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Home6 W’sHow Baltimore Became the U.S. Overdose Capital

How Baltimore Became the U.S. Overdose Capital

22 Min Read

Once, the city received praise for its response to addiction. However, as fentanyl flooded the streets and officials shifted priorities, deaths hit unprecedented heights.

People in Baltimore have been dying of overdoses at a rate never before seen in a major American city.

In the past six years, nearly 6,000 people have lost their lives. From 2018 to 2022, the death rate was roughly double that of any other large city, and it was higher than nearly all of Appalachia during the prescription pill crisis, the Midwest during the height of rural meth labs, or New York during the crack epidemic.

A decade ago, drug use killed 700 fewer people here annually. When the synthetic opioid fentanyl, so potent that even minuscule doses are deadly, began to rise in fatalities, Baltimore’s initial response became a national model. The city set ambitious goals, distributed Narcan widely, experimented with ways to steer people into treatment, and ramped up campaigns to alert the public.

But then city leaders became preoccupied with other crises, including gun violence and the pandemic. Many of those efforts to fight overdoses stalled, an examination by The New York Times and The Baltimore Banner has found.

Health officials began publicly sharing less data. City Council members rarely addressed or inquired about the growing number of overdoses. The deputy mayor, who had served as health commissioner during some of those years, and several other council members were unaware that the city’s situation had deteriorated significantly compared to other cities of similar size until Times/Banner reporters recently presented them with the compiled data. In effect, they were flying blind.

Little of the urgency that once characterised the city’s response is evident today. Since 2020, officials have set fewer, less ambitious goals for their overdose prevention efforts. The task force managing the crisis once met monthly but convened only twice in 2022 and three times in 2023. By that time, emergency workers were reviving fewer people, Medicaid was providing medication to kerb opioid addiction, and fewer people were participating in publicly funded treatment programmes.

In an interview, Mayor Brandon Scott defended the city’s response. He knows that Baltimore has had a severe problem with drug addiction for decades, he said, and while the analysis may provide a better understanding of its scale, it will not change his administration’s approach.

“This is an issue that we’re doing a lot of work on and that we can and will do more work on,” Mr. Scott said, “but we also know it requires a lot, lot more resources” than the city has.

The display of the mortality figures alarmed other city leaders and health experts.

It’s “really shocking,” said Dr. Joshua Sharfstein, a former Baltimore health commissioner and now a vice dean at the Johns Hopkins Bloomberg School of Public Health, adding that the deaths were “unprecedented in the city’s history.”

Councilman Mark Conway, who leads the city’s public safety committee, described the deaths as “completely unacceptable” and said he would have called for hearings if he had known how much Baltimore was an outlier.

The numbers are “horrifying,” said Dr. Laura Herrera Scott, Maryland’s health secretary since 2023, adding, “We haven’t deployed the right resources in the right places.”

To examine Baltimore’s response to overdoses, journalists for The Times and The Banner reviewed thousands of government documents. They interviewed more than 100 health officials, treatment providers, and people who have been addicted to drugs. The records and interviews reveal the extent to which the city’s leaders failed to grapple with the enormity of the crisis.

State and city agencies track deaths, reporting the overall count to the United States Centres for Disease Control and Prevention. But Maryland and Baltimore officials, often citing medical privacy concerns, have not published more detailed information on overdoses that is readily available elsewhere. Former city employees and community workers said secrecy has hindered awareness of the epidemic and its responses.

The State’s Office of the Chief Medical Examiner refused to provide complete autopsy reports until The Banner won a lawsuit compelling the agency to disclose the information, which identified who died, where they died, and how they died.

A diverse range of Baltimore professionals, including line cooks, lawyers, bus drivers, engineers, machinists, teachers, restaurant owners, carpenters, veterans, physicians, salespeople, and admissions coordinators for an addiction recovery centre, were among the lost. There were retirees and unemployed people.

Some victims were heartbreakingly young. Reports suggest that since 2020, drug exposure has resulted in the deaths of at least 13 children under the age of four. Black men in their 50s to 70s died at the highest rates.

A few overdose deaths drew headlines, but most were invisible to the public.

William Miller Sr., 65, founder of Bmore Power, an organization that hires people who have used and dealt drugs to give out the overdose antidote Narcan, was discovered in his bathroom in 2020, one day before the birth of his grandson. The trash can contained a single empty gel capsule, typically used to package powdered drugs.

