Smart Steps, Treating Baltimore's Drug Problem

Baltimore's Publicly-Funded Treatment System

Baltimore is developing new approaches to manage its publicly-funded treatment system and to deliver treatment services. The Board of Directors of Baltimore Substance Abuse Systems, Inc. (BSAS), the city’s substance abuse prevention and treatment agency, includes officials from city and state government agencies as well as representatives from private organizations. BSAS seeks advice on its operations from a Scientific Advisory Committee composed of treatment experts from across the country. Innovative treatment approaches have taken root in Baltimore, including outreach through the city’s needle exchange program and a drug court for drug-involved offenders.

Baltimore Substance Abuse Systems
In 1990, the Baltimore City Health Department created BSAS—a quasi-public, non-profit corporation—to administer a Target Cities treatment improvement grant awarded to Baltimore by CSAT. The Target Cities project led to the creation of a Centralized Intake Referral and Management Information System (CIRMIS), which gave the city a much clearer picture of treatment needs than had been previously available. The Target Cities project also established primary health care centers at five drug treatment programs, developed an addiction education program for primary care physicians, created an acupuncture drug treatment program at the Baltimore City Detention Center, and coordinated Maryland’s “One Church-One Addict” (a statewide effort to educate faith communities about addiction and support services for those in recovery).

In 1995, BSAS became the single substance abuse authority for the city, administering public funds, monitoring prevention and treatment programs, collecting client data, and collaborating with other agencies to improve services.[217] After the transfer of treatment oversight from the Baltimore City Health Department to BSAS, Baltimore began to increase treatment funding with the goal of providing ready access to treatment for all who request it. The signature program of this effort—the Mayor’s Initiative—was launched in FY 1998 and created new treatment slots with city revenues drawn from the Health Department budget and with federal grant dollars allocated to treatment by the Baltimore City Department of Housing and Community Development and the Housing Authority of Baltimore.[218]

Since 1996, funding from the Abell Foundation, the Robert Wood Johnson Foundation, the Open Society Institute-Baltimore, and the Harry and Jeanette Weinberg Foundation has allowed BSAS to invest additional funds in strategic planning, staff training, new staff positions for research and advocacy, and innovative clinical programs.

BSAS supports 38 alcohol and drug abuse treatment programs through a combination of federal, state and local grants. All programs funded by BSAS are certified by the Maryland Department of Health and Mental Hygiene’s Office of Health Care Quality. To ensure that publicly-funded programs are operating according to the relevant federal, state and city regulations and are providing high-quality services, BSAS staff conduct monthly on-site monitoring. These visits include meetings with patients, staff and program directors and examination of patient records to assess the appropriateness of treatment planning and care.

Of the 6,500 slots funded by BSAS in FY 2000, the great majority were for methadone maintenance (56 percent) or outpatient drug-free treatment (31 percent), which are the least expensive modalities. By comparison, there are very few slots for residential treatment of any kind (5 percent), and even fewer residential slots with an average stay as long as six months (3 percent). One methadone maintenance slot, serving one patient for 12 months, costs BSAS about $3,500 (a level of funding that supports only the bare minimum of services). Residential slots for women with children, with an average stay of six months, cost BSAS about $22,500 per patient.

Patients in BSAS-Funded Treatment FY 1999
*Modality*	*Episodes* *of Care*	*Percent of Total*
Outpatient	13,995	77.8
Intensive/Standard Outpatient	6,093	33.9
Methadone (Detoxification & Maintenance)	5,457	30.3
Youth Outpatient	1,275	7.1
Outpatient Detoxification	1,170	6.5
Inpatient	3,991	22.2
Intermediate Care Facility	2,538	14.1
Inpatient Detoxification	850	4.7
Intensive Transitional Living	333	1.9
Halfway House	216	1.2
Residential Women & Children	33	0.2
Therapeutic Community	21	0.1
Total	17,986	100.0

In addition to Baltimore’s BSAS-funded treatment programs, some 20 other treatment providers in the city only take patients who are able to pay for the services themselves or through their health insurance (including HealthChoice, Maryland’s Medicaid managed care system). BSAS programs serve about 70 percent of those who receive treatment in Baltimore. In general, BSAS patients face a greater array of problems than those who can access private programs. For example, only 19 percent of the 19,000 patients active in BSAS-funded programs during FY 2000 were employed full time, 54 percent had been arrested at least once within the previous two years, and 29 percent were placed in treatment via the criminal justice system.[219]

