Can methadone clinics and their neighbors find common ground?

Baltimore's heroin treatment. In recovery....On your block

Wanda Sanders and I step into line at Red Emma's, a bookstore café at North and Maryland. Sanders, a 48-year-old African-American, leans on a cane, wearing sparkle lipstick with her hair pulled back. We're here for an interview. I want to understand the world of a methadone patient in Charles North, a neighborhood notorious for its concentration of methadone patients.

"This is the first time I've ever been in here," she says of Red Emma's—her first time, despite spending almost every morning in this stretch of Maryland Avenue. Here's the routine: around 6 a.m., Sanders goes to Institutes for Behavior Resources at 2104 Maryland Avenue for a dose of methadone and support group meetings. Then it's off to Maryland Avenue Adult Day Care Center, a wide windowless building next door to Red Emma's, where she gets help with her medications and doctor appointments and joins dozens of older white, black, and Asian members among the workout equipment, game room, cafeteria, and arts and crafts stations. (Sanders receives a monthly $1,200 "widow's pension" from the U.S. Army; her husband, a Vietnam veteran, died in 2008. She says the clinic and the day care center are both covered by Medicaid.)

I ask Sanders what she'd like in her coffee. "Sugar," she says with a smile. "Lots and lots of sugar." Sanders says she's grown to expect hostility from local businesses but here no one bats an eye as she squeezes in among the crowd seated by the windows overlooking North Avenue. Other places have been less welcoming. "The first thing they think is you're here to shoplift," she says. "They'll say, 'That's why we don't like you methadone people, get the hell out of here. Don't stand around or we'll lock you up.'"

Sanders started using heroin when she was 19 or 20 and living in Park Heights. She liked to party, and dope was everywhere. It was an occasional thing, but then her nose would run and her body would ache. "Everybody say, 'Oh, that's not a cold you have,' you know what I mean?" she says. "Before I knew it, I had a habit."

Until recently, she was living in Park Heights and taking two buses each way to Charles North. There are no methadone clinics in Park Heights—yet. Residents are fighting the opening of a clinic next to a day care center right now, but state legislation to block methadone clinics within 500 feet of child care centers looks unlikely to pass.

In February, Sanders moved in with her boyfriend, 54-year-old Moses McNeil, at the 20-story J. Van Story Branch, Sr. Apartments, a public housing tower at the corner of 20th Street and Maryland Avenue, right around the corner from her clinic.

It was on this stretch of Maryland Avenue, with a cluster of methadone clinics in a half-mile radius, that I first met Sanders in late January. On the morning of my visit, pedestrians jaywalked wantonly, petty arguments filled the air with Baltimore's slurred opioid cadence, and a huddle formed around someone whose rapid hand movements resembled those of a blackjack dealer. Mornings here are never pretty, but that morning was exceptional in its messiness: a blizzard had left mounds of sooty snow and impassible sidewalks. Three middle-aged pedestrians in dark coats—Dee Jones, Sharon Johnson, and Sam Taylor—were walking south in the road's one passable lane when a passing car gunned its engine and honked.

"Why you honking your horn?" shouted Jones, whose bright red cap and tote bag were the only spots of color around. "You see somebody you know?"

In the 2100 block, a soft-spoken security guard in a light brown uniform confronted a group of women standing on the sidewalk.

"Ladies, you gotta go in," she said. "You can't smoke out front. Put it out."

The group broke up.

Like Jones, Johnson, and Taylor, Sanders and McNeil were there to visit a methadone clinic. Nearly 19,000 Baltimoreans used heroin in the past year, according to a city task force. Methadone maintenance programs help people quit heroin by substituting prescribed doses of a synthetic opiate that minimizes withdrawal symptoms and reduces cravings. A movement to treat addiction as a public health issue rather than a criminal justice issue has grown over the years. That treatment has to take place somewhere, though, and many methadone patients must come to the clinic every day to have their medicine dispensed. (There are strict rules regarding "take home" doses.) Wherever clinics have proposed opening in city neighborhoods—including, in recent years, Hampden, Hollins Market, Harwood, and Park Heights—calls for treatment have been subsumed by the din of residents and local businesses decrying the crime and grime they say follows the clinics. It is one of Baltimore's defining civic conflicts.