Before becoming a community activist, he had survived a shot, H.I.V., hepatitis C, and decades of overdoses. His son, William Miller Jr., said that he lost his life by concealing his relapses to discourage others.

Jaylon Ferguson, a 26-year-old linebacker for the Baltimore Ravens, fatally overdosed on cocaine and fentanyl, according to his autopsy, in an acquaintance’s home in 2022. It was a day before he planned to fly to Louisiana to belatedly celebrate Father’s Day with his fiancée and three children. On the first anniversary of his death, they brought stuffed animals to his grave.

In 2022, Bruce Setherley, 43, told his mother, Mona, that he was on his way to an addiction program. Because she didn’t hear from him, she assumed the providers had taken his phone. They found him dead in an abandoned rowhouse two weeks later. Ms. Setherley now wears a silver bracelet engraved with the word “love” in her son’s handwriting. “I keep waiting for him to come home,” she said.

Members of the City Council described losing friends and seeing people slump over on the streets. The mayor recalled coming home late one night to find his neighbour passed out on the steps of her apartment. He called 911.

For a while, Baltimore seemed to be getting a handle on its heroin overdoses, but then fentanyl swept across the country.Credit…Jessica Gallagher/The Baltimore Banner, for The New York Times

“That happens every day,” he said, “but knowing that, we have to figure out ways to do more.”

The sharp increase in deaths came as the city has faced numerous challenges: a shrinking population, tensions over policing following the death of Freddie Grey, turnover at City Hall, as well as rising shootings among young people and COVID-19.

“We have done a great job of trying to focus on multiple epidemics at the same time,” said Mr. Scott, a Democrat who took office in late 2020 and is expected to have an easy path to re-election this year.

Many residents say they need to see the government do more. The city needs to be more proactive in aiding people with addiction, said the Rev. Derrick DeWitt, whose church hosts recovery support group meetings in the West Baltimore neighbourhood of Sandtown-Winchester.

“These are not the people who say, ‘I need help,’ and go on a bus to get it,” he said. “You’ve got to bring it to them.” You have to hold their hand. Addiction has caused numerous issues. Overdose is the final step.”

A dangerous high

For nearly all of the past three decades, Baltimore has had one of the highest fatal overdose rates of any large U.S. city. But for most of that period, even as the HBO series “The Wire” helped cement the city’s reputation as the U.S. heroin capital, the death rate was much closer to the national average than it is today.

Officials have long tried to solve the city’s drug problem with arrests and aggressive policing. Baltimore was also at the forefront of innovative public health strategies to address addiction. In 1994, the city’s Health Department was among the first in the nation to start a legal syringe exchange to stop the spread of H.I.V. and other blood-borne illnesses.

Beginning in 2006, the city and state spent millions to expand access to buprenorphine, one of the most effective opioid addiction treatments. Fatal overdoses dropped, and Baltimore seemed to be getting a handle on its heroin problem.

Around the same time, pharmaceutical companies were inundating pharmacies across the country with addictive pain pills. Every week, four hundred thousand pills of opioids, such as oxycodone, began arriving in the city. According to Dr. Sharfstein, the city health commissioner, from 2005 to 2009, some patients from both inside and outside the city started selling their pills in Baltimore, thereby expanding the illegal drug market and making it easier for people to become addicted to opioids or relapse.

In a written statement last week, the mayor’s office claimed that The Times and The Banner’s reporting on the city’s response was “misguided victim blaming” and that the influx of pills from drug makers and distributors had caused the current fentanyl crisis.

The claim about the drug makers echoes a lawsuit the city is pursuing against more than a dozen companies, set for trial in September. However, the prescription pill epidemic was far less severe in Baltimore than elsewhere in the country. Baltimore received a fifth as many pills per capita as some areas, Drug Enforcement Administration records show. Oxycodone was the cause of relatively few deaths in the city, according to C.D.C. and state data.

The death rate remained relatively low until the mid-2010s when fentanyl flooded illegal drug markets across the country.

Frequent drug users describe being high on fentanyl as a carefree, sometimes euphoric stupor, followed by a painful withdrawal—nausea, anxiety, sweat, and flulike symptoms—that drives them to use it again.