Social and Economic Status of Baltimore’s Public Sector Treatment Patients[220]
Characteristic	Baltimore Treatment Patients	General U.S. Population
Percent Single	76	44
Percent Unemployed	68	4
Annual Family Income Percent under $5,000 Percent under $10,000	52 74	3 6
Percent with No Health Insurance	63	18
Percent with Medicaid	21	11

The BSAS Board of Directors
The 24-member BSAS Board of Directors includes officials from a range of city and state government agencies, as well as numerous representatives from private organizations with expertise in local treatment issues. In addition to Baltimore’s health commissioner, the BSAS Board includes officials from the city council, the police, the departments of social services and housing and community development, the state’s attorney for Baltimore, and Baltimore Mental Health Systems, Inc. (the city’s mental health equivalent of BSAS). The state government is represented on the Board by the Lt. Governor and by the directors of the departments of human resources, health and mental hygiene, and public safety and correctional services. (See Appendices for a list of the members of the BSAS Board of Directors.)

The BSAS Board’s Allocations Committee is responsible for recommending which treatment modalities and particular programs should be funded. Beginning with the FY 2001 round of funding decisions, the Allocations Committee was placed in charge of BSAS’ request for proposals (RFP) process. The Committee reviews each applicant’s internal operations and financial data as well as measures of treatment performance, including retention and utilization rates and drug test results. The performance measures, which are the responsibility of the Board’s Performance Evaluation Committee, are based on data generated by CIRMIS. The Performance Evaluation Committee is also responsible for developing performance criteria to assess results achieved by the BSAS treatment system as a whole.[221]

The BSAS Scientific Advisory Committee
In addition to the collective expertise of its Board, BSAS has assembled a Scientific Advisory Committee of 14 nationally recognized treatment researchers and practitioners tasked with identifying gaps in the city’s treatment system and suggesting strategies for improving services and for adopting state-of-the art practices being implemented elsewhere. No other city in the country has called upon such an expert group to examine its treatment efforts on an ongoing basis. In October 1999, the Scientific Advisory Committee submitted its first set of recommendations for how the city should go about expanding, evaluating and improving its treatment system. (See Appendices for a list of the BSAS Scientific Advisory Committee members.)

Baltimore’s Treatment Innovations
Baltimore’s recent efforts are noteworthy both for the city’s explicit commitment to treatment on request and for the extensive involvement on the part of private organizations, including local foundations, business leaders, the religious community and university researchers. Baltimore has been particularly creative in attempting to extend treatment to hard-to-reach populations, increasing the intensity of treatment counseling services, maximizing available methadone maintenance slots, and including treatment in criminal justice settings. Illustrative initiatives are described below:

Ø Outreach. Improving outreach efforts to people addicted to drugs but distrustful of or lacking confidence in treatment is crucial to reaping the benefits of an upgraded treatment system. If most people who are addicted to drugs never enroll in treatment, or at least not until many years into their addiction, then even a system that performs well for those who do enter is only beginning to address the true scope of the problem.[222] A 1998 study based on a nationwide sample of more than 38,561 heroin users (obtained through the National AIDS Demonstration Research Program) found very low levels of involvement with treatment: 58 percent reported never having been in detoxification, more than 70 percent were never in methadone maintenance, and more than 80 percent were never in any form of outpatient treatment. Even among the minority who reported some form of treatment experience, most had been in treatment only one or two times.[223]

Baltimore’s Needle Exchange Program as a Bridge to Treatment
Needle exchange programs curb the spread of HIV among injection drug users (IDUs) by decreasing needle sharing and other HIV risk behaviors.[224] Needle exchange can also be an effective bridge to treatment.[225] The National Institutes of Health, the National Academy of Sciences, the Centers for Disease Control and Prevention, and researchers at the Johns Hopkins University have found that needle exchange effectively reduces the spread of HIV and hepatitis-B without increasing drug use or other public safety risks.[226]

Baltimore’s Needle Exchange Program (BNEP) has become an integral part of the city’s public health system.[227] Since the program began in 1994, 12,000 people have participated in needle exchange through mobile vans and pharmacies. BNEP makes referrals to 390 treatment slots (primarily methadone maintenance) set aside for needle exchange participants in five Baltimore treatment programs. The city spends about $300,000 a year on BNEP, and another $250,000 on drug treatment for participants.

