After a decade defined by a swelling death toll, the rate at which Baltimoreans are dying of overdoses may be slowing — a national phenomenon that's given hope amid a devastating crisis.
Baltimore saw 566 fatal overdose deaths as of September, according to preliminary data from the Maryland Department of Health. While a myriad of preventable deaths remain, the number puts the city on track to possibly end the year with fewer than 800 deaths, a significant drop compared to recent years.
The last time the city saw less than 800 deaths was in 2017, which preceded a pandemic-era surge in fatalities caused by the proliferation of fentanyl.
“It seems like overdoses are significantly lower this year than last year or other recent years, particularly since the COVID-19 pandemic,” said Kenny Feder, assistant research professor at the Johns Hopkins Bloomberg School of Public Health’s Department of Mental Health. "And it’s not just a Baltimore phenomenon.”
The downward trend: The decline in fatal overdose rates has been mostly experienced in the eastern U.S., said Feder, who specializes in overdose prevention and health care for those who use drugs.
Last year, the country's fatal overdose numbers decreased for the first time in five years, though Baltimore's increased by 5.5% — marking a death toll of more than 1,000.
Now, however, Baltimore seems to be catching up as the decline becomes more significant.
The rebound comes after a "tragically high" surge in deaths that was worse than many thought was possible, Feder said. As extremely potent synthetic opioids rocked the drug market, deaths in Baltimore peaked in 2021, when the state reported 1,079 deaths.
Three years later, although the numbers are still relatively high — particularly in comparison to pre-pandemic levels — the new data shows the death rate may have reached its limit as fentanyl became the norm.
It's difficult to pinpoint just one reason for the decline, Feder said, although it seems to indicate that harm reduction initiatives are working.
Cities such as Baltimore have perhaps most importantly ramped up the distribution of naloxone, an opioid antagonist that is at the crux of strategies to prevent fatal overdoses.
Emergency service personnel administered the life-saving drug, which reverses overdoses, more than 1,600 times in Baltimore this year, according to the state health department.
Locally, the city and local harm reduction organizations have augmented their efforts. They've offered syringe service programs, or SSPs, as well as other resources such as naloxone distribution and training.
In tandem, they aim to reduce overdoses, prevent the spread of diseases such as HIV and help individuals access treatment, emphasizing a multifaceted approach to addressing the crisis.
“The thing is, those strategies are effective,” Fedder said. “They were effective before overdoses went up as the saturation of fentanyl went up, and we need more of them. It’s really positive we’re seeing overdoses going down, and those strategies are still saving lives.”
Caution about the numbers: Dr. Eric Weintraub, a psychiatrist specializing in addiction who serves as associate director of the Kahlert Institute of Addiction Medicine at the University of Maryland School of Medicine, cautioned that it may be too early to draw conclusions.
“I would say it’s probably too early to tell,” Weintraub said. “Generally, there’s a six to eight-month lag between what you see in the actual data and when the medical examiners would be able to confirm all of the deaths.”
Based on this, the more realistic number would be around 900 deaths, which would still mark a notable decrease from last year, he said. What's more certain is that the nation as a whole is seeing a decline.
Michael Coury, spokesman for the state's Office of Overdose Response, echoed Weintraub's caution about local data.
It's important to note that the data is preliminary, so numbers will likely grow as cases are confirmed, Coury said. Still, the data is encouraging and indicative of a downward trend after a concerted push by the state and local governments to tackle the crisis.
"Far too many people in Maryland continue to lose their lives every day to preventable overdoses, and Maryland is working to increase access to care for people with substance use disorders in every corner of the state," Coury said. "We’re continuing to expand access to crisis services, for example, by investing over $100 million to expand mobile crisis services and crisis stabilization centers."
Earlier this year, Gov. Wes Moore signed a budget with a 14% increase in funding for substance use disorder services alone. In total, $1.4 billion was allocated for addiction and mental health programs.
Mayor Brandon Scott had similar priorities in his budget, including a 44% increase in funding for mental health and substance abuse programs.
The result has been a "robust" harm reduction infrastructure in Baltimore, Coury said. Statewide, programming is also up, with most counties offering SSPs, naloxone programs and other resources.
Roadblocks remain: The investments reflect a dedication to driving overdose deaths down. But that's not to say that experts and public officials expect this year's downward trend to remain consistent, as numerous roadblocks remain.
"We cannot afford to be complacent in our efforts to save lives," Coury said.
In addition to the stigma surrounding drug use itself, barriers to treatment and life-saving medications still exist, whether it be because they're illegal or not done in practice.
For example, overdose prevention centers, which permit people to use drugs in-house alongside medical professionals, are largely illegal in the U.S. This comes despite the fact they have been proven to reduce overdose deaths.
And, even though pandemic-era laws made it easier to prescribe and distribute medications for opioid use disorder such as methadone and buprenorphine, which have been proven to improve health outcomes, many still go without access.
That is particularly true among minority groups, who are hardest hit by health disparities. That fact is manifested in Baltimore's death toll, as a majority of deaths are Black residents. Data shows that deaths are most concentrated in the city's "Black Butterfly."
“I think some of the patients we see in Baltimore are marginalized from the mainstream health care system and so a lot of these individuals, because of a lack of trust in the system, don’t do well in brick-and-mortar treatment,” Weintraub said. “We need to make an effort to meet them where they are.”
The issues are compounded by the fact that, while the drug supply has always been an issue because Baltimore is a port city and has in the past served as a hub for trafficking, the supply is getting increasingly more toxic.
That's become evident with the proliferation of xylazine, a tranquilizer that's often mixed with fentanyl and is resistant to naloxone. Nitazenes, a stronger form of synthetic opioids, have also become more prevalent.
"This is a major emerging threat to all people who use drugs," Feder said, adding it's unclear how they will impact death rates in the future.
The future of the crisis: Although barriers remain, The data indicating a potential for a notably low death toll in 2024 places the city at a key juncture in the overdose crisis — and in its mission to address it.
The crisis has killed more than 8,000 Baltimore residents in the past decade, and the city's death rate remains the highest in the nation, coming in at 144.4 deaths per 100,000 people, based on 2020 U.S. Census data.
That quadruples Maryland's average while dwarfing the death rates of other counties.
For Baltimore to end the year with less than 800 overdose deaths, its death rate would have to remain steady, despite some studies indicating an increase in fatalities during colder months.
To ramp up harm reduction efforts, the city is in hot pursuit of funds to continue to drive numbers down through litigation against opioid manufacturers and distributors over their role in the crisis.
The Baltimore City Health Department declined to comment, citing the litigation.
Baltimore is already slated to receive about $400 million from five settlements, more than $100 million of which has been earmarked for opioid remediation efforts. Ongoing litigation against McKesson and Censora, formerly called AmerisourceBergen, could bring in significantly more.
The windfall of funds will drastically bolster funding for overdose prevention initiatives and other harm reduction measures, officials have said. That comes on top of historic investments already included in the state and city's most recent budgets.
Although not much has been said beyond that as officials look to prevent hurting their chances in court, they've expressed confidence in putting funds through a governance structure to ensure they're used most effectively.
Officials are now waiting to see just how much money they can obtain to fill their war chest against the crisis. And the city will have to wait to see whether the trend of declining overdoses is sustained.
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