U.S. city hit hardest by opioid deaths is near the top for established factors predicting harm and deaths: methadone use, relaxed MAT opioid safety standards, Medicaid distribution of free street currency (buprenorphine) for fentanyl

by Clark Miller

Published May 27, 2024

The headlines are jarring,

in the Baltimore Banner and the New York Times, running a multipart series on the city with, by far, the worst levels of opioid-related deaths in the country.

And the subhead says it all –

Baltimore Banner subhead

Rightfully hailed, because state and city officials were doing everything right, have done everything according to an established consensus of American medical, addiction, and public health experts, with ample funding and success – to a lethal fault, as we will see and as was predictable.

From the Baltimore Banner –

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 lives have been lost. The death rate from 2018 to 2022 was nearly double that of any other large city, and 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.

Here’s the trend in overdose deaths, dominated by fentanyl and other opioids.

It’s important to note that the downward dip for 2022 does not represent a trend –

Baltimore’s fatal overdose rate has quadrupled since 2013. It dipped in 2022, but preliminary data for 2023, not shown below, indicates overdoses were on track to rise again.

Based on additional evidence provided in a Fox News report, we are compelled to conclude with near certainty that the opioid crisis in Baltimore has continued to worsen over the year 2023 as measured validly and more directly by nonlethal overdoses, rather than by OD deaths, not a valid measure of high risk opioid use and severity of the crisis. 

While there were 2,456 fatal overdoses in Maryland from February 2023 through January 2024, 4.1% fewer than the 2,560 reported from February 2022 through January 2023, the data shows in the 12 months ending in January 2024, there were 13.1% more non-fatal, opioid-related hospital emergency department visits compared to the previous 12 months, increasing from 8,589 to 9,714.

There’s a bit to unpack in these numbers.

Nonlethal opioid overdoses are a direct measure of high risk opioid use, as such a valid measure of severity or public health threat posed by the crisis. Another direct measure, unlike OD deaths, is incidence of opioid injection related infectious disease, again representing incidence of high-risk opioid misuse. Nonfatal overdose increasingly is expected to be underestimated due to increasing distribution of and  frequency of naloxone saves occurring in private and and community locations where they do not get reported. 

Opioid overdose deaths, in contrast, are not likely to be overestimates, directly determined by observation, medical examination, and death reports. OD deaths are not a valid or meaningful measure of severity of the opioid crisis because they are and have been from the beginning of the crisis inextricably confounded by differences over time and among populations in emergency reversal of overdoses that would have otherwise been lethal, each Narcan save representing a case of high-risk opioid use not prevented by crisis treatment approaches. 

That is, steadily and recently dramatically increasing distribution of naloxone to prevent an incidence of high-risk opioid use from becoming an overdose data point (a good thing) of course masks the true level of epidemic high-risk opioid use. 

So, for Baltimore, the data for 2022 and 2023 can only reasonably be interpreted as meaning one thing – that while fatal ODs dropped slightly and predictably as in other locales as naloxone campaigns increased reversals of potentially lethal ODs, high-risk opioid use was significantly increasing, underestimated due to the same Narcan saves that mask incidence of unreported opioid overdoses in community settings. 

That is, Baltimore’s opioid crisis continued to worsen while OD deaths may have ticked downward

And it’s equally important to read the fine print and engage in a reality check when considering this graphic featured by the Banner and the NY Times – 

From this NY Times piece in the series – 

State officials said that the pandemic, and a policy change in 2020 that allowed Medicare to cover payments for medication, might have contributed to the drops.

That’s a critically important disclaimer that, oddly, was left out of other pieces in the series from the Baltimore Banner and the Times here, and here

Were there in fact “Fewer people getting medication support” over these years? 

It turns out there is no reason to think so, instead established evidence pointing to the opposite. The bar graph represents only individuals using Medicaid expansion to gain access to MAT medications. But as the disclaimer notes, unrepresented Medicare members would have joined in the total beginning in 2020. 

