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Scoring Data Points

Baltimore’s Drug Treatment System is a Model—But No One Knows How Well It Works

Christopher Myers
FUZZY MATH: City Health Commissioner Joshua Sharfstein says that drug-overdose deaths in the city are at a 10-year low, though he admits that the numbers can be difficult to pin down.

By Edward Ericson Jr. | Posted 6/14/2006

Baltimore threw a party last week to celebrate its progress curbing drug addiction, and Mayor Martin O’Malley was front and center, basking.

“Give him another hand,” Denver Mayor John W. Hickenlooper implored the crowd of 400 or so drug-treatment specialists sipping wine and coffee in the Corinthian room of the Tremont Grand Hotel. The event was not called a party; it was the “opening plenary session” of a two-day drug-treatment conference called Cities on the Right Track: Building Public Drug Treatment Systems. Sponsored by the Open Society Institute (OSI), whose founder, George Soros, pledged an additional $10 million in drug-treatment money on top of the millions he’s already given, the conference attracted drug-treatment practitioners and policy-makers from across the country, according to OSI.

But the opening felt like a campaign rally, complete with political endorsements. Hickenlooper credited O’Malley with inspiring a “whole generation” of city mayors, echoing the statements of the other two mayors onstage—Buffalo, N.Y.’s Byron Brown and Providence, R.I.’s David Cicilline. Brown used the word “CitiStat” about 25 times in his opening remarks, referring to Baltimore’s highly touted computerized city services management tool, which came in response to a question about what illegal drugs are most popular in his city (eventually he divulged that Buffalo’s drug of choice is crack). Brown also pledged to borrow “drugstat”—O’Malley’s system of tracking drug-treatment outcomes—and apply that to Buffalo as well.

There is no doubt that O’Malley targeted drug addiction when he became mayor, and he has presided over an impressive increase in drug-treatment budgets and what many regard as improvements to the system of treatment services—expanding them to include help finding housing, for example, and jobs. The system combines traditional therapy and/or methadone maintenance with so-called “wrap-around” services designed to get recovering addicts back into society.

But the statistics released with fanfare at the beginning of the conference are, like the mayor’s crime statistics, impossible to verify—and subject to multiple interpretations. According to the Baltimore City Health Department, funding for drug-treatment services increased from $17.7 million in 1996 to nearly $53 million in 2005. The money increased the number of drug-treatment “slots” from 5,136 in 1996 to 8,295 last year. And during that time, the number of Baltimore residents who died from drug overdoses decreased, from 328 in 1999 to 218 in 2005.

“These new data show again that drug treatment saves lives,” said Baltimore Health Commissioner Dr. Joshua Sharfstein, in a June 6 press release. And, indeed, that was the message trumpeted by The Sun and USA Today: Treatment works, and Baltimore needs millions more dollars for it. None of the news outlets reported footnote No. 2 of the city Health Department’s two-page statistical “snapshot,” which says, in part, that “the methodology for counting deaths that took place in Baltimore changed over the last decade.”

Actually, the methodology changed about two weeks before the conference, after Sharfstein, who O’Malley appointed last November, asked state Chief Medical Examiner Dr. David Fowler to provide data on drug-overdose deaths in Baltimore since 1995.

The Maryland medical examiner’s office had been providing these statistics monthly for many years, Fowler says. But the old method might have undercounted the occasional overdose death that came near the end of the month, because the statistical report would be generated and sent to Baltimore before the cause of death had been determined, he says.

The new numbers counted all deaths, but then—at Sharfstein’s request—excluded deaths due to alcohol. “This is just the way we wanted to do it based on the overall sense of the drug problem,” Sharfstein explains, “for this particular purpose.”

Fowler says alcohol deaths numbered only a few each year on average.

Also, the database manager took pains to not count the heroin overdoses of out-of-towners. “If we did it by jurisdiction—place of death—people from Baltimore County will get pulled into the city,” Fowler explains. That would increase Baltimore City’s death rate, possibly making the expensive upgrades in drug treatment appear ineffective.

“Everybody knows that the easiest place to find drugs is Baltimore City. And that unfairly loads Baltimore City with drug deaths,” Fowler says. “So what was done here—we wanted to look exclusively at those who would be entitled to services by Baltimore City. We thought that was a fair reflection of their responsibility.”

