We are encouraged that the overdose crisis in Baltimore is receiving national attention through a series of articles published in The Baltimore Banner and The New York Times. The series describes in detail what those who work on overdose prevention in Baltimore have long known: This crisis has escalated locally during the past decade with widespread impact. It results from and perpetuates racial and socioeconomic disparities, and inadequate resources have been allocated to keep pace with the scope of the problem.
What the series misses, however, is the dynamic and rapidly evolving drug market, the deep local commitment to combating this crisis, the range of scientifically proven effective interventions underway and the urgent need for policies to reduce death and other harms associated with drug use.
Undoubtedly, the proliferation of synthetic opioids in drug markets has had an unprecedented and profound impact on overdose death rates in Baltimore. This is not a new phenomenon.
Our research just prior to the COVID-19 pandemic showed that death rates due to overdose in Baltimore began increasing in 2012, with rates among people who inject drugs reaching the astronomical rate of 1,300 per 100,000 in 2018. In a different study that same year, we showed that approximately one in three people who inject drugs had overdosed in the past year and a staggering 82% had witnessed an overdose in the same period.
The burgeoning problem of unknown and emerging substances in drug markets is complicating overdose prevention across the country. Xylazine is now pervasive in drug markets in Baltimore as elsewhere: Upwards of two-thirds of participants we surveyed at the end of 2022 reported having felt its effects when using drugs.
We are concerned because the next drug or unanticipated adulterant is never very far behind, as we are already seeing in recent alerts about nitazenes, which can be up to 40 times stronger than fentanyl. New approaches that address the changing drug supply are urgently needed to keep our communities safe.
We are fortunate in Baltimore to have a substantial and growing harm-reduction infrastructure that works tirelessly to ensure that people who use drugs have access to nonjudgmental resources to protect their health. As they did with HIV and HCV, the Maryland harm-reduction community has strived to stay in front of the overdose crisis and the parallel emerging wound care emergency now associated with xylazine. It is safe to assume that our overdose numbers would be even more tragic if not for their efforts.
The challenge is that our existing overdose prevention strategies, developed largely in response to heroin and prescription opioids, are not sufficient to adequately prevent overdose in the context of synthetic opioids being used in combinations with other emerging substances. Synthetic opioids are highly potent in comparison to other opioids, meaning that doses of methadone and buprenorphine, two highly effective medications for treating opioid use disorder, must be adapted to high levels of tolerance seen today. This is critical to ensuring retention in treatment. Naloxone, an opioid antagonist that works to reverse overdose, may require multiple doses when synthetic opioids are involved, and it does not work to reverse the sedating effects of xylazine.
To reach more people in need, there could and should be greater investment in the evidence-based overdose prevention strategies that are already underway, including naloxone, test strips and drug testing services. We also need an active commitment to facilitated and rapid engagement in evidence-based treatment for substance use disorders. We should prioritize non-stigmatized access to treatment and other health and social services, including in hospitals and jails.
But we are missing several effective overdose-prevention strategies. Other countries have shown us the powerful and positive impact of safe consumption spaces, where individuals can use drugs in an environment monitored by individuals trained to respond, and safer supply, where people diagnosed with substance use disorder are prescribed access to regulated drugs with provider supervision.
Both strategies are known to prevent overdose, enhance engagement in care and promote health and wellbeing for those enrolled. They could also help prevent substance use progression. Our policymakers can show that they too are heartbroken about the magnitude of loss our city is experiencing due to overdose by mobilizing funding and removing political roadblocks to effective strategies such as these.
It is time for the U.S. to catch up to our neighbors, and for cities like Baltimore, to follow the evidence and boldly demonstrate that we care enough about our communities to do everything we can to end the overdose crisis.
Becky Genberg is an associate professor of epidemiology and Danielle German is an associate professor of health, behavior and society at the Johns Hopkins Bloomberg School of Public Health.
