A Maryland Delegate proposes bills for pilot heroin and opioid maintenance programs to tackle the state's drug epidemic

Maryland Delegate Dan Morhaim, a lawmaker who has pledged the nation's most comprehensive package of drug policy bills, legislation that, if passed, could change the way the United States thinks about addiction treatment, doesn't have any personal experiences with drug addiction. Instead, Morhaim's drive to change drug policy comes from the more than three decades he has spent as an emergency room doctor treating and observing direct and indirect victims of drug abuse. From late last year, he vividly remembers two patients at Sinai Hospital in Baltimore, where he has worked for about 20 years.

The first was a 35-year-old man with a pus-filled, softball-sized abscess on his inner thigh, the spot where he had been injecting heroin. The man didn't have insurance, and his care involved X-raying the wound to check for broken needles, administering pain medication, slicing off the abscess with a scalpel and irrigating and wrapping the wound. U.S. healthcare costs for medical consequences of drug abuse like this, as well as drug treatment, hit $11 billion in 2007.

Then, last November, Morhaim was working a shift at the hospital when he saw the police and heard commotion coming from the opposite side of the emergency room. He walked over. Morhaim saw a man's clothes in the corner of the room, and the body of a gunshot victim lying on a gurney, covered with a blood-soaked sheet. Morhaim was not involved in the patient's care and just thought in that moment that it was a sad case. But the next day, he read about the patient: He was Kendal Fenwick, a community activist and single father of three who was building a fence around his yard in Park Heights to keep out drug dealers. Fenwick's family has told the media that they believe his death was the result of his work to end drug dealing in his community. "I've been seeing [cases like] that for 35 years. It's nothing new," Morhaim says. "That was just one that hit me again."

Introduced in February, Morhaim's legislative package includes four bills designed to shift addiction from a law enforcement issue to a public health issue. On the law enforcement side, the first bill calls for the decriminalization of small amounts of drugs, while on the public health side, the second bill would allow for the creation of a Treatment on Demand program where addiction specialists would work with drug users in emergency rooms.

But it's the last two bills that might be the most controversial: If passed, they would establish safe injection facilities (SIFs), where users could safely inject their own drugs with clean equipment under medical supervision, and a pilot poly-morphone-assisted treatment program, where a small group of chronic users who have not responded to other modes of treatment would be given pharmaceutical-grade heroin, hydromorphone, or other opioids. Though other countries have yieldedwith positive results with these programs, it would be the first of their kind in the United States.

"To a lot of people, [some of these bills] will seem too intense and radical. I understand that," Morhaim says. "[But] the war on drugs isn't working…[and] my ideas are pretty grounded in defensible arguments. We have to move past our sense of personal experience and into some realm of actual information. So I think it's time."

Susan Sherman, an epidemiology professor at the Johns Hopkins Bloomberg School of Public Health who specializes in harm reduction and has visited Insite, a safe injection facility (SIF) in Vancouver says that these facilities "aren't like shooting galleries where there are couches and people are just shooting up, from what I've seen. They're completely clinical in the way they look…It really medicalizes this notion of drug addiction."

Opened in 2003, Insite is North America's first SIF. A 2006 video tour explains how the facility works: First, users are led into a 12-station room where they wash their hands, then collect a disposable injection kit that contains clean needles, tourniquets, and water. They sit down at their mirrored station and inject their own drugs. Nursing staff are in the room to provide medical attention, if needed. Then users head to the "chill out" room, where they have access to counseling and treatment referrals before they are discharged. Those who have abscesses or wounds can also visit the primary health care room for treatment.

Dozens of studies have shown that SIFs attract the most marginalized drug users, promote safer injection conditions, and enhance access to primary care services. And, at the approximately 100 SIFs in nine countries, there has never been an overdose fatality.

