, according to a Post analysis of data provided by those cities.

In 2017, Baltimore distributed an average 178 kits per month per 100,000 residents, and Philadelphia 141. Boston distributed 87 kits per month per 100,000 people, San Francisco 86 and New York City 59.

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The District’s figure: 38.

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D.C. Department of Health Director LaQuandra Nesbitt said complaints about naloxone shortages had been valuable feedback in what she described as a two-year test run. “I want to emphasize it was a pilot, and so we wanted to hear from them what was working and what wasn’t working,” Nesbitt said.

She said the health department was overhauling the program so that HIPS and FMCS would receive funding to buy their own naloxone instead of relying on the city, a move she said should resolve disputes.

Nesbitt said it was wrong to judge the effectiveness of the District’s program based on the number of Narcan kits that had been handed out without tracking other measures, such as whether overdose victims were offered medical care or long-term addiction treatment after their lives were saved.

“It’s not just about whether or not naloxone was given — did you spray something in the nostrils. It’s what happened as a result of that, and those things are critically important for us to understand,” Nesbitt said.

She added, “I don’t determine the success of a program based merely on the number of kits that have been distributed.”

That view goes against best practices for naloxone distribution, according to Eliza Wheeler, national overdose response strategist for the Harm Reduction Coalition.

“Measuring the success of a naloxone program has to be based on how much naloxone gets into the hands of people who use drugs,” Wheeler said. “The analogy that we use is thinking about a flu shot drive in the community.” Such efforts are judged based on how many people at risk of flu get vaccinated, she said, not what happens to them afterward.

The District has also been an outlier when it comes to another means of increasing naloxone’s availability: a government policy that allows anyone to buy the medication in a pharmacy without a doctor’s prescription. As of January 2018, such policies existed in more than two dozen states, including neighboring Maryland and Virginia, according to the National Alliance of State Pharmacy Associations.

The D.C. Council passed a law that would have allowed District residents access to the medication in pharmacies in 2016. But Nesbitt refused to implement it, saying the legislation gave too much authority to pharmacists and did not protect pharmacists who chose not to dispense naloxone from legal liability. She did not take action to make naloxone available until this month, when the council approved changes she requested to the policy.

'It just fell apart'

Victor Williams, a 56-year-old heroin user, was discharged the morning of Sept. 28 from United Medical Center (UMC), the District's public hospital, where he had been treated for an overdose. Close to midnight on the same day, his younger brother, Phillip Williams, got a call he had long dreaded.

Victor had gone into the bathroom at Phillip Williams’s house, according to a friend, and wasn’t responding to knocks. The friend called 911. Phillip arrived home in time to see his brother — with whom he still stayed up late playing dominoes and pinochle, despite the damage heroin had done to their relationship — carried out the door in a body bag.

A syringe was found in the bathroom. The medical examiner’s office later determined that fentanyl killed Victor Williams.

Phillip Williams, himself a recovering heroin user, said he thinks his brother could have been persuaded to enter treatment with professional outreach. “When people that need help, that you should offer help, they can’t get no help — they go back to what they used to know,” he said, explaining his brother’s relapses.

What Phillip Williams didn’t know until recently was that an outreach program for overdose victims like Victor should have been in place at UMC more than a year ago — one of several federally funded initiatives that D.C. officials failed to carry out.

Along with every state and four U.S. territories, the District was awarded money to combat the opioid epidemic under the 21st Century Cures Act, signed by then-President Barack Obama in December 2016. The city’s eligibility for the grant — $2 million a year, for two years — gave it an advantage over municipalities with no direct access to federal money for anti-opioid campaigns.

That advantage has led to few results. Outreach initiatives to heroin users the grant was supposed to fund never materialized. At the height of the epidemic last year, District officials failed to spend $620,000 of their federal money, or about a third of the amount allotted to the city in the grant’s first year.

The grant was overseen by the D.C. Department of Behavioral Health, which along with the Department of Health manages the District’s opioid strategies. In its application, the agency described an extensive street outreach effort, with a group of 10 peer counselors — former drug users trained to counsel others about treatment options — visiting spots where heroin users gather.

However, in an August 2017 strategic plan the department submitted to the federal government, agency officials said they were having trouble recruiting outreach workers. An initial training session in May hadn’t drawn enough participants to launch the peer outreach program as originally planned, they wrote.

Instead, the agency said it would launch a more focused outreach campaign at a location where peer counselors could be sure to encounter drug users: a hospital emergency room. Two counselors would be stationed at UMC, city officials said, shepherding recent overdose victims to on-site treatment with buprenorphine, a medication that diminishes opioid cravings.

Similar programs have been launched in multiple cities, based on a 2015 study at Yale-New Haven Hospital that showed users who begin buprenorphine treatment during visits to the emergency room often have more success in recovery.

“We really have an opportunity to see a lot of these patients in that wake-up moment,” said Ali Raja, a physician who oversaw the introduction of a buprenorphine program at Massachusetts General Hospital in Boston last year.

UMC was an ideal site. Last year, it saw 400 opioid overdose patients, far more than any other hospital in the nation’s capital, according to city data. Medical Home Development Group, the city’s contracted buprenorphine treatment provider, leased an office two floors above the hospital’s emergency room in anticipation of the program.

But the city’s promised outreach workers never showed up. The office, rather than treating overdose victims from the emergency room, is now used for other patients, said Edwin Chapman, MHDG’s chief medical officer.

Chapman, who treats Phillip Williams at his practice on Benning Road NE, said Victor Williams was just one of many patients whose lives could have been saved if the city had followed through.

“It just fell apart,” Chapman said. “They reneged on everything.”

Tanya Royster, who until two weeks ago was the director of the D.C. Department of Behavioral Health, said in an interview that she was unable to provide any information about why the city never carried out the program at UMC. “I can’t answer that,” she said.

