In Rural Maryland Counties, Communities Fight Back Against the Opioid Crisis
In the face of the opioid crisis, rural counties in Maryland are relying on a regional source of strength: the durable bonds of community.
Some folks still call Kevin Simmers “Sarge”—a nod to his 30-year career as a Hagerstown, Maryland, policeman. No longer in uniform, Simmers can be found most days overseeing the construction of a 16-bed rehabilitation facility rising just outside the county seat of 40,000 where he once kept the peace. When not on site wrangling contractors amid the din of power tools, Simmers is busy chasing down donors to help fund this nonprofit project he’s spearheading.
It’s not the retirement he expected. But then, Brooke’s House, as the facility will be called when it opens by year’s end, is named after his 19-year-old daughter, whose multi-year struggle with opioid addiction ended in a fatal overdose in 2015. “She was at a church where she used to play basketball as a kid—dead in the back seat of her car,” Simmers says.
This was not the fatherhood he expected, either.
The athletic, blond policeman’s daughter—who’d been taken to antidrug lectures since she was 5—began abusing prescription painkillers in high school. And when they became harder to come by, she, like so many others swept up in our national opioid epidemic, turned to a ready replacement: heroin.
“She was prostituting and stealing and embezzling—doing it all to support that habit, but she legitimately wanted to get off heroin,” Simmers says. The family desperately wanted her off, too. But how and where? There were no safe, long-term facilities in the area, and the few hardscrabble halfway houses Simmers looked at, he says, catered to men and “were not the kind of places you’d feel comfortable dropping off a teenage girl.” Too late to save Brooke, he hopes her namesake home will provide a lifesaving space for women with addictions to get treatment.
Simmers admits that he first joined the force as an eager foot soldier in the War on Drugs. “I believed arrests and incarceration were the answer to this problem,” says the former member of the Hagerstown Narcotics Task Force. But all that’s changed. “We have to treat addiction as a health issue,” Simmers says.
“It’s inhumane to just lock someone up for suffering from a disease.”
A Double Threat
Opioids now kill more Americans than car crashes. More than firearms. And more than breast cancer. Brooke Simmers was one of the 1,089 Marylanders who died of an opioid overdose in 2015 and among the more than 33,000 nationally, according to the CDC. In 2016, opioid-related deaths in the state rose 70 percent to 1,856, and in 2017 the number of drug- and alcohol-related intoxication deaths reached an all-time high of 2,282. Part of this troubling trend is the increased appearance in Maryland of fentanyl, a synthetic opioid that’s up to 50 times more potent than heroin—as little as the equivalent of a few grains of table salt can be a lethal dose. During this same two-year period, fentanyl deaths more than tripled in the state.
Hagerstown is some 75 miles northwest of Baltimore, where Danielle German, PhD ’09, MPH, an associate professor in Health, Behavior and Society at the Bloomberg School, has been interested in the public health approach to drug use for more than two decades. Her particular focus is on the nexus of drug use, sexual behavior and the spread of HIV. Since 2009 she’s been the principal investigator for BESURE Baltimore, the city’s branch of the CDC’s National HIV Behavioral Surveillance project. This project monitors trends in HIV prevalence and related social and behavioral factors to inform a comprehensive public health response. (Annual new HIV diagnoses in Baltimore, while still troublingly high, have been cut in half since 2008.)
Since 2017, supported by a $150,000 grant from the NIH Centers for AIDS Research, she has also begun looking beyond the city to focus on the opioid crisis unfolding in Washington, Allegany and Garrett counties in rural western Maryland. “We wanted to see if there was a way that we could do some similar work to support some other underserved communities,” German says, noting that the nonprofit Maryland Association of County Health Officers and colleagues at the Maryland Department of Health steered her and her co-investigators—Sean Allen, Oluwaseun Falade-Nwulia, Carl Latkin, Susan Sherman and doctoral student Laura Kroart—toward the state’s Appalachian quarter as a place that would welcome the help. “We want to inform the overall public health response related to opioids, and overdoses in particular. But there is also a strong motivation to be in front of what we need to understand in order to prevent the potential of an HIV outbreak or continued hepatitis C transmission.”
Maryland’s mountainous stretches have certainly not been spared by the opioid crisis that has been devastating much of rural America. Between 2007 and 2016, the number of heroin-related deaths rose faster in the state’s three Western counties than in metro Baltimore. Washington County had one fentanyl-related death in 2014. By 2016, that number had risen to 31. And what everyone hopes to avoid is what happened in rural Scott County, Indiana, three years ago, when there were more than 180 new HIV diagnoses in a single summer—largely the result of intravenous drug users sharing needles in a setting with limited prevention services. And the drug epidemic is unfolding here against a backdrop of economic decline now decades old as industries have folded or moved away. Hagerstown’s poverty rate is worse than Baltimore’s. In Cumberland, nearly one in four residents lives below the poverty line.