Dealers started spiking heroin with fentanyl, a drug up to 50 times more potent and easily manufactured from inexpensive chemical compounds. They also began mixing fentanyl with cocaine, pressing it into fake prescription pills, and selling it on its own. Drug-testing data reveals that purchasing illegal opioids in Maryland without mixing them with other dangerous additives like xylazine is nearly impossible, reducing the effectiveness of naloxone, the generic name for Narcan. These days, heroin is rarely found.

The distribution of fentanyl’s granules is uneven. One hit may be just enough to get you high. The next one could be deadly.

In 2010, the overdose death rate was near a 20-year low: 29 deaths in the city for every 100,000 residents. By 2015, the rate had doubled, then doubled again three years later. By 2021, it was 190 per 100,000, and three people were dying on average every day.

‘A Broken World’

Yvonne Holden, 67, gazed up at the two-story rowhouse where she had grown up in north-west Baltimore, just down the street from Pimlico Race Course, home to the Preakness Stakes. There is a sagging porch roof and a boarded-up front door. Despite the structure’s lack of safety following a fire decades ago, her brother, who declined an interview, continues to reside there.

He is in his 50s and has long battled addiction. Standing there, Ms. Holden considered the impact of drugs on those closest to her. Two siblings contracted H.I.V. from needles and died within a week of each other in 1999. Her best friend passed away from heart problems after long-term cocaine use. Another friend overdosed last year, probably on fentanyl, and cannot speak clearly or use the left side of his body; she now helps care for him.

Ms. Holden herself used heroin, and then a mix of methadone and whatever prescription pills she could get, for decades while raising four sons and working as a nurse technician at hospitals across the city. In 2010, with intensive treatment and support from her church, she was able to stop getting high.

She regularly peruses her collection of Bibles in her one-bedroom apartment, where Scripture quotes adorn nearly every wall. “It shows you how to live in a broken world,” she said.

Her son, Al Holden, smiles in a baby portrait on her windowsill, all chubby cheeks and tiny fists.

He loved watching boxing videos and dreamed of starting a landscaping business with his brothers. Instead, he cycled in and out of prison. A few weeks after his final release, on Sept. 21, 2021, he planned to celebrate his 50th birthday with a cookout for family and friends. Ms. Holden stopped by the house where he stayed that morning, but he said he wanted to rest before the party. As she left, she told him she loved him. “I love you,” he said back.

When she returned less than an hour later, he was kneeling at the side of his bed, head bowed as if in prayer, dead of a fentanyl overdose. His family performed C.P.R. Ms. Holden, who often gives out Narcan on the street with other church members, had none with her that day.

While waiting for the medical examiner’s office to retrieve his body, Mr. Holden’s relatives gathered in the backyard with a cake and sang happy birthday to him one last time.

Years of Tumult

Alarmed by rising overdose deaths in 2014, Mayor Stephanie Rawlings-Blake created a task force to plan a response.

The city’s health commissioner, Dr. Leana Wen, widely distributed Narcan before it was available without a prescription, and the Health Department trained police officers and the public on how to use it. The department also opened a “crisis stabilisation centre,” a place to find help after an overdose. It created an alert system to send aid groups to overdose clusters and piloted a “real-time capacity tracker” to help patients and doctors find open treatment slots.

The city issued detailed plans and prioritised public awareness. The city promoted a website named DontDie.org on billboards and bus stops, aiming to raise awareness about the risk of fatal overdoses.

Dr. Wen presented the initiatives to Congress and spoke with President Barack Obama on a panel. In 2018, a national group of health officials honoured the department.

Even then, coordinating a response across city agencies was difficult, said Amanda Latimore, a Health Department epidemiologist at the time.

The city’s Law Department was resistant to agencies sharing overdose data, she recalled in an interview, sometimes citing the Health Insurance Portability and Accountability Act, or HIPAA. This federal law protects patients’ medical information. Dr. Wen and her team’s near-singular focus on the topic enabled her to assemble the data she needed to understand overdose trends and treatment.

As overdose deaths continued to accelerate, the next mayor, Catherine Pugh, drew criticism when she objected to the proliferation of treatment centres within neighbourhoods, saying that people needing help for addiction would have a better chance if they were removed from Baltimore’s drug-afflicted communities and “put on a plane to Timbuktu or somewhere.”