Fowler says he doesn’t know what the death rate would be if the deaths were tallied according to where they occurred, but he says homeless people and those with no fixed address do not skew the results much.

And he says he doesn’t know how the “methodology for counting deaths” changed.

“I honestly don’t know exactly what the query was before,” Fowler says. “What I do know is, we would supply the deaths to the [city] Health Department and the Health Department would occasionally come over and pull the information.”

Fowler turned down City Paper’s request to talk to the database manager, saying the person who used to be in that position was recently replaced. And no media outlet will be allowed to examine the raw data, Fowler says—because doing so would be illegal. “Under Maryland law,” Fowler says, “the database is a confidential medical record.”

Armed with the exclusive new data, Sharfstein and O’Malley claimed that drug overdose deaths of city residents have fallen to a “10-year low,” dropping nearly 34 percent. The decrease in deaths was 11 percent just from 2004 to ’05, the data show.

“A decade ago, many people thought it was impossible for Baltimore to make progress in the fight against drug addiction,” O’Malley said—both in the Health Department press release and at the dinner at the Tremont Grand. “Today, the entire nation can see that our investment in drug treatment is paying off.”

But the data also show this: In 1996 drug overdose deaths in the city numbered about 240—fewer than the 244 deaths in 2004. Yet drug-treatment funding began increasing in 1996, from about $17.7 million that year to $60.3 million in fiscal year 2003, which ended in July 2004.

Sharfstein says he doesn’t know why the numbers don’t track better, but that the major funding increases began in fiscal 2001, when it increased from about $25 million to about $45 million. “The ramp-up of the drug-treatment system hasn’t been over the whole period here,” he says. “The way I look at it is things were still getting worse [in the late 1990s]. And it’s fair to say there were other factors,” such as occasional batches of unusually potent heroin.

Even so, the city Health Department’s new figures downplay such complicating factors in favor of the simple story: Drug treatment saves lives. In that, the week’s conference and festivities continue a tradition of using malleable drug-addiction statistics for specific, sometimes conflicting purposes—such as increasing funding for treatment or celebrating “success”—rather than measuring long-term efficacy. In Baltimore, this tradition goes back decades, beginning with the city’s alpha statistic: 60,000.

The number of drug addicts in Baltimore City is usually estimated to be 60,000, or nearly one out of 10 residents. That alarming estimate has held steady since the early 1990s. It was used by mayors Kurt Schmoke and O’Malley to scare up more money for drug treatment, and was cited by The Sun again last week to call for increased drug-treatment spending.

But if there were 60,000 drug addicts in Baltimore in 1990, when the city’s population was 736,000 and there were few drug-treatment slots, and there are still 60,000 drug addicts in 2006, when Baltimore’s population is less than 650,000 and there are more than 8,000 drug-treatment slots, then how effective is drug treatment?

Sharfstein estimates the number of addicts at 50,000, adding quickly that the estimate is “not particularly scientifically valid” and that the actual number is unknown. He cites a Sun article published last August that debunked the 60,000 number while raising questions about other drug-addiction statistics. “The 60,000 estimate has been built on hazy projections and on misinterpretations of researchers’ findings, a review of its sources shows,” according to the story, by reporter Alec MacGillis.

But whether the number is 50,000, 60,000, or something else, drug-treatment programs measure their success not by reducing the population of people who are using illegal drugs but by the number of days each addict uses illicit drugs.

That’s because many addicts keep using illegal drugs even while in treatment and most return to drugs afterward. So the standard measure of success is the reduction of days of drug use each month.

Sharfstein says this measure makes sense: “The amount of illegal drug use is a really important outcome in treatment,” he says. “If you’re paying $500 a day to feed a heroin habit, a 10-day reduction [in days of heroin use] a month is $5,000 you don’t have to steal. It’s a big impact on illegal activity. It’s a big impact on [the patient’s] ability to function.”

Sharfstein, who before becoming health commissioner worked on the staff of U.S. Rep. Henry Waxman (D-Calif.) for four years, downplays the political utility of his statistics. He says the other mayors’ effusive praise for O’Malley was genuine. “What was really obvious to me—you got mayors around the country who consider Martin to be a model,” Sharfstein says. “I’ve not been here that long, so I’m just dealing with the mayor as the mayor. I’m not dealing with Martin as a guy who was doing this before anyone else.”

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