Almost 6,000 Dead in 6 Years: How Baltimore Became the U.S. Overdose Capital

BALTIMORE — People in Baltimore have been dying of overdoses at a rate never before seen in a major U.S. 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.

A decade ago, 700 fewer people here were being killed by drugs each year. And when fatalities began to rise from the synthetic opioid fentanyl, so potent that even minuscule doses are deadly , Baltimore’s initial response was hailed as a national model. The city set ambitious goals, distributed Narcan widely, experimented with ways to steer people into treatment and ratcheted up campaigns to alert the public .

But then city leaders became preoccupied with other crises, including gun violence and the pandemic. Many of those efforts to fight overdoses stalled, an examination by The New York Times and The Baltimore Banner has found.

Health officials began publicly sharing less data. City Council members rarely addressed or inquired about the growing number of overdoses. The fact that the city’s status became so much worse than any other of its size was not known to the mayor, the deputy mayor — who had been the health commissioner during some of those years — or multiple council members until they were recently shown data compiled by Times/Banner reporters.

Little of the urgency that once characterized the city’s response is evident today. Since 2020, officials have set fewer and less ambitious goals for their overdose prevention efforts. The task force managing the crisis once met monthly but convened only twice in 2022 and three times in 2023. By then, fewer people were being revived by emergency workers, fewer people were getting medication to curb their opioid addiction through Medicaid, and fewer people were in publicly funded treatment programs.

In an interview, Mayor Brandon Scott defended the city’s response. He knows that Baltimore has had a severe problem with drug addiction for decades, he said, and while the analysis may provide a better understanding of its scale, it will not change his administration’s approach.

“This is an issue that we’re doing a lot of work on and that we can and will do more work on,” Scott said, “but we also know requires a lot, lot more resources” than the city has.

When shown the mortality figures, other city leaders and health experts reacted with alarm.

The numbers are “horrifying,” said Dr. Laura Herrera Scott, Maryland’s health secretary since 2023, adding, “We haven’t deployed the right resources in the right places.”

To examine Baltimore’s response to overdoses, journalists for the Times and The Banner reviewed thousands of pages of government documents and interviewed more than 100 health officials, treatment providers and people who have been addicted to drugs. Taken together, the records and interviews reveal the extent to which the city’s leaders failed to grapple with the enormity of the crisis.

State and city agencies track deaths, reporting the overall count to the U.S. Centers for Disease Control and Prevention. But Maryland and Baltimore officials, often citing medical privacy concerns, have not published more detailed information on overdoses. That secrecy has hindered awareness of the epidemic and responses to it, former city employees and community workers said.

The state’s Office of the Chief Medical Examiner refused to provide full autopsy reports until The Banner won a lawsuit compelling the agency to disclose the information, which identified who died, where they died and how they died.

Those who were lost represented a cross-section of Baltimore: line cook, lawyer, bus driver, engineer, machinist, teacher, restaurant owner, carpenter, veteran, physician, salesperson and admissions coordinator for an addiction recovery center. There were retirees and the jobless.

Some victims were heartbreakingly young: Since 2020, at least 13 children younger than 4 have died after being exposed to drugs, according to the reports. Black men in their 50s to 70s died at the highest rates.

A few overdose deaths drew headlines, but most were invisible to the public.

The sharp increase in deaths came as the city has faced numerous challenges: a shrinking population, tensions over policing, turnover at City Hall, rising shootings, and COVID-19.

A Dangerous High

For nearly all of the past three decades, Baltimore has had one of the highest fatal overdose rates of any large U.S. city. But for most of that period, the death rate was much closer to the national average than it is today.

Officials have long tried to solve the city’s drug problem with arrests and aggressive policing. Baltimore was also at the forefront of innovative public health strategies to address addiction. In 1994, the city’s Health Department was among the first in the nation to start a legal syringe exchange to stop the spread of HIV and other blood-borne illnesses.