Dr. Wen left the agency in October 2018. Ms. Pugh resigned in a corruption scandal the following year, becoming the second mayor criminally charged in a decade.

A year had passed since Mr. Scott’s election in November 2020, and the COVID pandemic was in full swing. Mr. Scott, previously City Council president, had for years pushed for supervised drug consumption sites as a way to prevent overdose deaths. They were never approved in Maryland.

Baltimore also had one of the country’s highest homicide rates, and Mr. Scott’s administration prioritised reducing shootings. (When homicides fell by 20 per cent last year amid a national decrease, Mr Scott credited his administration’s efforts.)

While there were three times as many drug deaths as homicides, some of the overdose initiatives began to fade away during those tumultuous years.

Only six of the 160 addiction service providers posted their wait times on the capacity tracker. The city now claims to have abandoned the effort.

So has the “Don’t Die” public awareness campaign. According to the Internet Archive, the website stopped working sometime around February 2023. At some point, the Health Department stopped updating the overdose pages on its website altogether and only resumed for a short time.

The multiple crises and resulting turnover from mayor to mayor had “lasting ramifications” for city agencies, said Mr. Conway, the councilman.

“I wonder if changes in leadership and lack of focus or guidance have resulted in many of these things falling apart,” he said. “And you end up in a situation where you don’t know what you don’t know, and you don’t know whether these programmes even existed or stopped existing.”

Scattered Efforts

Baltimore’s overdose response involves several city agencies and community groups, many of which receive government funding. Every year, emergency workers rush to scenes of suspected overdoses and revive thousands of people, with an exceptional crew handing Narcan and pamphlets to people they find nearby. Johns Hopkins doctors, in collaboration with the city, operate a mobile medical clinic out of a van. To raise awareness in schools, the Health Department recruits local celebrities.

The state and federal governments spend hundreds of millions of dollars each year combating drug addiction in Baltimore. Medicaid’s annual spending on treatment programs grew significantly recently, reaching $245 million in June.

Behavioural Health System Baltimore, or B.H.S.B., a publicly funded nonprofit under the leadership of the city health commissioner, distributes more than $50 million annually in grants for drug and mental health treatment, primarily from state and federal funds. Because services overlapped, the organisation did not track addiction and mental health spending separately. However, a Times/Banner analysis reveals a $5.5 million decline in drug treatment spending from 2019 to 2023, partially attributed to Medicaid’s initiation of specific service coverage.

The job of coordinating all these efforts belongs to the city health department. The department oversees the state-mandated Overdose Prevention Team, whose duties include data sharing, problem identification, and the development of a citywide strategy. The group cut back to meeting just a few times a year. In 2020, it released a three-year plan described as “intentionally brief,” given the pandemic. One goal: become “more action-oriented.” Another option is to list the ways people can get Narcan. Since then, it has not published any updates or new plans.

In a statement, the Health Department said the committee had working groups that met more frequently but declined to say how often or which goals it had achieved, citing the lawsuit involving the pharmaceutical industry.

The 900-person department had only three full-time positions in 2022 to work on drug addiction and mental health, which doubled to six in 2023 with state funding, according to budget documents.

The city pays for just one of those positions. Since 2016, it has spent very little of its revenue on the Health Department’s mental health and addiction budget, with a yearly average of $1.5 million. The mayor’s office stated that this figure does not include the cost of overdose prevention programs run by other agencies or other parts of the Health Department. The staffing figures do not include employees who are involved in these programs.

The department last presented data on overdose deaths to the City Council in 2020. The numbers it showed were from 2017 and 2018 when the fatality rate was a quarter lower than it is now. Even after a local television station, W.B.A.L., reported last year that a San Francisco Chronicle database showed Baltimore was a significant outlier, many officials the Times/Banner reporters interviewed said they were unaware.

In an interview, Dr. Letitia Dzirasa, a deputy mayor who had been health commissioner from 2019 to 2023, said that she knew the rate in Baltimore was the highest in Maryland and higher than in other large cities in the region. However, she still needed to understand how the rate ranked nationally across all counties. On Wednesday, the city announced that the deputy mayor was stepping down, which Dr. Dzirasa said had been in the works for several months.

Her successor as health commissioner, Dr. Ihuoma Emenuga, declined repeated interview requests.