In Charles North, there are two clinics in the 2100 block of Maryland Avenue alone. There's another half a mile away. "There's the trash, you've got throngs of people hanging out on the sidewalks, it's not uncommon to see people passed out on neighbors' stoops," says Kelly Cross, who lives on the 2300 block of Maryland Avenue. Cross serves as the president of the Old Goucher Community Association and is running for the Baltimore City Council in the 12th District.

"The police acknowledge it," he says. "The police all say, 'We wish there was something we could do about it, but this is what happens when you have all the clinics here.'"

"It's a bad idea to put them here in these locations with businesses and residents," says a Baltimore city police officer one morning in the 2100 block of Maryland Avenue. (He asked to remain anonymous.) "Instead of getting methadone and leaving, they hang around all day. There's a lot of buying and selling pills, constantly. They're involved in prostitution and other crimes. Sometimes the street is cluttered with people, up and down like zombies—you know what they look like."

In 2014, 192 city residents died of heroin overdoses. Critics of Baltimore's treatment landscape say too many methadone clinics are concentrated in too few neighborhoods, with "saturation" in places like Charles North and large "treatment deserts" in west and northeast Baltimore (see map online at www.citypaper.com ).

Is there a way for neighborhoods and clinics to get along? And will Baltimore ever have clinics everywhere it needs them? Activists in Charles North think they have some answers, and they are appealing to City Hall and the State House for help.

In 2014, 12th District City Councilman Carl Stokes heard about a methadone clinic planning to open near Greenmount Avenue, about 10 blocks from the two clinics in the 2100 block of Maryland Avenue. Stokes and 14th District Councilwoman Mary Pat Clarke submitted a bill that would rezone 428 East 25th Street and a property next door so that use as a methadone clinic would require approval by the Board of Municipal and Zoning Appeals.

The city Law Department sent a letter warning that passage of the bill could attract civil lawsuits that would "inevitably run into the millions of dollars." Two years earlier, a federal court had ordered the city to stop forcing small residential drug treatment programs to get "conditional ordinances" requiring a full council vote. That burden singled out people recovering from substance abuse, the court argued, a class protected under the Americans with Disabilities Act.

"It is clear from case law across the country," read the letter from Chief Solicitor Elena R. DiPietro, "that the current scenario at the very least puts the City at great risk of violating the ADA should passage of the legislation prevent the opening of a methadone clinic on the subject property."

Stokes says that solicitor's recommendation that the bill not get a hearing "basically killed the legislation."

By the time Stokes' bill died, the Central Baltimore Partnership, a community development organization, had formed a "Saturation of Metropolitan Services Agencies" task force to deal with the problems it saw clustered around methadone clinics. The Central Baltimore Partnership asked a Charles North Community Association board member named Alan Mlinarchik to chair it. Mlinarchik, 57, lives in the Glen Arm section of Baltimore County but became involved in Charles North in 2009 when he bought a building at the corner of St. Paul and 21st streets. That's two blocks east of the clinics on Maryland Avenue, and two blocks west of a state parole and probation office.

"I call this the boulevard of broken dreams right here," Mlinarchik says. "You can sit here and just watch people trudging back and forth."

Early on, Mlinarchik says, the task force supported legislation that would have allowed the state to deny licenses to methadone clinics based on the concentration of existing clinics in a given area. However, the ADA eventually colored the task force's public strategy, Mlinarchik says, and the task force declined to back Stokes' 2014 bill.

"We stood back," Mlinarchik says. "We saw early on that zoning isn't the way to do this. Every case where a municipality tries to use zoning, they get sued and they lose. Zoning is problematic because it says, 'We're going to separate clinics from other facilities, zone them out of existence, or prevent them from opening.' That is discriminatory. Our argument is that we need to not just solve the problem of concentration but solve the problem of treatment deserts."