Beginning in 2006, the city and state spent millions to expand access to buprenorphine, one of the most effective opioid addiction treatments. Fatal overdoses dropped, and Baltimore seemed to be getting a handle on its heroin problem.

Around the same time, pharmaceutical companies were inundating pharmacies across the country with addictive pain pills. Some 400,000 pills of opioids like oxycodone started arriving in the city every week. Some patients from inside and outside the city began selling their pills in Baltimore, expanding the illegal drug market and making it easier for people to get hooked on opioids or to relapse.

In a written statement last week, the mayor’s office said that the current fentanyl crisis had been triggered by the influx of pills from drugmakers and distributors and that the Times and The Banner’s reporting on the city’s response amounted to “misguided victim blaming.”

The claim about the drugmakers echoes a lawsuit the city is pursuing against more than a dozen companies, set for trial in September. But the prescription pill epidemic was far less severe in Baltimore than elsewhere in the country. Baltimore received one-fifth as many pills per capita as some areas, Drug Enforcement Administration records show. Oxycodone was the cause of relatively few deaths in the city, according to CDC and state data.

The death rate remained relatively low until the mid-2010s, when fentanyl flooded illegal drug markets across the country.

Dealers began spiking heroin with fentanyl, which is up to 50 times more potent and can be manufactured from cheap chemical compounds. They also began mixing fentanyl in cocaine, pressing it into fake prescription pills and selling it on its own. Drug-testing data shows that it is now all but impossible to buy illegal opioids in Maryland that have not been mixed with it and other dangerous additives like xylazine, which makes naloxone — the generic name for Narcan — less effective. These days, heroin is rarely found.

Because fentanyl is combined with other substances, the distribution of the opioid’s granules is uneven. One hit may be just enough to get high. The next could be deadly.

In 2010, the overdose death rate was near a 20-year low: 29 deaths in the city for every 100,000 residents. By 2015, the rate had doubled, then doubled again three years later. By 2021, it was 190 per 100,000, and three people were dying on average every day.

Years of Tumult

Alarmed by rising overdose deaths in 2014, Mayor Stephanie Rawlings-Blake created a task force to plan a response.

The city’s health commissioner, Dr. Leana Wen, widely distributed Narcan before it was available without a prescription, and the Health Department trained police officers and the public in how to use it. The department also opened a “crisis stabilization center,” a place to find help after an overdose. It created an alert system to send aid groups to overdose clusters and piloted a “real-time capacity tracker” to help patients and doctors find open treatment slots.

The city issued detailed plans and prioritized public awareness. One effort, promoted on billboards and bus stops, was a website called DontDie.org, designed to “knock people over the head” about the risk of fatal overdoses.

Even then, coordinating a response across city agencies was difficult, said Amanda Latimore, a Health Department public health researcher at the time.

The city’s Law Department was resistant to agencies sharing overdose data, she recalled, sometimes citing the Health Insurance Portability and Accountability Act, or HIPAA, the federal law that protects patients’ medical information. Assembling the data she needed to understand trends in overdoses and treatment took “almost an act of God,” she said, and happened only because Wen and her team had a nearly singular focus on the topic.

As overdose deaths continued to accelerate, the next mayor, Catherine Pugh, drew criticism when she objected to the proliferation of treatment centers within neighborhoods.

Wen left the agency in October 2018. Pugh resigned the next year in a corruption scandal, the second mayor criminally charged in a decade.

By the time Scott was elected, in November 2020, an interim mayor had been in place for a year, and the COVID pandemic was in full force. Scott, previously City Council president, had for years pushed for supervised drug consumption sites as a way to prevent overdose deaths. They have never been approved in Maryland.

Baltimore also had one of the country’s highest homicide rates, and Scott’s administration prioritized reducing shootings. (When homicides fell by 20% last year amid a national decrease, Scott credited his administration’s efforts.)