In public, there were signs that the response needed to be more cohesive. In 2021 and 2023, Councilwoman Danielle McCray, head of the health committee, called meetings for city agencies to discuss fighting overdoses. She asked how the police and fire departments were sharing information about overdose hot spots. Representatives of those agencies needed more satisfactory answers, Ms. McCray said in an interview.

She asked whether the city could create a dashboard tracking the number of overdoses. A Health Department representative said the department was working on it, but the state’s restrictive data-sharing rules made it hard. The city would launch one last year, eight years after it said it should build one.

“We just need to all work together on this issue with a greater sense of urgency,” Ms. McCray said in the interview.

Despite this, some treatment efforts were reaching fewer people than before.

According to state data, the number of patients in the city’s public treatment system, which assists impoverished and uninsured individuals with addiction, decreased by nearly 5,500, or 16 per cent, in 2023 compared to 2020, despite a surge in funding. The number of Medicaid patients on drugs that treat opioid addiction, long a staple of Baltimore’s response, also fell by thousands.

According to state officials, the pandemic and a policy change in 2020 that allowed Medicare to cover medication payments may have contributed to the drops.

City officials did not always know what to make of their statistics.

In 2023, emergency workers revived nearly 1,000 fewer people from overdoses annually than in 2018, despite a significant increase in deaths. It is not clear why that happened, said James Matz, assistant chief of emergency medical services for the Fire Department. “I don’t know the answer to that; I’ll be honest with you,” he said in an interview.

Dr. Herrera Scott, the health secretary, said Maryland’s overdose response needed to be based on a sophisticated understanding of the data. She acknowledged that the department had previously faced difficulties with data sharing but said the state was now using data to target its efforts better and planned to start publishing information about deaths in specific neighbourhoods.

In his annual State of the City address in March, Mr. Scott said he was creating an overdose prevention cabinet. His administration, which announced the plan after reporters began asking city officials about overdoses, provided few details, except that the cabinet would include top city leaders.

A National Outlier

Other parts of the country with lower death rates have addressed overdoses more aggressively.

In Portland, Ore., the city, the surrounding county, and the state declared a 90-day emergency this year. Agency leaders met daily to coordinate services and share data. A 2021 mayor’s emergency declaration in San Francisco prompted outreach efforts in a particularly affected area, as well as the establishment of a supervised drug consumption site, which the city closed the following year due to opposition. Both places have hundreds of fewer deaths each year than Baltimore, even though they are significantly larger than the Maryland city, which has a population of roughly 570,000.

Some states and counties have seized on strategies experts say can make a difference.

Vermont, for example, created a “hub and spokes” model that connects addiction centres to a network of prescribers, such as family doctors, who work together to get people the help they need. It now serves about 12,000 patients a year.

Baltimore started its own “hub and spokes” pilot in 2017. But in 2023, one city’s two treatment hubs served only 88 patients. That model is no longer employed by the other organization.

Some cities send teams of trained professionals, such as recovery specialists, EMTs, and sometimes law enforcement officers, to knock on people’s doors 24 to 72 hours after they overdose to offer connections to treatment and other help. Those initiatives in Houston, Louisville, Ky., and Montgomery County, Ohio, reach hundreds of people a year.

Studies show the effort can work; one tracked people the Houston team contacted over three months and found that more than half stayed in treatment, and none overdosed again. In Baltimore, the city’s emergency rooms provide access to care and resources. However, according to Gabby Knighton, executive director of People Encouraging People, which runs the group, emergency workers only gave the names of 50 people to the only team that reaches out to those who refused to go to a hospital after an overdose last year.

Baltimore residents who are struggling with addiction frequently have to seek help on their own.

Vernon Hudson Jr., 54, was a defensive end on Virginia Tech’s football team who first used opioids after receiving a painkiller for a knee injury. He returned to Baltimore from college with a growing addiction and no football career. He cycled from relapse to recovery for more than two decades.

In December 2021, he sniffed a powdered drug and then overdosed while driving, crashing his Mustang into the front steps of a church. Naloxone administered to him in the back of an ambulance helped him regain consciousness. Racked with shame, he refused to go to a hospital.

He has since stopped using drugs, thanks to a support group. But in the ambulance at the time of his overdose, no one offered to connect him to any treatment resources or social services, he said. After he asked to get out of the vehicle, he said that no one from the city checked up on him again.

By Alissa Zhu, Nick Thieme, and Jessica Gallagher

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