Abstinence not required: How a Baltimore drug treatment program prioritizes saving lives

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Anthony Kelly trudged through the streets of southwest Baltimore, each step a painful reminder of his past as a Marine, suffering from chronic pain and battling an opioid addiction. After a roofing accident, Kelly underwent surgeries and months of rehabilitation. Thus began his downward spiral into substance use disorder, gradually eroding his physical health and consuming his identity as a loving husband, father, hard worker, and proud veteran.

When his prescribed painkillers ran out, Kelly resorted to traveling to Florida, taking advantage of loosely regulated pain management clinics. Eventually, he turned to a dangerous combination of heroin and cocaine, costing him up to $500 per day.

Over a decade later, Kelly’s substance use is more manageable, although it remains a powerful force in his life. He now receives buprenorphine, a prescription medication considered the gold standard for treating opioid addiction. This medication helps reduce cravings and ease withdrawal symptoms. Through a mobile health clinic housed in a retrofitted van, doctors and nurses provide free services, including medication prescriptions, basic wound care, hepatitis C treatment, naloxone overdose reversal kits, and more. The clinic operates in Baltimore’s most drug-affected communities, including Kelly’s neighborhood.

This clinic represents a shift in the nation’s approach to combatting overdose deaths, which reached unprecedented levels during the pandemic due to the proliferation of potent synthetic opioids like fentanyl. Known as the harm reduction model, this approach, supported and funded by the Biden administration, provides life-saving services to opioid users without requiring immediate abstinence. Advocates argue that it prioritizes keeping individuals alive while they navigate the immense challenges of recovery. Critics, however, argue that it enables illegal activities.

In Baltimore’s “Healthcare on the Spot” program, most patients continue to use street drugs, but the majority report reduced usage. According to clinic staff, addressing addiction is more complex than commonly believed. Kelly, 49, explained, “We built this web we’re entangled in. We didn’t get here overnight, and we’re not gonna get better overnight. You can’t just snap out of it.”

Baltimore’s overdose death rate exceeds both the statewide and nationwide averages. In 2020 alone, the city lost over 1,000 lives to overdoses, representing more than 35% of the state’s total overdose deaths, despite accounting for only 10% of Maryland’s population. While addressing the issue remains a challenge, Baltimore has been ahead of the curve in implementing solutions. The city established a needle exchange program in 1994 and has recently focused on expanding access to naloxone while reducing arrests related to low-level drug offenses. Another mobile treatment program operates outside the city’s jail, providing buprenorphine prescriptions to individuals upon their release.

The Spot van, where Kelly receives his treatment, features a waiting area, two small exam rooms, and a small bathroom. During private consultations, medical providers often establish a friendly rapport with their patients. They discuss various topics, including family dynamics, housing situations, mental health concerns, long-term goals, recent substance use, and more.

The clinic collaborates with several pharmacies across the city, allowing patients to fill their prescriptions promptly after leaving the van. No ID or health insurance is required to enroll in the program. The only condition for patients to continue receiving buprenorphine through the clinic is to demonstrate consistent medication usage.

Buprenorphine, approved by the FDA for treating opioid use disorder in 2002, binds to opioid receptors in the brain without producing a euphoric high. Often prescribed under the brand name Suboxone, it typically comes in orange dissolvable strips. Research shows that this drug significantly reduces the risk of overdose and death. However, only a small percentage of individuals with opioid addiction receive this medication, unlike methadone treatment, which involves highly regulated clinic visits on a daily basis. Buprenorphine prescriptions can last for weeks or even months.

In December 2022, federal lawmakers passed legislation to make it easier for doctors to prescribe buprenorphine, recognizing its life-saving potential. Since 2020, drug overdoses in the United States have claimed over 100,000 lives annually, with fentanyl accounting for approximately two-thirds of these fatalities.

Many patients at the Spot van seek treatment because they are exhausted, tired of chasing the dangerous high of fentanyl and living in constant fear of withdrawal symptoms, sometimes even desiring an end to their suffering. Saprena Culver, 40, who joined the program earlier this year, explained, “It controls your whole entire life, your whole entire being.”