In person and at a February 29 task force meeting in a dining hall at St. Mark's Church in Charles North, Mlinarchik returns over and over to the message that the effort against clinic "saturation" is as much about the patients as it is about the community. In many neighborhoods with great need, he argues, there is little treatment, and where there is too much treatment, predators descend on methadone patients, trying to sell them other drugs. "They wade through this every day," he said at the meeting. "We've heard from them. It makes it hard for them to recover."

Mlinarchik's professed concern for patients doesn't mean, however, that he feels completely shackled by the ADA. "There is room to make decisions like this about the siting of medical facilities, specifically clinics, if it is in the interest of the protected class," he says. "If you're not hanging out with the people who are using, you are less likely to use. What we have in concentrated areas is the exact opposite of that."

More decentralized treatment options, Mlinarchik argues, will lead to better treatment. "What happens when the interests of the patient diverge from the interests of the clinic?" he asks. "Where should the ADA come down? Our answer is the patient."

Wanda Sanders and Moses McNeil know very well the challenges for those in recovery on the streets near their clinic, including people selling pills. "You see people nodding and they going all the way down to the ground, that's not methadone," says Sanders, who says she's seen two people get hit by cars after walking into the street and going into a nod. "That's methadone mixed with something else, the prescription drugs that doctors are prescribing to people: Clonidine, Klonopin, Xanax/alprazolam—'bars,' which they call them out on the street."

Sanders says methadone alone makes you feel normal, not high. The mixture of prescription drugs is called a cocktail, and it approximates the high of heroin. She's tried the cocktail before—just to see what it was like, she says. "Man, it was horrible," she says. "Who would want to be that comatose?" (There were 54 methadone overdoses in Baltimore City in 2014, including methadone prescribed for pain, not just opioid treatment. There were 22 benzodiazepine overdoses—Klonopin is a benzodiazepine, as is Xanax/alprazolam. In Maryland, more than half of benzodiazepine overdoses were in combination with prescription opioids, and almost one in five prescription opioid deaths were in combination with a benzodiazepine. )

Methadone alone is powerful enough, though, that even a day without it can start to trigger withdrawal, Sanders says. And so every day, she and McNeil make their way to the clinic, trying like so many other patients to ignore the fracas on the street.

"Some people really do the right thing," Sanders says, "then some people don't want to do the right thing."

"We try to do the right thing," says McNeil. "We stay together."

"We come and go about our business," Sanders says. "If you don't, then [the clinic] will write you up, and they'll give you a sanction for that. We're not supposed to be on the property in front of the program or even on the corner hanging around, period."

Sanders and McNeil met at Turning Point, a "walk-in" east Baltimore clinic that claims to serve over 2,100 methadone patients a day and tries to get new patients admitted in just hours. Federal guidelines require all methadone clinics to provide counseling, and Turning Point has a mental health clinic and a psychiatric nurse practitioner, but Sanders and McNeil regard it as a "gas and go" clinic. Turning Point Clinic founder Rev. Milton Williams did not respond to requests fror an interview.

"Ain't gotta take no groups at all," McNeil says of these kinds of clinics.

"You go get medicated and leave," says Sanders.

Institutes for Behavior Resources, Sanders says, is not a "gas and go." She has attended the clinic for four years, and she says the group sessions there, not just the methadone, help her and McNeil stay clean because they can talk about their problems.

"There are meetings throughout the whole day," Sanders says.

"Till they're getting ready to close," adds McNeil.

"They try to keep everybody busy," Sanders says, "so they don't have to hang out anywhere in the neighborhood."

Vickie Walters is a social worker and executive director of R.E.A.C.H. Health Services, the opioid treatment program at Institutes for Behavior Resources. On a tour of the program's six-story building at 2104 Maryland Avenue, she points out the office of a "nurse care manager."