In a later email, department spokeswoman Jasmine Gossett denied the program had ever been planned. After she was shown the plan submitted by the department to the federal government, Gossett acknowledged the proposed UMC project but said it was part of an interim plan and not “an official proposal.”

Other initiatives outlined as part of the city’s grant documents likewise made little progress. An effort to persuade 125 older patients at the city’s methadone clinics to switch to buprenorphine treatment — which, unlike methadone, is fully covered by Medicare — went nowhere.

As time passed with no action or direction from the city on the grant programs, MHDG used the federal money it had been paid to offer primary care to patients at the Foundation for Contemporary Mental Health, a methadone clinic in Foggy Bottom.

The attention was welcomed by men and women who often have grave health problems after decades of addiction, but it was not treatment for drug abuse. Although MHDG received $1.46 million of the city’s $4 million in total grant funds, it ultimately did not treat a single patient for opioid addiction in connection with the grant.

Department of Behavioral Health officials acknowledged problems with the grant in a July report to the federal government. They said the District had spent $1.38 million of the $2 million awarded in the grant’s first year, citing “a lack of clarity in communicating to the sub-grantees their roles and responsibilities” and “unexpected turnover” in the department staff overseeing opioid programs.

Royster had a more positive appraisal. She told The Post it was normal to leave federal grant money unspent in the first year, and pointed to a use of the funds that she said had been successful: Some $200,000 spent on posters that warned drug users of fentanyl and promoted naloxone.

She acknowledged her agency was not using tried-and-true strategies other governments have adopted but said this was a strength rather than a weakness. The city’s approach has been tailored to its distinctive population of older, African American heroin users, she said.

“We’re not behind the curve. We’re actually, I would say, ahead of the curve,” Royster said. “And one of the ways that you can be confident of that is that we’re not just doing what everyone else is doing. We’re doing what’s important for D.C.”

In response to questions from The Post about the District’s use of its grant money, SAMHSA spokesman Brian Dominguez said grant recipients “have flexibility to design their systems and plans.”

On Nov. 30, after her interview with The Post and before this article was published, Royster was removed from her job by the mayor. A Bowser administration official, speaking on the condition of anonymity to discuss a personnel matter, said the mayor had grown frustrated with the slowness of the agency’s responses to various issues, including drug overdoses.

Bowser chose as a replacement Nesbitt, who will continue leading the Department of Health while overseeing the Department of Behavioral Health on a temporary basis.

Just another day

There is at least one precedent for a more successful opioid program managed by city officials. Last year, the Department of Health began giving out $1.7 million to help clinics hire and train medical staff for buprenorphine programs. Five clinics, along with Howard University Hospital, obtained funding.

The money has been one factor in a rapid expansion of addiction treatment providers in the District. The federal government has certified at least 150 new buprenorphine prescribers — with a capacity to treat 5,550 patients — over the past two years, SAMHSA data show.

But the rate at which patients most at risk are entering treatment has not kept up. Since 2016, the number of Medicaid beneficiaries receiving buprenorphine has increased by 132 people, according to data from the D.C. Department of Health Care Finance.

After training new buprenorphine prescribers with city funding, the addiction clinic at Mary’s Center in Adams Morgan is now able to treat roughly 500 people, said Daniel Smith, the doctor who oversees the program. It currently has about 135 patients, he said.

“We’re growing, and we grow every month by 5 or 10 percent,” Smith said. “But we’re not close to our capacity.”

The District will have ample opportunity to close its treatment gap over the next two years, as it begins receiving $21 million annually in new federal funding for local governments to combat the opioid crisis.

The Department of Behavioral Health, which will oversee the grant, outlined dozens of new programs in its grant application, some of which expand on unfulfilled initiatives from the past two years. The city is planning to launch outreach programs for overdose patients in multiple hospitals, with both the new federal money and unused funds left over from its earlier grant.

Four years into the District’s opioid crisis, city officials are beginning to adopt other measures long urged by advocates.

D.C. health officials say they are finalizing a comprehensive plan for responding to the opioid epidemic, created by a task force of government workers, treatment providers and advocates. In August, the health department began distributing naloxone through homeless shelters.

This month, the D.C. Council approved a package of changes sought by treatment providers to the District’s opioid policies, including the removal of restrictions on Medicaid reimbursement for addiction treatment. The bill was originally introduced in 2017, and took almost 15 months to come to a vote.

Some on the front lines of the epidemic say these developments are welcome but come after inexcusable delays.

“They could have saved a lot of lives,” said Robert Keisling, a physician who runs one of the city’s most active addiction medicine practices. “It’s way late. But late is better than never.”

In Marvin Gaye Park, a notorious hangout for heroin users in Northeast Washington, a small group gathered on Aug. 31 — International Overdose Awareness Day — to remember those for whom help did not come soon enough.

Lewis Blakeney, a 62-year-old recovering heroin user who has survived two overdoses, estimated that a dozen older black men who had once nodded off alongside him on the park benches were now dead. Durrell Gray, 55, recalled his cousin, found dead of a heroin overdose in the park. Alvin Wynn, 62, remembered his ex-girlfriend, who died several years ago, and a friend he had tried unsuccessfully to revive with Narcan.

Since fentanyl-tainted heroin hit the District in 2014, Wynn said, “I went to 50 funerals.”

In Baltimore, 35 miles to the north, a mayor, a congressman and the city’s health commissioner were holding a news conference at city hall, pledging their resolve to reduce the city’s drug deaths.

But the vigil in the District was informal, organized by recovering heroin users and needle-exchange workers. The mayor didn’t show up, and D.C. health agencies hosted no events. For most of the nation’s capital, International Overdose Awareness Day was just another day.