Culver’s four children currently live with relatives in West Virginia, but she hopes to be reunited with them soon. This is not her first attempt at seeking treatment; she previously spent 12 years in a methadone program that had stricter rules. Although she was eventually removed from the program due to a relapse, she found the added accountability beneficial.

Unfortunately, it is not uncommon for individuals to buy Suboxone illegally to alleviate withdrawal symptoms, indicating that some patients at the Spot van may be profiting from their prescriptions.

Despite the clinic staff’s firm belief in expanding access to medication, they continually grapple with how to best serve individuals who are not yet ready to stop using drugs.

Kelly, who grew up in Baltimore after his grandparents immigrated from Ireland, had an adventurous spirit. He participated in his high school’s wrestling team and joined the Marines in 1992, serving for eight years, including deployments to Egypt, Thailand, and other parts of the world. Kelly considered himself lucky to have a job that allowed him to fulfill his lifelong dream, experience different cultures, and get paid for physical training.

It was during his military service that he met his future wife, a fellow Marine. Their son was born in 2000 and spent his early years in Baltimore.

After his marriage ended, Kelly’s ex-wife and son moved to Florida, while he stayed in Baltimore, residing in his grandmother’s rowhouse. Over time, he inherited the property.

During a recent visit to Kelly’s house, an unopened naloxone kit lay on the kitchen table among dishes, pans, and groceries. A framed photo showcased a teenage Kelly competing in a wrestling match, his bulging muscles overpowering his opponent. A sign above the front door conveyed “Irish Blessings” to the building’s inhabitants.

Kelly’s elderly Pomeranian-long haired Chihuahua mix named Annie Oakley energetically descended the staircase, her wagging tail demanding attention. Kelly shared an incident when he overdosed, and Annie alerted a neighbor who discovered him unconscious and called for help.

While the three-story brick rowhouse holds cherished memories for Kelly, it has seen better days. The interior is sparsely furnished and cluttered. Kelly rents out rooms, sometimes to people struggling with addiction and in need of a place to stay, which occasionally creates a volatile environment.

The previous weeks had been challenging for Kelly, dealing with a leg infection from a bicycle accident and a dispute involving a former tenant who owed money. Pain and stress, common triggers for addiction, weighed heavily on him.

He spoke affectionately about his son, who is currently studying environmental engineering in college. Looking at recent photos of his son on his phone, Kelly realized that his son is worth fighting for. He nostalgically remembered the years before his addiction took hold, when he was a dedicated father and hardworking individual.

Kelly yearns for more people to understand the realities of substance use disorder, how it gradually consumes one’s life until they no longer recognize themselves. He compares the process to traversing a road laden with improvised explosive devices (IEDs), so focused on avoiding immediate danger that one fails to notice the path leading deeper into hostile territory.

Several years ago, while visiting his family in Florida, Kelly began using Suboxone to avoid using heroin in front of his son. Although the medication helps curb his opioid cravings, he finds it ineffective for the persistent pain stemming from his roofing accident. To manage the pain, he still requires stronger substances.

In his neighborhood, heroin and fentanyl are easily accessible, exacerbating the challenges he faces due to rising poverty and population decline.

Every Monday morning, the Spot van parks in Baltimore’s Upton community, once a thriving Black cultural center renowned for its jazz clubs, upscale shops, and vibrant nightlife. Today, the neighborhood reflects the visible impact of the local drug trade, with dealers conducting business near vacant buildings, their customers drowsily nodding on public benches, and individuals scrambling to gather enough money to get through another day.

Baltimore police cruisers patrol the area as part of the city’s strategy to combat gun violence. Just a block away from the van’s parking spot, deflated balloons mark the site of a January shootout that injured three people and claimed the lives of two, including a young mother waiting to pick up takeout with her children.

Lenwood Johnson, 62, frequently visits this location. After three months on buprenorphine, Johnson significantly reduced his opioid use, saving money and enabling him to stay sober for family visits and important events. His reduced dependence on fentanyl also decreases his risk-taking behavior, as he no longer feels compelled to maintain a constant supply.

