Baltimore is losing more people to drug overdose than ever before. Between 2011 and 2018, there was a 500% increase in the number of people who died of an overdose. This stunning rise has led city and state officials to increase funding and programming for overdose prevention. However, these efforts have not been able to adequately address the crisis. There is growing literature supporting the efficacy of harm-reduction strategies to minimize and prevent behavior with potential health risks.
Harm reduction includes policies, programs, and practices that aim to keep people safe and minimize death, disease, and injury from high-risk behavior, especially substance use. Harm-reduction services are open to all people who use substances, at any stage of their substance use. Despite the need for medical care, people who use drugs are often not engaged with the health system because of stigma, perceived discrimination in health care settings, negative attitudes of providers toward people with substance use disorders, and structural barriers to participate in services. These barriers to care perpetuate the poor health outcomes of people who use drugs.
In her November 2019 Abell report, The Whole is Greater than the Sum of its Parts, Natanya Robinowitz, executive director of Charm City Care Connection, examines how Barcelona, Spain, built a comprehensive network of care for people who use drugs and the lessons it offers Baltimore. In the 1990s, Barcelona had some of the worst health outcomes in Western Europe among people who use drugs, including the highest rate of HIV infection related to drug use. Through a significant investment by the city government and other stakeholders, Barcelona created a robust network of low-barrier services aimed at reaching people who use drugs and engaging them wherever they are in their drug use, in an effort to move people toward better health. Today, Barcelona serves as an international model of an effective public health system for people who use drugs, having greatly reduced rates of overdose and drug use-related HIV infection.
Charm City Care Connection
Charm City Care Connection (CCCC) was founded in fall 2009 by a group of students and community leaders concerned about health outcomes and life expectancy among East Baltimoreans. CCCC began by assisting its clients with enrollment in health insurance programs; primary medical care management; mental health treatment; substance abuse disorder treatment; and access to resources such as food stamps, energy bill assistance, and job training. Recognizing and responding to the rapidly increasing overdose deaths among its clients who use drugs, and acknowledging the role of CCCC in addressing poor health outcomes in East Baltimore, its executive board elected to establish a harm-reduction drop-in center (HRDC) at its site on Wolfe Street. The HRDC was established in 2019 with support from the Abell Foundation. CCCC currently has two main programs:
- A harm-reduction drop-in center, which provides case management, health screenings, vaccine clinics, syringe services, fentanyl test strips, naloxone, suboxone treatment, hepatitis C testing and treatment, and peer support; and
- An outreach program, which connects with people who use drugs in all different settings including alleyways, abandoned houses, homeless encampments, and drug-selling areas to distribute sterile syringes and naloxone, build relationships, and connect people to CCCC services.
All of the HRDC services are easy to access and aim to reach people who are at the highest risk of overdose. In 2019, the HRDC had 2,702 visits. They worked with 207 unique individuals in case management; provided 653 individuals with sterile syringes; and distributed 4,110 doses of naloxone, 35,587 syringes, and 2,386 fentanyl test strips through its outreach. Among the people receiving naloxone, they had each witnessed an average of eight overdoses in the past six months. In 2019, CCCC received funding from the Maryland Department of Health to evaluate the HRDC efforts through the Johns Hopkins School of Public Health (expected completion in 2020).
In 2017, with funding from the National Institute of Drug Abuse, the Johns Hopkins Bloomberg School of Public Health opened a drop-in center for female sex workers in Southwest Baltimore, called the SPARC Center. Part of a federally funded research study on the needs of female sex workers, the SPARC Center and a companion street outreach project seek to identify and respond to the needs of the female sex worker population in Baltimore. Interviews conducted by the outreach workers with 385 women uncovered alarming rates of trauma, instability, and risk behaviors among this population: 67% have experienced homelessness in the past six months; 84% have used opioids and 58% report injection drug use in the past six months; 41% have been sexually assaulted by clients and 52% have experienced some type of violence at the hands of their clients; 52% report symptoms of post-traumatic stress disorder; 46% report depression symptoms; and 43% reported that mental health was their most important health concern in the past six months.
In response to these needs, the SPARC Center has developed a range of services to address the challenges these women face, including: case management, testing and treatment for HIV and sexually transmitted infections, contraception and other reproductive health services, legal services, medication-assisted addiction treatment, and individual and group therapy. The SPARC Center also makes referrals to other agencies for additional services, such as employment, housing, and health care. Since it opened in November 2017, 420 women have visited the SPARC Center on more than 4,600 occasions.
On-site service providers address the needs of women in a convenient, safe, and nonstigmatizing environment, reducing the need for outside referrals and increasing likelihood of continued engagement in care and service utilization. SPARC employs people with lived sex work and drug use experience to conduct street-based outreach in the community, and peer navigation in the space.
In 2019, with funding from the Abell Foundation, the center was able to hire a full-time case manager to supplement the full-time social worker who serves as the center’s clinical director and previously provided case management as well as individual and group therapy. Since the case manager began in July 2019, case management visits have tripled, and daily attendance at the center has increased from an average of 20-30 visits to an average of 50-60 daily visits, with spikes as high as 80-100.
Information published March 2021.