Saving lives is the top priority of a Baltimore drug treatment program that doesn’t require abstinence

Anthony Kelly walked with difficulty in southwest Baltimore, each step a painful reminder of the roofing accident that happened years after he returned from serving in the Marines. Doctors used metal plates to reconstruct his lower legs and it took him months to learn to walk again. However, this marked the beginning of his struggle with substance use disorder, which gradually weakened him physically and mentally. He lost touch with who he used to be: a supportive spouse and parent, a dedicated professional, and a proud veteran.

When his prescribed painkillers were no longer enough, Kelly made multiple trips to Florida to take advantage of its loosely regulated pain management clinics. Eventually, he turned to a combination of heroin and cocaine that cost up to $500 per day.

Anthony Kelly’s substance use disorder is now more manageable and less expensive than it was a decade ago, but it still has a significant impact on his life. To help manage his addiction, he takes buprenorphine, which is considered one of the most effective medications for treating opioid addiction because it reduces cravings and alleviates withdrawal symptoms.

Kelly obtains his medication through a mobile health clinic that is located in a renovated van. The clinic provides care to patients in some of Baltimore’s most drug-affected areas, including Kelly’s own neighborhood. Doctors and nurses offer consultations, write prescriptions, provide basic wound care, and administer treatments for conditions like hepatitis C. The clinic also distributes packages of naloxone, an overdose reversal medication, free of charge.

The mobile health clinic that provides free addiction treatment, including the distribution of buprenorphine and naloxone, exemplifies a shift in the country’s approach to addressing overdose deaths. The COVID-19 pandemic led to a surge in overdose deaths as fentanyl became increasingly prevalent and replaced heroin in many drug markets.

The harm reduction model is an approach endorsed and funded by the Biden administration, which offers potentially life-saving services to opioid users without requiring abstinence in return. Supporters argue that it prioritizes saving lives while acknowledging the debilitating challenges associated with recovery. Some critics, however, argue that this approach condones illegal activity.

According to clinic staff in the “Healthcare on the Spot” program in Baltimore, where patients receive addiction treatment and other healthcare services through a mobile health clinic, many patients continue to use street drugs, although most of them report using less. This suggests that the harm reduction model employed by the program may be effective in reducing the harms associated with drug use.

However, as Anthony Kelly, a patient of the program, points out, addiction is a complex issue that cannot be solved overnight. It involves social, psychological, and environmental factors that contribute to the development and maintenance of substance use disorder. Recovery from addiction usually requires comprehensive, long-term care that addresses not only physical symptoms but also underlying causes and co-occurring mental health conditions.

Baltimore has a significantly higher overdose death rate than the statewide and nationwide averages, with more than 1,000 lives lost in 2020. Despite efforts to address the problem, including expanding access to naloxone, reducing low-level narcotics arrests, and launching needle exchange programs, large-scale change has been slow to come.

Moreover, the city’s overdose crisis underscores the need for a comprehensive, evidence-based approach that recognizes addiction as a chronic illness rather than solely a criminal justice issue. In addition to harm reduction services, such as needle exchange and naloxone distribution, comprehensive care should include medications for addiction treatment (MAT) like buprenorphine and methadone, behavioral therapies, and support services addressing housing and employment needs. Parked outside the local jail, another mobile treatment program offers buprenorphine prescriptions to individuals upon release, an approach reflective of the benefits of medication-assisted treatment.

Dr. Letitia Dzirasa, the former health commissioner of Baltimore, suggests thinking about harm reduction on a spectrum where individuals may want to stop using substances entirely or use them in a safer manner. This approach meets people where they are and helps reduce the stigma surrounding addiction by recognizing it as a disease rather than a moral failing. Stigma reduction is particularly important since it can prevent those who need help from accessing necessary care and perpetuate a harmful cycle of shame and blame. Medical professionals and policymakers should prioritize creating a comprehensive system of support that empowers individuals to choose what works best for them while addressing the underlying social and structural determinants that contribute to the overdose crisis.