Johnson, a former correctional officer at Baltimore’s jail, began using opioids decades ago when a marijuana possession arrest derailed his law enforcement career.

The Spot program, launched in 2018, is a collaboration between the Baltimore City Health Department and the Johns Hopkins University School of Medicine. Annually serving approximately 900 patients, the program primarily caters to a profoundly underserved population, with nearly 75% of patients being Black and over half experiencing homelessness or housing instability.

Building trust with this population is crucial, as many individuals are wary of the healthcare system. Dr. Kathleen Page, a professor at the Johns Hopkins medical school involved in the program’s inception, emphasized the importance of establishing trust.

Darryl Jackson Sr., who enrolled in the program with his adult son last year, considers the clinic to be a stable source of support in his life. Currently researching rental assistance programs, he recently had to leave his previous apartment. However, bureaucratic hurdles and long waitlists often impede access to housing support. Jackson, known for his cleanliness and neat appearance, finds it challenging to tolerate shelter environments. While his construction background is evident in his work pants and sneakers, internally he struggles to manage his addiction and fight off growing feelings of hopelessness. After missing a few appointments, he returned to the Spot van, appreciating the care provided by the staff.

Program staff understand the daily obstacles faced by Jackson and other participants. Their mere presence at the clinic is often a small miracle.

Treating patients in front of them becomes the primary focus for the clinic’s staff when the larger picture feels overwhelming. Dr. Amanda Rosecrans, the clinical chief, expressed her empathy, stating that she cannot imagine living a day in her patients’ shoes. She had received news of a patient’s recent death that morning, a tragically common occurrence in Baltimore’s poorest communities plagued by overdose and gun violence.

For this vulnerable population, stable housing is crucial for successful recovery, according to Bobby Harris, the program’s medical director. Feeling safe and secure is essential to focus on other aspects of their lives.

When overwhelmed by the larger challenges, Harris and his team concentrate on the patients in front of them, providing the best care they can.

Islah Hadith, 45, had her life transformed after discovering the clinic in 2019. Several years prior, she broke her ankle playing basketball and was prescribed Percocet. Once her prescription ran out, she experienced withdrawal and resorted to purchasing pills on the street. Despite working and raising children, she felt disconnected and absent. However, upon finding the Spot van, she arrived with nervousness and shame but left with newfound hope.

Hadith started taking buprenorphine and ceased using other opioids. After four years on the medication, she recently began tapering her doses to gradually wean herself off. She sought therapy and distanced herself from people and places that could jeopardize her progress.

She believes that recovery isn’t easy, but it does get better.

During his recent visit to the clinic, Kelly’s infected leg had worsened significantly. He could barely walk, relying heavily on a metal cane. Despite the setback, he remained positive and clear-eyed, buoyed by a recent visit to his family in Florida. The trip offered respite from Baltimore and instilled in him a glimmer of optimism. He contemplated leaving the city, potentially relocating to South Carolina to focus on work and begin a new chapter.

Kelly expressed gratitude for his support system, although he worries about becoming a burden. His addiction continues to strain his most cherished relationships.

He contemplates prioritizing his health by consistently taking Suboxone and abstaining from illicit drugs. This way, he envisions offering his family the support and stability they deserve.

Later that day, Kelly planned to check into the hospital to have his leg examined. But first, he headed to the pharmacy to fill his prescription, taking it one step at a time.

Frequently Asked Questions (FAQs) about Harm reduction approach to substance use disorder treatment

More about Harm reduction approach to substance use disorder treatment

• Baltimore City Health Department
• Johns Hopkins University School of Medicine
• National Institute on Drug Abuse: Medications to Treat Opioid Use Disorder
• Centers for Disease Control and Prevention: Understanding the Epidemic
• Substance Abuse and Mental Health Services Administration: Medication-Assisted Treatment
• National Harm Reduction Coalition
• Baltimore Sun: Baltimore had more than 1,000 fatal drug overdoses in 2020, deadliest year ever