The rate of new HIV infections among Baltimore IDUs has fallen by 35 percent since the Baltimore Needle Exchange Program began; each HIV infection prevented saves at least $150,000 in direct medical costs.[228]

In a 1998 Johns Hopkins University study, methadone maintenance patients referred by BNEP showed reductions in drug use and criminal activity comparable to those of other methadone patients, even though BNEP referrals had more severe drug habits, less treatment experience and more medical problems.[229]

In light of the strong results for needle exchange participants who enter treatment, Baltimore has won NIDA funding to evaluate the impact of a motivational interview designed to enhance treatment interest and participation by BNEP clients.[230] Based on 150 participants through June 2000, the study has found a high level of interest in treatment reported by new BNEP registrants: Close to 90 percent say they are interested in treatment, and half are interested in methadone maintenance in particular. As study participants are followed over the next two years, the strength of their interest in treatment as initially reported will be compared to their actual treatment participation and length of stay in treatment. The high level of interest in treatment that the study has already found underscores the great potential of the needle exchange program as a bridge to treatment, and also highlights the need to expand treatment capacity so that slots are readily available when drug users say they want treatment.[231]

Mobile Treatment Partnerships
Methadone and LAAM (levo-alpha-acetyl-methadol) suppress opiate withdrawal symptoms and cravings, thus reducing drug use and improving treatment retention. LAAM, which is long-acting, can be administered three times a week rather than daily, as is the case with methadone. In early 1999, Baltimore launched the nation’s first program to distribute LAAM through a mobile treatment van in combination with outpatient counseling. A van operated by REACH Mobile Health Services stops three times a week at the University of Maryland’s Harambee outpatient program to provide methadone and LAAM to patients referred from Baltimore’s Needle Exchange Program.

Johns Hopkins University researchers have found that the mobile LAAM program successfully engages and retains needle exchange participants in treatment. Between February 1999 and January 2000, 70 percent of the 121 needle exchange participants referred to the LAAM program enrolled, and over three-quarters of enrollees remained active in the program for at least six months. Even more importantly, nearly three-quarters of enrollees (average age of 42) had never entered a treatment program before.[232] These findings confirm the effectiveness of Baltimore’s Needle Exchange Program as a bridge to treatment and suggest that mobile LAAM and methadone programs may engage greater numbers of drug users in treatment than would be possible through fixed-site clinics alone. The National Institute on Drug Abuse (NIDA) and the Center for Substance Abuse Treatment (CSAT) funded the mobile LAAM-counseling partnership through June 2000, when the program was discontinued until new funding can be found.

Recovery in the Community and AID First
In 1999, the Abell Foundation began funding a new community treatment program targeting Baltimore neighborhoods where many residents have been addicts for as long as 10 to 15 years with little, if any, experience with treatment. Recovery in the Community combines street outreach, treatment readiness services, case management, and placement in treatment with transitional housing services and strong links to key community organizations, which expand the program’s service referral network.[233] With funding from OSI-Baltimore, the Johns Hopkins University School of Hygiene and Public Health has launched AID First, another community-oriented effort, which trains family and community members to recognize the early signs of serious drug involvement and to provide support and referral when an individual seeks help. A triage agent receives referrals from AID First volunteers in the community and, where warranted, helps the individuals who have been referred to prepare to enter treatment.[234]

Ø Intensive Services. More frequent contact with counselors early in the treatment process has been shown to increase the length of time that patients remain in treatment, which is a major factor in successful treatment outcomes. By comparison with methadone maintenance programs, “drug-free” outpatient programs (which for the most part do not involve the use of medications) typically retain a lower proportion of their patients in treatment.

To address this problem, in FY 1997 BSAS began the phased implementation of intensive front-end services at all BSAS-funded outpatient programs. Instead of the standard minimum counseling schedule of one to three hours per week, all BSAS-funded programs now provide a minimum of nine hours per week during the first month of treatment. The frequency of counseling sessions is gradually reduced in subsequent months (outpatient services are typically meant to last for six months), with the pace of transition depending on each patient’s progress.

Ø Maximizing Resources. Baltimore treatment providers and researchers are conducting demonstration projects which show that medical methadone maintenance for stabilized, well-functioning patients is a safe, effective way to free up standard methadone maintenance treatment slots for new patients.