While there were three times as many drug deaths as homicides, some of the overdose initiatives began to fade away during those tumultuous years.

The capacity tracker was hardly used: Only 6 out of 160 addiction service providers ever posted their wait times. The city now says the effort has been abandoned.

So has the “Don’t Die” public awareness campaign. The website stopped working sometime around February 2023, according to the Internet Archive. At some point, the Health Department stopped updating the overdose pages on its website altogether and did not resume for years.

Scattered Efforts

Baltimore’s overdose response involves a number of city agencies and community groups, many of which receive government funding. Emergency workers rush to scenes of suspected overdoses and revive thousands of people every year, with a special crew giving Narcan and pamphlets to people they find nearby. Johns Hopkins doctors run a mobile medical clinic out of a van in collaboration with the city.

The state and federal governments spend hundreds of millions of dollars each year combating drug addiction in Baltimore. Medicaid’s annual spending on treatment programs grew significantly in recent years, reaching $245 million last June.

A publicly funded nonprofit whose board is led by the city health commissioner, Behavioral Health System Baltimore, or BHSB, also gave out more than $50 million a year in grants for drug and mental health treatment, with most of that money coming from state and federal funds. The organization said it did not track its addiction and mental health spending separately, because services overlapped. But a Times/Banner analysis shows that its spending earmarked for drug treatment dropped by about $5.5 million from 2019 to 2023, though some of the decline was explained by Medicaid beginning to cover certain services.

The job of coordinating all these efforts belongs to the city Health Department. The department runs the state-mandated Overdose Prevention Team, which is tasked with sharing data, identifying problems and developing a citywide strategy. The group cut back to meeting just a few times a year. In 2020, it released a three-year plan that it described as “intentionally brief,” given the pandemic. One goal: Become “more action-oriented.” Another: List the ways people could get Narcan. Since then, it has not published updates or a new plan.

In a statement, the Health Department said the committee had working groups that met more frequently but declined to say how often, or which goals it had achieved, citing the lawsuit involving the pharmaceutical industry.

The 900-person department itself had only three full-time positions in 2022 to work on drug addiction and mental health, which doubled to six in 2023 with state funding, according to budget documents.

The city pays for just one of those positions. It spends very little of its revenue on the Health Department’s mental health and addiction budget: a yearly average of $1.5 million since 2016. (In a statement, the mayor’s office said this figure did not include the cost of overdose prevention programs run by other agencies or other parts of the Health Department. The staffing figures would also not include employees working on those programs.)

The department last presented data on overdose deaths to the City Council in 2020. The numbers it showed then were from 2017 and 2018, when the fatality rate was one-quarter less than it is now.

Dr. Letitia Dzirasa, a deputy mayor who had been health commissioner from 2019 to 2023, said she knew the rate in Baltimore was the highest in Maryland and higher than in other large cities in the region but did not know its ranking nationally among all counties. Her successor, Dr. Ihuoma Emenuga, declined repeated interview requests.

The number of patients in the city’s public treatment system, which helps poor and uninsured people with addiction, dropped by almost 5,500, or 16%, in 2023 from 2020, even as the amount of money being spent on it soared, according to state data. The number of Medicaid patients on drugs that treat opioid addiction, long a staple of Baltimore’s response, also fell by thousands.

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

The number of people being revived from overdoses annually by emergency workers dropped by nearly 1,000 in 2023 from 2018, while deaths rose significantly.

Herrera Scott, the health secretary, said Maryland’s overdose response needed to be based on a sophisticated understanding of the data. She acknowledged the department had had challenges with data sharing previously but said the state was now using data to better target its efforts and planned to start publishing information about deaths in specific neighborhoods.

In his annual State of the City address in March, Scott said he was creating an overdose prevention Cabinet. His administration, which announced the plan after reporters began asking city officials about overdoses, provided few details, except that the Cabinet would include top city leaders.

This article originally appeared in The New York Times .