The Crisis

President Richard Nixon declared the "War on Drugs" in 1971. Forty-plus years later, in 2014, more than 1.5 million people nationwide were arrested for drug abuse violations—the number one reason for arrests—but only 17 percent of those people were taken into custody for the sale or manufacturing of drugs. The other 83 percent were for possession. Morhaim says that law enforcement absolutely has a role in addressing the drug epidemic. "But we've had so much emphasis on that and not enough emphasis on the public health aspect," he adds.

In Maryland, health issues surrounding drug use, especially heroin and opioids, have reached crisis levels. The number of heroin-related overdose deaths in the state has catapulted from 238 in 2010 to 578 in 2014, with deaths increasing among whites and African-Americans and in all age groups, sexes, and state regions. In Baltimore City, there are an estimated 20,000 heroin users, and 192 people died from heroin-related overdoses in 2014. Preliminary data from 2015 shows that the heroin epidemic is only getting worse: There were 527 heroin-related deaths in the state and 189 in Baltimore City for the January to September time period—numbers that are right on the heels of the overdose death totals for the entire 2014 year. In response, Governor Larry Hogan put together the Heroin & Opioid Emergency Task Force last year to make recommendations about preventing, treating, and reducing heroin and opioid use.

Then there are the secondary affects of drug use. Using drugs is expensive—the 19,000 heroin users in Baltimore are spending $365 million a year to get drugs. Some users who don't have the money to buy drugs commit crimes to get it; a 2004 Bureau of Justice study found that 17 percent of state prisoners and 18 percent of federal prisoners did just that. Federal and state governments have spent $1 trillion on the drug war, a cost that is borne by taxpayers. And in 2013, the most recent data available, nearly one-third of Marylanders with HIV contracted it from drug use.

To address Maryland's drug epidemic, Morhaim has grounded his legislative package in harm reduction, which is built on the belief that the world will never be drug free. As such, programs need to be established to ensure that people are as healthy as possible while they are using, and that the negative secondary affects of drug use are minimized.

"Would you rather [people] not use drugs at all?" Morhaim asks. "Of course you would. I wish everybody would behave responsibly and do all the things we tell them to do. They don't. So you find people and relate to them where they're at."

His legislation comes at a time when the changing demographic of drug addiction, which was once seen as an inner city problem that affected communities of color and the poor, has pushed the issue to the forefront. "We're seeing the shift into white, upper class, suburban neighborhoods," says Lindsay LaSalle, an attorney at the Drug Policy Alliance (DPA) who worked with Morhaim on the legislation. "When you see that shift, then people all the sudden start to conceptualize drug users as their neighbors or their sons or their daughters. And when you start seeing users that way, then you want to treat then more compassionately, you want to provide them with health services [and] access to treatment."

Although Mayor Svante Myrick of Ithaca, New York, has also said that he wants to establish a SIF, Morhaim is the first U.S. government official to put forth a comprehensive legislative package that focuses on harm reduction. "I think we've actually been waiting for someone to step up on this issue," says LaSalle, adding that Morhaim is a long-time DPA supporter. "A lot of people who are crafting policies are trying to see how it plays out in our criminal justice system. [But Morhaim] really has the frontline experience and has seen how [addiction] plays out in our public health system."

Morhaim, who got into politics in the early '90s because he believed that Baltimore (the city and the county) should have a recycling program, has, in part, focused on drug policy for a good portion of his 22-year legislative career. In 2001, he was on a drug treatment task force that issued a final report recommending that the war on drugs shift from a focus on incarceration to drug treatment. In 2009, he took the lead on the medical cannabis legislation. The first bill, a version of which was first introduced in 1980, passed in 2014. "[Medical cannabis] isn't a cure for all things, [but] it ought to be available for clinicians to use as appropriate," he adds. "It's just another tool in the toolbox."

SIFs and poly-morphone-assisted treatment programs could be viewed the same way—as other tools in the toolbox of harm reduction, a strategy to addressing addiction that Baltimore is already actively engaged in.