Methadone maintenance is unavailable to many who would benefit, due both to inadequate funding and to regulations that restrict prescribing practices; even highly stable patients must attend a methadone clinic one or more times per week to receive medication. Medical maintenance reduces this reporting schedule to once per month, with medication dispensed and counseling provided by medical staff either at a traditional methadone clinic or in a physician’s office.

Researchers in Baltimore have obtained exemptions from existing regulations to evaluate the safety and effectiveness of medical maintenance for patients who have done well in standard methadone maintenance. A demonstration project following 21 medical maintenance patients in Baltimore for 12 years reports high retention in treatment, very low rates of illicit drug use—only 0.5 percent of the 2,290 urine specimens collected tested positive—and no evidence that medication was diverted to others in the community.[235] Research based on a larger sample of 78 patients at three different Baltimore clinics has shown similar results at the six-month follow-up.[236]

These findings reinforce earlier research done in New York City[237] and suggest that Baltimore should be permitted to implement medical maintenance on a larger scale. Maryland’s Alcohol and Drug Abuse Administration (ADAA) estimates that 10 percent of Baltimore’s methadone maintenance patients might qualify for medical maintenance.[238] Since these patients generally would be able to pay for their own treatment, expanding the medical maintenance model would free up traditional methadone slots at no cost to the public, allowing city programs to admit more new patients and concentrate their resources on less stable patients.

Ø Criminal Justice. The criminal justice system is a critical venue for integrating treatment—from the pre-trial stage, to prison-based programs, to community-based treatment for parolees and probationers.

Drug Court
The Baltimore City Drug Court opened in March 1994 and includes separate programs for misdemeanor offenders (District Court) and felony offenders (Circuit Court).[239] As of August 2000, more than 500 people had graduated from the Drug Court. Only 7 percent of graduates have had new criminal convictions within three years of graduation, compared to 37 percent for all probationers in Baltimore. The University of Maryland is currently conducting a randomized, controlled evaluation of treatment outcomes for drug court participants. The drug court receives $2.3 million annually in state funding, of which $1.5 million is spent on treatment. The program, which was filled beyond capacity in December 2000, will be expanded in FY 2001. An additional $900,000 in treatment funding has been obtained from the state, allowing the drug court to increase the number of participants from 600 to 900.[240]

Treatment for Heroin-Dependent Prisoners Nearing Release
In February 2000, Baltimore’s Friends Research Institute (FRI) began evaluating the effectiveness of providing LAAM maintenance treatment to heroin-dependent inmates at the Metropolitan Transitional Center, a pre-release facility in Baltimore.[241] Over the course of the study, 60 male inmates will be randomly assigned to 12 months of LAAM maintenance treatment, including three months of treatment while incarcerated and nine months while on parole; another 60 inmates will be randomly assigned to the control group and will not receive LAAM treatment. Both groups will receive standard correctional and parole supervision. To prevent relapse, FRI’s project combines prison-based treatment (medication and counseling) and continued treatment in the community. In prison and in the community, treatment will be provided by the same program (Man Alive, one of Baltimore’s oldest and largest methadone and LAAM maintenance programs). FRI researchers anticipate that the LAAM treatment participants will be more successful in avoiding a return to heroin use, other criminal activity, HIV risk behaviors and reincarceration.

Break the Cycle
Break the Cycle (BTC), championed by Maryland Lt. Governor Kathleen Kennedy Townsend, is the state’s first systematic effort to address drug use among offenders on probation and parole. The goals of BTC are to reduce drug use and criminal recidivism among offenders by using regular drug tests and graduated sanctions and incentives to keep drug-abusing offenders in treatment.[242] BTC eventually will be instituted statewide, but the strategy was initiated in Fall 1998 in Baltimore and six counties. A January 2000 process evaluation found uneven implementation of BTC across the participating jurisdictions and recommended conducting an outcome study when all of the strategy’s components—drug testing, sanctions and rewards, and treatment—are in place.[243]

Since 1997, Maryland’s ADAA has required BSAS to reserve 35 percent of block grant funding for treatment slots for clients referred by criminal justice agencies. Full implementation of BTC will include closer monitoring and sanctions for Baltimore offenders who fail to attend treatment, which should improve treatment compliance among probationers and parolees.

Demand for treatment of criminal offenders is expected to grow in coming years, raising concerns that voluntary treatment applicants will be pushed further back on program waiting lists unless treatment capacity expands at the same time.

[217]. Baltimore Substance Abuse Systems, Inc. (BSAS). Fact Sheet and FY 1996-FY 1999 Budget. 1999.