"She might be out with a patient," Walters says. "She'll accompany patients sometimes to appointments." The clinic also has a full-time nurse practitioner and reproductive health services, and it is part of the state's "health home" program, which means it coordinates the treatment of patients' substance use disorders with their overall health needs.

As Walters and I round a corner, we cross paths with a tall man. "Hey, Darrell," she says.

Darrell Hodge, 59, works for the clinic as a peer recovery specialist. "I was just going downstairs, I've got some people there," Hodge says, and we enter a conference room and meet several more men who are there for an "anti-stigma" group meeting.

"I never thought a methadone maintenance program was for me," says one of the men. "I only wanted to go in the back door."

Another man says he felt ostracized at Narcotics Anonymous meetings. "If you're on methadone, they say you're not 'clean'," he says.

"It's bad enough that you have to deal with stigmatizing yourself and family and friends that stigmatize you," Hodge says. "Some of the places you go for help, they stigmatize you, which can be discouraging. It makes it difficult to overcome."

While critics of methadone clinics—like the Central Baltimore Partnership's task force—say they have the interests of methadone patients at heart, the staff at Institutes for Behavior Resources believe those efforts increase the stigma and thereby make recovery more difficult. Both Walters and the clinic's medical director, Yngvild Olsen, have testified in Annapolis against bills that could create more hurdles for those seeking a license to open a methadone clinic.

Last year, they opposed a bill from Sen. Joan Carter Conway (D-District 43, Baltimore City) that would have required the state's licensing process to include a zip code-level assessment of existing opioid treatment slots and "the number of individuals in need" of treatment—in other words, an assessment of whether or not the zip code is "saturated" the way critics claim Charles North is.

When it comes to the inability of clinics and their neighbors to find a way to coexist, the feeling of being singled out is a major sticking point for the clinics. "It just strikes me you wouldn't require that of a clinic setting to treat heart disease or diabetes," says Institutes for Behavior Resources president Steven Hursh. "You wouldn't say, 'Are there enough people in your community who need orthopedic services?' Applying a standard that is very specific to this particular disorder as if somehow it needs to be regulated to a greater extent—that's the stigma that pervades the perception of this disorder and the people who provide treatment for it."

Hursh and Walters say they are already extensively regulated, more so than other kinds of treatment. "We're singled out in that respect, as well," Hursh says.

"Today we actually have an auditor from Behavioral Health System Baltimore looking at charts," says Walters. "Last Tuesday, we had an auditor from [the state's] Behavioral Health Administration looking at charts and policies. Two months before that, we had someone from [the state's] Office of Health Care Quality looking at charts and policies, then in a month from this week, the CARF [Commission on Accreditation of Rehabilitation Facilities] people will spend two days with us. The DEA [federal Drug Enforcement Administration] can pop in any time."

It is activity outside the building, however, that generates complaints. Institutes for Behavior Resources shares a security guard with Man Alive, the clinic across the street, and they allow police to look at footage from their security cameras. The clinic also has a "diversion plan"—a federal requirement—to keep their methadone off the street.

Walters says all patients who have earned "take-home" doses get random callbacks. "If on a Monday they picked up 28 doses," Walters says, "they may get a callback on Tuesday to bring back 26 doses."

Federal guidelines do not stipulate when it is appropriate to kick patients out of the program, although the guidelines say "standard practice" provides for situations like violence, drug dealing, and "repeated loitering."

"If a patient assaults another patient, they can't stay here," says Walters. Dealing drugs can lead to removal at Institutes for Behavior Resources, too.

"Sometimes we can see it on camera," says Yngvild Olsen. "If it appears as if this is what is happening, we say, 'You can't stay here, you're a threat to other folks and their recovery.' The selling part, that's where we draw the line."

"If they're buying," however, says Walters, "that's a symptom of their disorder. We'll increase their level of care."

That is in keeping with the federal guidelines, which suggest keeping patients in treatment with "intensified counseling" and mental health evaluations even after instances of drug dealing or loitering. But this fails to satisfy neighbors who don't want those symptoms playing out blocks away from the clinic.