The longest-running harm reduction program in Baltimore is needle exchange, which the Baltimore City Health Department (BCHD) has offered since 1994. The program now operates at 13 city locations during 23 weekly time slots and serves 2,500 drug users who exchange about 200 needles annually. In recent years, the department has expanded the program: Instead of adhering to a one-to-one exchange, it now offers users as many needles as they need, a practice that has been shown to reduce HIV transmission rates.

In 2004, BCHD also established the Staying Alive Drug Overdose Prevention and Response Program, which provides overdose prevention training and dispenses Naloxone, also known by its brand name Narcan, a prescription medication that reverses opioid-related overdoses. As of December 2015, the program has trained nearly 15,000 injection drug users, drug treatment providers, correctional staff, and inmates and saved 282 lives by reversing overdoses. In February, the Department, along with the Office of Mayor Stephanie Rawlings-Blake, the Maryland Department of Health and Mental Hygiene, and Behavioral Health System Baltimore, also unveiled a new website called dontdie.org where people can watch a 13-minute training video and answer five questions, then print out a Naloxone prescription that they can bring to a pharmacy.

Morhaim says that SIFs, which target hard-to-reach users who are the most resistant to abstinence-based treatment options, would build on already established programs. "Safe consumption facilities are sort of like needle exchange, but a little bit more," he adds. Having SIFs also addresses a challenge with Naloxone, which is that people have so little time to administer it to save someone's life. People who overdose on narcotics only have two minutes before they have brain damage; a few minutes longer, and they are dead.

"You've got to get them in the first five minutes," says Morhaim, who has used Naloxone with hundreds of patients. "Where do people with substance abuse tend to consume their drugs? Back alleys. Streets…Bathrooms by themselves. You don't get to them. Maybe it's a kid, a teenager, in her bedroom. Nobody goes in for an hour. The person is dead. You know, that's how it happens. So safe consumption bills are safer for a group of folks."

Kathleen Westcoat, president and CEO of Behavioral Health System Baltimore (BHSB), the nonprofit organization responsible for managing Baltimore City's behavioral health system, agrees that harm reduction strategies are the way to address the city's drug epidemic. BHSB is working with the health department on the Naloxone program, and will partner with the Baltimore Police Department and the Open Society Institute-Baltimore to offer the Law Enforcement Assisted Diversion (LEAD) program, which will allow law enforcement officers to transfer drug users to a new stabilization center that is expected to open in the city by the end of the year, instead of arresting them for minor drug offenses.

But, even though the research she's read about SIFs is compelling, Westcoat also sees the challenges to starting this type of program. "For Baltimore City, the devil is really in the details, and there's so much we don't know yet," she says. "My concerns largely lie around if [a SIF] is operationalized, what will it look like? How will it be funded; will it be open 24 hours; what is the accessibility of it?" She can't say whether BHSB would support them without knowing some of these details.

But when it comes to a pilot poly-morphone-assisted treatment program, Westcoat has a more definitive view. "We're not a big fan at the BHSB of using pharmaceutical-grade heroin," she says. "We feel like there are other modalities, less risky modalities. We're more in favor of pushing buprenorphine and methadone." These maintenance medications used to treat opioid addiction prevent withdrawal and block cravings. Physicians can prescribe buprenorphine, while methadone is dispensed at dozens of clinics and hospitals in Baltimore.

But a pilot poly-morphone-assisted treatment program would specifically target a small group of chronic heroin users who have not responded to other modes of treatment, including maintenance medications, and who consume the most resources in terms of health and law enforcement costs. Addiction is a disease, and the idea behind this program is that heroin is the medication of sorts that these users need to survive.

"It's a public health approach," says Morhaim, who is also an associate professor at the Johns Hopkins Bloomberg School of Public Health. "We don't say to diabetics, 'Hey, toughen up! Live without your insulin!' We give them the insulin. Some of them probably could do more about losing weight and exercising, but we still take care of them…That's what we [would] be doing [with poly-morphone-assisted treatment]: We're taking this hardcore group of people who have failed at everything, and we're trying to give them something that moves them a little bit better. In the end, what you're [also] going to do is give them a drug largely so that they aren't getting money to buy drugs by doing all sorts of crime that preys on the rest of us."

