In 2014, MD faced the second highest rate of opioid-related hospitalizations in the country and the number one highest rate of inpatient opioid addiction stays at 403.8 people per 100,000 citizens. 2008–2014 emergency department data showed that visits for alcohol and drugs are highest among non-Hispanic Whites, men, and those ages 45–64. Baltimore City residents were in the ER more than twice that of the state's average. Additionally, expenditures on heroin-related visits increased nearly seven fold in the state between 2008 and 2014.
As in many other states, heroin cut with the much more powerful and dangerous synthetic opioid fentanyl has been a major source of overdoses. Many regular users in the state unknowingly purchase fentanyl-laced heroin, potentially resulting in increased risk of addiction and mortality.
Maryland's heroin and opioid death rate is currently ranked fifth worst in the country. Intoxication-related deaths of all kinds have risen steadily in Maryland over the last five years, with a 21% increase between 2014 and 2015. Specifically, opioid-related deaths made up 86% of all overdose deaths in 2015. In contrast, non-opioid-related death rates have held relatively stable, even slightly decreasing from 187 in 2007 to 170 in 2015.
Despite renewed efforts to combat the problem, heroin and fentanyl were associated with 1,468 deaths during the first nine months of 2016, a 62 percent increase compared to the same period of time in 2015. Final data for the year has not yet been released, but current estimates suggest at least 2,000 opioid-related deaths in 2016, nearly doubling 2015's numbers. While sobering on their own, it is important to remember that these figures specifically represent only overdose-related deaths rather than the true cost to human life seen — they do not factor in the many other sources of mortality precipitated by opioid addiction, such as infective endocarditis.
Specifically, a dramatic increase in heroin-related deaths has occurred in the state after a brief period where anti-drug measures finally seemed to be working, from 399 in 2007 down to 247 in 2011 and back up to 464 in 2013 and 748 in 2015. Fentanyl has also become a key player, having been responsible for only 26 overdose deaths in 2007, 29 in 2012, followed by near doubling annually up to 340 in 2015. While fentanyl deaths have been rising throughout state, the highest has been seen in the Baltimore metropolitan area. Despite the role in creating opioid epidemic, there has been no corresponding jump in prescription opioid overdose deaths over this same time period, from 302 in 2007 to 351 in 2015. Additionally, this increase has been specifically attributed to methadone-related deaths rather than prescription painkillers.
While opioid use has seen a dramatic rise throughout Maryland, some groups continue to be disproportionately affected by the crisis.
Since 2010, there has been a 24% increase in opioid use among White and a 17% among Black Marylanders. However, young Black men are still being arrested at grossly disproportionate rates. Where older Whites are more likely to be seen for opioid-related issues in the emergency room, young Black men are more likely to be arrested for opioid-related crimes.
Long known for its enduring heroin culture during decades when cocaine was the drug of choice for most of the country, Baltimore continues to be devastated by opioids. While overall usage rates have increased by comparable amounts throughout the state, Baltimore's unfortunate "head start" has meant that its community has been the hardest hit. With a state emergency department visit rate average of 278 per 100,000 and 177 average nationwide for large cities, Baltimore's is at 977.
There was an increase in opioid-related deaths by 20% in men between 2014 and 2015 and 22% in women over the same time period. As a greater trend, overdose deaths have doubled in men since 2010 while increasing 64 percent in women.
While overdose deaths have increased across all age groups, the biggest jump was seen among those 55 and older. Opioid emergency room visit increases in 2009 were greatest among individuals 15–24. Additionally, the age-adjusted rate for prescription opioid-related visits doubled between 2008 and 2014 and was highest among residents 25–44.
However, some data suggest that opioid usage is declining among middle and high school students, which may be due to education efforts focused on teen prevention. Additionally, since 2012, prescription opioid-related deaths have been rising among ages 45–54 but falling among those 25 and under.
As in other states, there is a significant risk of overdose death following release from Maryland prison or jail, especially within the first week. Additionally, 13 fatal overdoses within state correctional facilities occurred between 2010 and 2016.
There has also been a disturbing increase in overdose deaths among pregnant women and new mothers. Likewise, NICU doctors and nurses have reportedly seen a sharp jump in withdrawal cases and the number of babies born with drugs in their systems has risen 56.6 percent over the last nine years.
Over the last few years, MD's official policies have seen a gradual shift from punitive measures for opioid abuse to better strategies for addiction prevention and treatment.
The continued success of MD's prescription drug monitoring program may be part of the reason for the slow climb in prescription opioid-related deaths compared to the dramatic rise seen from heroin and (usually illicit) fentanyl. In October 2015, the Good Samaritan Law went into effect, protecting many from prosecution when seeking treatment for others. Additionally, MD's public health has benefited from decades of successful needle exchange programs. Between 2008 and 2016, the number of new HIV cases in MD has dropped by 8% annually compared to national average of 3.6% (9). The state has also made further steps towards medical marijuana use, a much less dangerous option for chronic pain patients.