Not just Medicare recipients, but over the next years others including with private insurance who would have found more programs and more medical practitioners able to prescribe them bupreneorphine as Maryland, like other states, engaged in intensive efforts to relax standards and recruit more such providers outside of traditional programs and settings, described here. With relaxation of federal and state standards beginning pandemic year 1, 2020, “bupe” became more and more accessible, with in-person visits replaced by even a phone call. 

prescribing by telemedicine

Those considerations are rendered less than determinative, far less, by what we have known, what has been established for decades – that the streets, communities of all sizes, everywhere, are flooded with cheap, easily accessible, safe, buprenorphine, “subs”, described in detail here and in other posts, functioning integrally in illicit economies of opioids and other drugs as consumable, commodity, and primarily as currency – for fentanyl, for “real dope”. That is, America’s gold standard, proven, addiction medicine has not only never been supported by compelling evidence as effective, instead has been fueling a worsening opioid epidemic all along. It is not unavailable, it is unlimited in availability. That’s the lethal problem.  

That’s why, for example, Medicaid expansion – putting more street currency for fentanyl in the hands of opioid-dependent users not accessing any form of evidence based treatment – generated failed outcomes

As was implemented successfully in Maryland beginning in 2013 driven by the reigning consensus on effective treatments from America’s top experts. Take a look at the trend again for Baltimore. Medicaid expansion in 2013, and it was in 2014 when city and state officials brought together years of planning, preparation and funding to actually achieve significant expansion of programs and providers to prescribe and dispense buprenorphine. That timeline is described in detail here

In 2013 and 2014  dramatic boosts in dispensing of free street currency for fentanyl, by medical prescription.

What do you see? 

But bupe isn’t the only form of expert-assured, proven, “medication support” for problem opioid use. 

There’s methadone. 

And that’s where Maryland’s efforts based on guidance from the consensus of America’s top experts really stand out. 

Here’s a graphic generated by the DEA and presented in this research paper, showing Maryland 3rd highest in the nation through 2021 in number of methadone outpatient programs per 1 million population. 

And magnifying that effect, also from the DEA, average daily dose of methadone for those it is dispensed to was in 2020 4th highest for Maryland among all states. 

The graphic is annotated by the author of the piece it appeared in, here

graphic of average daily methadone dose by state

That’s a high level of dispensing of methadone to individuals with history of high-risk use, completely in line with emerging expert consensus of “the more the better”, reflecting the push beginning around 2020 for relaxation of methadone safety standards, notably “take-home” rules. 

And Maryland, among the top states for dispensing methadone, again complied with calls to loosen standards

map of states adopting 2020 opioid dispensing flexibilities

How has that worked out, relaxing safety standards for dispensing of methadone, like buprenorphine commonly abused with additional substances

Consistently, locales that adopted relaxed standards and/or significant expansion in provision of methadone have experienced increased methadone-related deaths, described here for:




Washington DC, and 

Ontario, Canada

And in a post soon to appear, for Vermont. 

That’s no surprise, based on what a longstanding body of evidence tells us about methadone

Baltimore has been inundated, with mass casualties, by an inevitable confluence of unnatural forces driven by pathological levels of diminished capacity for competence, research literacy, ethical discernment, and critical thought, each gross failure of clinical, scientific, and journalistic judgment running against longstanding established evidence of harm predicted by implementation of failed expert medical treatments for the entirely non-medical condition of compulsive substance use. 

All that’s left, the unremarkable part, is for the New York Times to hide the obvious institutional pathology and lethality behind a constructed sheen of expertise woven of lies and rationalizations. 

Why A Critical Discourse?

Because an uncontrolled epidemic of desperate and deadly use of pain-numbing opioid drugs is just the most visible of America’s lethal crises of drug misuse, suicide, depression, of obesity and sickness, of social illness. Because the matrix of health experts and institutions constructed and identified by mass media as trusted authorities – publicly funded and entrusted to protect public health – instead collude to fabricate false assurances like those that created an opioid crisis, while promising medical cures that never come and can never come, while epidemics worsen. Because the “journalists” responsible for protecting public well-being have failed to fight for truth, traded that duty away for their careers, their abdication and cowardice rewarded daily in corporate news offices, attempts to expose that failure and their fabrications punished.

Open, critical examination, exposure, and deconstruction of their lethal matrix of fabrications is a matter of survival, is cure for mass illness and crisis, demands of us a critical discourse.

Crisis is a necessary condition for a questioning of doxa, but is not in itself a sufficient condition for the production of a critical discourse.

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