The Spot van is a mobile clinic that provides a confidential and non-judgmental space for individuals seeking medication-assisted treatment (MAT) for opioid addiction. The van is equipped with two exam rooms, a waiting area, and a bathroom. Medical providers at the clinic take an empathetic approach, treating patients like old friends and addressing everything from medical issues to mental health concerns, family dynamics, housing conditions, and long-term goals.

The clinic partners with various pharmacies across the city to enable patients to fill their prescriptions immediately after leaving the van without requiring ID or health insurance to enroll. To continue receiving buprenorphine through the clinic, patients only need to show that they are taking the medication on a regular basis. This low-threshold approach is critical in that it facilitates better access to care for those who might otherwise face obstacles to treatment, whether related to cost, fear of stigma, or other factors. It also reflects harm reduction principles by recognizing that a continuum of care is necessary to address addiction as a chronic illness.

Buprenorphine, available under the brand name Suboxone, is a medication used to treat opioid addiction that binds to opioid receptors in the brain without producing a euphoric high. Studies show that it significantly reduces the risk of overdose and death, yet only a small percentage of people with opioid addiction receive this treatment. Buprenorphine prescriptions can last weeks or months, offering a less regulated alternative to methadone maintenance.

Legislation passed in December 2022 has made it easier for doctors to prescribe buprenorphine, recognizing its potential to save lives amid widespread drug overdoses, with about two-thirds related to fentanyl. Patients at The Spot often seek treatment after getting tired of chasing fentanyl’s dangerous high and living in perpetual fear of withdrawal sickness.

Enrollment in the program does not require an ID or health insurance, but clinic staff struggle with how to best serve people who are not ready to stop using and may be profiting off their prescriptions by selling them on the street. Despite these challenges, The Spot’s low-threshold approach and harm reduction principles prioritize access to non-judgmental and confidential care for those seeking help with opioid addiction.

Kelly is a former Marine who grew up in Baltimore to Irish immigrant grandparents. He was drawn to adrenaline-fueled activities from a young age and joined the Marines after high school, serving for eight years and traveling the world. Through the military, he met his future wife, also a Marine, with whom he had a son.

After their marriage ended, Kelly’s ex-wife and their son moved to Florida, while he stayed in Baltimore and lived in his grandmother’s rowhouse which he eventually inherited.

During a recent visit to Kelly’s home in Baltimore, an unopened package of naloxone was found on the kitchen table alongside dishes, groceries, and a framed photo of Kelly as a teenager competing in a wrestling match. Kelly’s dog, Annie Oakley, is beloved and saved his life once by alerting a neighbor after he overdosed.

Though the rowhouse is well-maintained and filled with family memories, the interior is cluttered with sparse furniture. Kelly rents out rooms, sometimes to individuals struggling with addiction and looking for a place to stay. He has been dealing with pain and stress caused by a leg infection from a bike accident and a dispute with a former tenant, both common triggers of addiction.

Kelly is committed to doing right every day, but he acknowledges that it can be challenging.

Kelly’s face lit up when talking about his son, who is studying environmental engineering in college. He proudly showed a photo of him on his phone and said that his son was worth fighting for. Kelly reminisced about the time before his addiction when he was a hard-working father.

He wants people to understand the devastating effects of substance use disorder, where it slowly takes over your life until you hardly recognize yourself. Kelly likened the process to navigating a road full of IEDs, where you’re so focused on avoiding immediate danger that you don’t see yourself moving deeper into hostile territory.

Kelly tried taking Suboxone several years ago while visiting his family in Florida, hoping to avoid using heroin around his son. Although it reduces his opioid cravings, Kelly claimed that it dulls his senses and doesn’t provide much relief for the pain he still feels from his roofing accident. He needs something stronger to manage his pain.

Unfortunately, heroin and fentanyl are easily accessible in his neighborhood, which has been hit by increased poverty and population decline in recent years. Kelly acknowledged that he can’t entirely fault his surroundings for his addiction, but the availability of drugs in his area doesn’t make it any easier.

It is stated that every Monday morning, the Spot van parks in the Upton community of west Baltimore. This area has a rich history as a Black cultural center and was previously famous for its renowned jazz clubs, trendy stores, and lively nightlife.