Most significantly, MD has increased its focus on ensuring more people have access to addiction treatment. As one of several states to have been recently granted a Medicaid waiver, Maryland opened up more beds for low-income patients in larger residential drug treatment centers. Previously, facilities with more than 16 beds were prohibited from receiving federal funding. Unfortunately, the continued general lack of aftercare for treatment programs has led to many with substance abuse disorder to be in and out of treatment for years.
Last year, MD became the first state to remove Suboxone film strips from its Medicaid Preferred Drug List. This action was based on recommendations from the Maryland Medicaid Pharmacy and Therapeutics, due large amounts of the strips being diverted into prisons. Since then, drug use in MD correctional facilities may have decreased as a result, with a reported a 41 percent drop in recovered contraband. Suboxone was replaced with a comparable tablet form Zubsolv, which is more difficult to smuggle in. However, some patients in recovery who had been stable with the strips find the tablets less effective, leading to withdrawal symptoms. Consequently, some addiction specialists disagree with the change, as a relatively small amount is actually being diverted compared to the total number of prescriptions given. Some worry that this shake up may have the potential to ruin many lives that were starting to be put back on track.
On March 1, 2017, Governor Larry Hogan declared a State of Emergency in response to the opioid epidemic. This legal status allows for increased coordination between state agencies to address the crisis. In an executive order, he submitted a supplemental budget request that committed an additional $50 million in funding to prevention, treatment, and enforcement programs over the next five years. These actions drew criticism from the Maryland Democratic Party, as a major focus of the governor's 2014 campaign promises had been to address the problem immediately. There had been an estimated 1,600 heroin-related and 1,000 fentanyl-related deaths between Hogan's swearing in and his emergency declaration.
In 2015, an Executive Order from Hogan established the Inter-Agency Heroin and Opioid Coordinating Council. A second Executive Order this year amended it to establish the Opioid Operational Command Center, which is intended to facilitate better coordination between government agencies overseeing public health, education, and safety.
Over 30 bills related to the opioid epidemic were considered during 2017's General Assembly, which ended April 10.
In its original form, the Prescriber Limits Act proposed a seven-day limit on new opioid prescriptions with exceptions for patients undergoing cancer treatment or in hospice care. In a compromise with MedChi, Maryland's Medical Society, the new law will instead will MD doctors to follow the best practices put forward by the Centers for Disease Control. Practically, this still means a seven-day limit in most cases but leaves more flexibility for doctors and other health professionals. The bill passed on the last day of this year's General Assembly and is likely to be enacted soon.
Another last-minute legislation, is the Start Talking Maryland Act effective this July. The act seeks to bolster educational efforts by requiring state school programs to provide information about fentanyl, as well as providing naloxone and training for its use. The law adds a mandatory $3 million appropriation for the 2019 budget.
The Heroin and Opioid Prevention Effort (HOPE) and Treatment Act will require the Department of Health and Mental Hygiene to establish heroin crisis centers. The act also promotes the use of telemedicine in combating the opioid crisis, creating a special crisis hotline that would allow addiction treatment to begin through the phone. The act also expands access to drugs used in addiction recovery, requiring hospitals to have someone on staff able to prescribe buprenorphine and lifting the requirement for special training before being able to obtain naloxone. It also raised the reimbursement rates for addiction treatment to better keep up with inflation. As another bill passed during the final hours of the general assembly, the HOPE Act will likely be enacted soon.
Further expanding access to care is HB0887. This health insurance bill prohibits payers providing coverage for substance use disorders from requiring preauthorization for prescriptions used treat opioid-use disorder containing methadone, buprenorphine, or naltrexone. This bill passed unanimously in both the House and the Senate.
The Recovery Residence Residential Rights Protection Act would require behavioral health programs and certain health professionals to provide a list of certified recovery residences and resources for where specific related services can be obtained when referring patient for recovery residence treatment. This list will be published and publicly available on the website of the Department of Health and Mental Hygiene. While the act passed the Senate and reached the House in early April, further progress was not made and further work will not resume until next year's session.
The Distribution of Opioids Resulting in Death Act may help combat fentanyl-laced heroin overdoses. As originally proposed by the Hogan administration, the legislation would have created a new felony category carrying up to 30 years in prison for selling fentanyl-laced product involved in a fatal overdose. The bill also allowed for defense of dealers who themselves were struggling with opioid addiction at the time and complete immunity for those who have been incriminated solely by evidence collected as a result of seeking or providing medical assistance. In its present form, no new felony class would be created. Instead, 10 years would be added to sentencing for knowingly selling fentanyl, regardless of whether it was involved in overdose deaths. While introduced to the House this year, the bill did not make much progress but will probably be addressed next year.
Black History Month: Celebrating Black Pioneers in Public Health (Dr. William Montague Cobb)