"We're not asking for a policing effort on the part of clinics," says Mlinarchik of the Central Baltimore Partnership's Saturation of Metropolitan Service Agencies task force. "We're asking for, as part of the therapeutic process, if you see somebody in your program standing on the corner buying or selling, you can go say to them, 'This is not part of the program—this is problematic for your participation in the program.'"

Mlinarchik says he has compassion for those with substance use disorders. "But I think the solution is not to simply say, 'We know you're addicted and so anything you do is okay'," he says. "There's gotta be that mix of compassion and determination to get people out of the habits."

Anti-loitering policies may look good on paper, Mlinarchik says, but "we've been told flat out by some providers, 'We will never enforce them, we will never kick someone out of a program because that means we've given up on them.'"

Mlinarchik says he's helping build a coalition of people who believe methadone and other opiate medications are "not the answer." Their answer is group therapy and 12-step programs, he says, "not simply moving from illegal to legal substances." I asked Mlinarchik if it was his task force's position that meetings and 12-step programs are better than medication. He said it was not. "But we're working with this group," he said. "In the Venn diagram of what they're doing and what we're doing, the intersection is, 'The current system ain't working.'"

I asked Mlinarchik whether he thought a coalition that sounds almost anti-maintenance might antagonize or stigmatize methadone patients. "Well," he answered, "we don't want to stigmatize them, and that's why I say we don't have a complete overlap with the goals of this group. I won't say we're partnering with them. We've had discussions, because what we agree is, the current system is not ideal."

Last summer, the Mayor's Heroin Treatment and Prevention Task Force published a template for a "Good Neighbor Agreement" between clinics and communities. Institutes for Behavior Resources and the Central Baltimore Partnership were already negotiating such an agreement a year before that. Those negotiations fell apart, and they have yet to sign one—despite the fact that Mlinarchik and Walters were both on the mayoral task force that drew up the template. During a February meeting with Walters, medical director Yngvild Olsen, and president Steven Hursh at the Institutes for Behavior Resources offices, I asked about the negotiations.

"It was not a 'good neighbor agreement,'" said Walters. "It was very one-sided. It was like, 'You will, you will, you will.'"

Walters says Institutes for Behavior Resources staff attended community meetings until about 12 or 18 months ago. "It became pretty clear that we were not wanted in this community," she said. "It's disheartening when you come to the table when we do want to be good neighbors and to get a sense that's not something that can happen because revitalization and growth somehow means that we can't be here."

I asked Walters, Hursh, and Olsen whether they thought it was just a cut and dried "not in my backyard issue" for the critics of the clinics.

"I think that's part of it," said Walters. "I think they're very savvy, they do present this in the light that they care about folks that come in our doors, and they don't want them accosted by drug dealers and people trying to sell them other medications when they are trying to get recovery. But I can't help but think that has a lot to do with it."

The two sides don't even agree on what's happening in their backyards. Olsen says that studies in Baltimore City show that crime decreases around opioid treatment programs. An often-cited 2012 study of Baltimore by University of Maryland School of Medicine researchers in the journal Addiction found no differences between areas around clinics and the rest of the city when it comes to what the FBI calls "Part I" crimes, which include homicide, rape, aggravated assault, robbery, and arson. A January 2016 study led by a researcher at Johns Hopkins Bloomberg School of Public Health concludes that "violent crime associated with drug treatment centers is similar to that associated with liquor stores and is less frequent than that associated with convenience stores and corner stores."

Critics of the clinics say they're more concerned with nuisance crimes like drug dealing, which weren't part of that study, and they do see a link between clinics and crime. Mlinarchik points to a 2004 investigation of five Washington, D.C. methadone clinics by the federal Government Accountability Office, which found that "patients frequently must navigate their way through a virtual bazaar of illegal drug dealing when they enter and exit the facilities." Peter Duvall, a neighborhood revitalization manager for Strong City Baltimore (formerly Greater Homewood Community Corporation), crunched some numbers from records of district court cases archived by the Charles Village Community Benefits District and found that the sale of benzodiazepines—often part of the street "cocktail"—was the number one reason for drug arrests. Of the 48 drug arrests chronicled by the benefits district in the first ten months of 2014, Duvall says 44 took place within two blocks of opioid treatment clinics.

