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Bringing addicts in from the streets

It is mid-morning on a recent Friday in West Baltimore, and there is a long line snaking down the street and around the corner. Why? Vendors are dispensing free heroin samples.

In other areas of the city, buyers are risking arrest and drug contamination to illegally purchase buprenorphine. It is legal medication when given with a prescription. It is used to treat opioid addiction and facilitate recovery. So why buy it illegally? Not to get high as a substitute for heroin. They are using it to treat their heroin addiction. These purchasers can't afford or otherwise access this medication legally. Their only option is to buy it on the streets and self-treat. These purchasers are addicts who are so motivated to get clean that they are taking great risks to get it.

On July 11, The Sun reported that "[h]eroin overdose deaths soared last year in Baltimore, a city that has struggled with one of the highest rates of heroin addiction in the nation and with the violence that comes with illegal drug dealing."

The above scenarios reflect different facets of a tragedy. Addiction to opioids, including heroin and prescription drugs, affects a diverse population in increasing numbers. The results are often fatal and extremely costly in both human and economic terms. Yet, addiction is treatable. There are highly effective medications. When these medications are given along with therapy to repair the ravages caused by long-term addiction, there is a good chance for recovery.

So why is the situation worsening instead of improving? And why do we allow this to happen?

Drug addiction is a disease, but the stigma of addiction continues.

Opioids are narcotics that mimic naturally produced chemicals our bodies need, but they have much stronger effect and are introduced into the brain in much greater quantities than natural hormones. Opioids act primarily by interacting with the central nervous system and result in sedation, pain reduction and sometimes euphoria. All opioids are highly addictive and can lead to physical dependence in most people.

There are a variety of treatment options available for opioid addiction. Some programs treat with total abstinence accompanied by personal support, and some addicts succeed with this approach. However, most patients need medication to address the chemical and physical damage. The two primary medications are methadone and a compound called buprenorphine.

Both medications are effective in promoting recovery. Methadone is dispensed only by special clinics and the patient has to go weekly and stand in line, making it inaccessible and highly stigmatizing for many. Buprenorphine can be dispensed like a regular prescription at a clinic or by a private physician who gets certified training, so it lends itself to integrated treatment in doctors' offices or integrated health care homes.

Buprenorphine is a safe and effective medication. However, as evidenced by the increase in overdose deaths in Baltimore, there remain many who have difficulty accessing treatment. The Behavioral Health Leadership Institute, with funding from the Open Society Institute-Baltimore and the Abell Foundation, offers a unique treatment program to reach unserved populations. A doctor and nurse from Johns Hopkins Bayview go into recovery centers to provide treatment. These centers provide peer support and are trusted by community members, thus improving engagement. The clinical team then works with peer support staff at the sites to function as a treatment team.

This program is unique for several reasons: because of the untraditional community settings; because it uses medical professionals as necessary, but sparingly; and because it is flexible, cost-effective and user-friendly.

The program outcomes, which include successfully engaging clients and transitioning them into permanent treatment, are positive. Current enrollees say the program is so valuable because it is so accessible. Developing creative, flexible and effective programs is critical to meeting needs of the diverse populations that fall prey to addiction. To stem the tide of addiction, violence and death, funding must support and expand an array of flexible, effective, well-researched programs. Then we can invite everyone in from the streets.

Deborah Agus is executive director of the Behavioral Health Leadership Institute and adjunct faculty at the Johns Hopkins Bloomberg School of Public Health. Her email is deborahagus.bhli@gmail.com.

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