Indeed, some argue that the biggest benefit of poly-morphone-assisted treatment programs is crime reduction. Peter Reuter, a public policy and criminology professor at the University of Maryland who has studied heroin-assisted treatment (HAT) programs in other countries, says that users in Switzerland who were getting heroin twice a day through a HAT program had no contact with the illegal drug market. As a result, "they were much less involved in criminality," adds Reuter, who wrote a 2009 report analyzing the feasibility of a heroin maintenance program in Baltimore.

But would providing pharmaceutical-grade heroin be condemning Baltimore's users to a lifetime of addiction? Maybe not. At the HAT program in Switzerland, where there was a high dropout rate, 60 percent of those who left did so to go into methadone maintenance or abstinence programs. This suggests that heroin maintenance is a transitional state that can funnel some users into other treatment options. If this is the case, "then you can make a much more powerful argument that this really is in the long run helping [users], even if you're queasy about having the state maintain them for a while on a powerful drug," Reuter says.

Of course, there are big challenges to starting a polymorphone-assisted treatment program. Storing heroin requires more security than storing methadone. And more so than other countries, the U.S. could have a harder time getting stakeholders to support this type of program. "Heroin arouses more fear and hostility in the U.S. than it does elsewhere. That's a reality," Reuter says. "A program will have to contend with that."

Still, despite the challenges, Reuter says a poly-morphone-assisted treatment program experiment in Baltimore would be extremely useful. "[Heroin-assisted treatment] does reduce crime rates. Very substantially. And I think that would probably be the case here."

If these two bills pass, Bankole Johnson, MD, chair of the Department of Psychiatry at the University of Maryland School of Medicine, has said that the school's Division of Alcohol and Drug Abuse, a large, comprehensive opiate treatment facility, would consider establishing pilot SIF and poly-morphone-assisted treatment programs. But getting to that point would require buy-in from federal, state and local governments, which might prove challenging.

Treatment on Demand

Morhaim's Treatment on Demand bill may be the most likely to pass, largely because it fits in with our established ideas about addiction treatment.

"You need that kind of mental scaffolding for these kind of bills, [and] I don't think people have it for safe injection sites," Sherman, the Hopkins professor, says. "[But] something like Treatment on Demand…This is not new. There's scaffolding in people's minds. There's a foundation for that."

In 2014, there were more than 2,600 heroin and prescription opioid-related visits to emergency rooms in Maryland, and Treatment on Demand seeks to reach those users. Addiction counselors at acute care hospitals would get to know these users well enough to determine what type of treatments are the best fit, then connect them with those options—a significant change from the way hospitals currently operate. "Even in the hospital I work in, which has a very good social services department, in the end, we just give addicts phone numbers and say, 'Call a bunch of places,'" Morhaim says. But with Treatment on Demand, "of the 20,000 hardcore heroin addicts in Baltimore City, let's say you got 5,000 in treatment tomorrow. Overnight, you literally decompress the criminal justice system, the crime rate and the health care system."

This bill is one that BHCS, the city's behavioral health nonprofit, is behind. "We're always going to support additional dollars being put into Treatment on Demand," says Westcoat, who adds that she admires Morhaim for introducing innovative solutions to Maryland's addiction crisis, even if she doesn't support all of them.

"He's really pushing the envelope with some of these bills, and I think somebody needed to do it," she adds.

But Morhaim is also aware that all of his bils might not pass right away. And, as frequent op-ed writer for the Baltimore Sun, he knows how to tell a good story. At the end of February, sitting in his office in Annapolis, he begins sharing a suspense-filled account of the passge of another once radical bill, one that "was as controversial any legislaton, as much as say marriage equality or the death penalty. We were told that if we passed this bill, we would cause economic calamity, erosion of the tax base, massive unemployment, and dislocation."

He pauses.

"That bill was to ban smoking in restaurants." The lesson? "It takes time for persuasion," he says.

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