Mlinarchik says the Central Baltimore Partnership is on good terms with Man Alive, the clinic across the street from Institutes for Behavior Research. "We've had lots of good productive conversations with them," he says, and both sides have signed a "good neighbor agreement." After an acrimonious start with Concerted Care Group, the clinic that opened near 25th Street and Greenmount Avenue in 2014, Mlinarchik believes they are starting to develop a better relationship with the community.

Wherever the relationships between existing methadone clinics and their communities are headed, the state's Department of Mental Health and Hygiene is taking new steps to influence the location of new clinics.

In March 2015, the Maryland State Senate voted unanimously to pass Sen. Joan Carter Conway's bill to assess methadone treatment "saturation" as part of the clinic licensing process. The Central Baltimore Partnership called it a "monumental" achievement. However, the bill never got a hearing in the House of Delegates. That summer, the Central Baltimore Partnership began meeting with Department of Health and Mental Hygiene (DHMH) and Delegate Peter Hammen, chair of the House Health and Government Operations Committee, about ways to address community concerns at the regulatory level.

As regulators continued working, however, legislators took another shot. This February, Del. Mary Washington (D-District 43, Baltimore City) introduced a similar bill, saying she was disappointed in DHMH's progress. (Sen. Conway sponsored a cross-filed version of the bill.) At a March 11 House committee hearing, no one besides Del. Washington testified in favor of the bill. (The Central Baltimore Partnership, says Mlinarchik, was "keeping its powder dry on the legislative front.") In testimony against the bill, Barbara Bazron, executive director of DHMH's Behavioral Health Administration, addressed community concerns.

"I'd like to emphasize the fact that we do not have zoning authority," Bazron said, "so we are not in a position to say that a program cannot locate in a particular area. However, we can have the conversation and we can certainly present information that will inform the decision of the provider."

DHMH acknowledges community concerns about the concentration of clinics in agency documents. In the effort to influence the location of clinics, the state agency plans to give more leverage to local addiction agencies like Behavioral Health System Baltimore, giving them data so they can "meet with prospective providers and direct them to areas of need."

The chairmen of the committees handling Sen. Conway's bill and Del. Washington's bill have indicated that they will not move the bills forward. For now, changes in Baltimore's methadone treatment landscape will rely primarily on any influence that state regulators and the city addiction agency can wield outside the shadow of the Americans with Disabilities Act. And while the state and city work on a way to steer clinics to where they're most needed, the Central Baltimore Partnership has begun recruiting community associations all across Baltimore for a coalition to advocate for a citywide "master plan" for locating treatment facilities.

Now that Wanda Sanders is living at the corner of 20th Street and Maryland Avenue, she doesn't have to worry about whether or not a clinic will be opening in her old stomping grounds of Park Heights. But moving closer to a methadone clinic hasn't solved her biggest problem. What she really wants is to get off methadone completely.

"I've been on methadone on and off I'd say for about 25 years," she says. "If I knew then what I know now, I would have gone cold turkey on heroin. I would never have gotten on methadone at all."

Sanders believes methadone aggravates her many health problems. But the idea of never taking methadone again is daunting. Sanders has gone three days without methadone before, and that was hard enough.

"After that third day, I'm hightailing it down here, haha!" she says.

A change of scene might help. She says she and her boyfriend, Moses McNeil, are planning to get married and move to North Carolina, perhaps as soon as this summer.

North Carolina is over 300 miles away. But it's a much longer road from 75 to 0 milligrams.

"I want to be off of it really bad," Sanders says of methadone. "But I'm going to get there."

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