The Upton community of west Baltimore is currently a shadow of its former self, with visible impacts of the local drug trade, such as drug dealers doing business outside vacant buildings, their customers nodding drowsily on public benches, stumbling through alleys, and struggling to find enough money to get through another day. To combat gun violence in these communities, Baltimore police cruisers routinely patrol the area near where the Spot van parks on Mondays. Unfortunately, even with increased law enforcement presence, there have been instances of gun violence, including a shootout in January that injured three people and resulted in the death of a young mother who was waiting with her children to pick up a takeout order just one block away from the parking spot. A tangle of deflated balloons serves as a memorial for the victims.

The location is frequently visited by Lenwood Johnson, who is 62 years old.

Lenwood Johnson, a former correctional officer at Baltimore’s jail, began using opioids years ago after his law enforcement career was derailed by an arrest for marijuana possession. However, after approximately three months on buprenorphine as part of the Spot program, developed through a partnership between the Baltimore City Health Department and Johns Hopkins University School of Medicine in 2018, he reported a significant reduction in his opioid use. As a result, Johnson now has more money and is able to stay sober during family visits and other important occasions, while also taking fewer risks with fentanyl due to a decreased need to maintain a consistent supply. The program typically serves around 900 patients each year, with roughly 40% having a recent history of intravenous drug use, nearly 75% identifying as Black, and over half experiencing homelessness or housing instability.

Dr. Kathleen Page, a professor at Johns Hopkins medical school who helped establish the program, stated that many of the people the program serves are deeply underserved and lack trust in the healthcare system. As such, building trust is a critical aspect of the program’s success. Darryl Jackson Sr. and his adult son enrolled in the program last year and have found it to be a stable presence in their lives. Jackson recently had to move out of his previous apartment and is now researching rental assistance programs, which are often weighed down by bureaucracy and long waitlists. Although he spent much of his career in construction, he still dresses in canvas work pants and sneakers, but struggles internally with addiction and feelings of hopelessness. He returned to the Spot van after missing some appointments.

The program staff at the Spot clinic provides a caring environment for participants facing daily challenges, such as Darryl Jackson Sr. and other patients who struggle with drug addiction, poverty, and violence in Baltimore’s poorest communities. The clinical chief, Dr. Amanda Rosecrans, acknowledges the difficulties faced by patients and the need for stable housing, while also mourning the loss of patients to overdoses and gun violence. The program’s medical director, Bobby Harris, emphasized the importance of stabling housing, as it is critically important to recovery and helps patients feel safe in their surroundings.

Islah Hadith, 45, had struggled with opioid addiction after being prescribed Percocet for a broken ankle and began buying pills off the street. She felt ashamed when she first arrived at the Spot clinic in 2019 but left feeling hopeful after receiving treatment with buprenorphine and therapy. Over four years, she worked towards recovery and recently began reducing her medication doses to eventually wean herself off. Additionally, she severed ties with negative influences to maintain her progress, recognizing that it is a challenging but worthwhile journey towards a better life.

Kelly arrived at the clinic last month with a severely infected leg that had worsened over time, making it difficult for him to walk without a metal cane and causing him much physical pain. He appeared physically burdened and seemed to carry the weight of addiction on his shoulders. Despite this, he sought help and arrived at the Spot clinic for treatment.

Kelly acknowledged the intense pain he was experiencing, but smiled through it nonetheless. It’s possible that he was trying to maintain a positive attitude despite the discomfort. However, it is important to prioritize medical treatment and alleviate any physical pain in situations like these.

It’s great to hear that Kelly was able to spend time with his family and take a break from Baltimore, as this can provide a much-needed change of pace and renewed sense of hope. Planning for the future and setting goals, like moving to a new city or focusing on work, can also be helpful in providing a sense of direction and purpose.

It’s wonderful that Kelly has a support system he can rely on, and it’s understandable that he may worry about the impact his addiction has on his relationships. However, seeking medical treatment and committing to regular use of prescribed medication like Suboxone can be a crucial step towards recovery. Taking things one step at a time and prioritizing one’s health is commendable and can lead to positive changes in all aspects of life.