State lawmakers have been addressing the opioid crisis with a number of laws aimed at harm reduction. In 2015, for instance, the state passed a good Samaritan law that protects people who call emergency services when someone is overdosing from facing criminal charges, even if responders find them in possession of drugs or drug paraphernalia. Since 2016, jurisdictions statewide can now apply to set up needle exchanges where intravenous drug users can drop off used needles and acquire new ones. Previously, only Baltimore City had such exchanges; Washington County has such a system now. And in June, the injectable opioid-blocking drug naloxone (trade name, Narcan), which can reverse overdoses, became available at pharmacies without a prescription. With this drug and a little training anyone can be in the position to save the life of someone actively overdosing.
“Our first goal is to build community relationships and understand the current response landscape,” German says. “So, who are the drug treatment providers, and who are the people engaged in any infectious disease or overdose prevention–type work—community agencies and advocates and health department stakeholders.”
German’s community collaborators now include Simmers and his emerging women’s rehab facility and Jim Raley, executive director of the Office of Consumer Advocates, a peer-support mental health nonprofit organization that provides addiction recovery services in Hagerstown, Cumberland and Oakland. “We deal with a sizable homeless population here in Hagerstown, which just compounds the dynamic of substance abuse,” Raley says from his office in a Hagerstown rowhouse, where the halls brim with boxes of canned goods to support a food pantry. “Drug abuse, homelessness, poverty—all those things combine to make it kind of a whirlwind here most days.”
Raley is relieved that his county has set up a needle exchange. He knows the HIV risk is real and recently added monthly HIV screenings to his services. But his group’s main struggle is with the opioid epidemic itself and the lack of resources on hand to battle it.
“If someone walks through my door today and says, ‘I’m ready. I can’t do this anymore...’ I don’t know if I can help them right away,” Raley says. “And if I can’t, by tomorrow they’ve changed their mind because it’s easier to go back out and use.”
German says she is interested in understanding the “social and geographic context of opioid injection and potential HIV transmission” in the region—who is using, and where, and how. A pilot biobehavioral assessment is underway that will include qualitative interviews with 150 or more opioid users. This effort is being led locally by Stephanie Hutter Thomas, PhD, program manager for Conquering Opioid Abuse Together, an AmeriCorps outreach initiative of Frostburg State University. This summer she was hired by the Bloomberg School as German’s project coordinator. “We hope to build a large collective sampling of the individuals that are active in their addictions right now,” Hutter Thomas says. “We want to know whether or not they’re practicing safe sex, whether or not needles are being reused, things like that. And, initially, the question is going to be, How much are needles being used at all, because there are a lot of people that are heavily addicted and they’re doing everything but injection.”
The pilot study is using a peer-referral approach, wherein a handful of opioid users referred by area service providers will be surveyed initially. Then, with a supply of coupons that active drug users can exchange for financial compensation for participating, they will go out to the community to encourage other users to come in as well. This approach worked well for BESURE in Baltimore, but its effectiveness in a rural Maryland setting is untested.
As German familiarized herself with her new environment—swapping city blocks for winding mountain roads—and met the dedicated service providers operating on shoestring budgets out of small-town offices, she became inspired. “It’s a different service landscape in terms of what people have access to, but there really are just so many strengths,” German says. “There’s just a lot of richness in the communities in terms of how they really care about who’s having struggles that’s been really amazing to see.”
An example might be Boonsboro resident Debbie Fling.
“It’s not a crisis—it’s a pandemic,” she says of opioids.
From her small town just south of Hagerstown, she watched her two sons, one of whom is now incarcerated, become addicted to heroin. But instead of getting sad or mad, she got busy. Fling is now a member of Maryland Heroin Awareness Advocates, a nonprofit support and education resource run by and for families impacted by heroin addiction. She is also involved with Justice and Recovery Advocates, which does similar work focused on families whose loved ones have been incarcerated for drug offenses while also promoting better mental health and recovery services in prisons. And two years ago, she launched Save Our Children Boonsboro, whose peer-support meetings in a church every other week bring together people whose lives have been affected by opioid use. All these volunteer duties are tantamount to a second full-time job.
"I LITERALLY FEEL LIKE NOW YOU COULDN’T FIND A PERSON IN CUMBERLAND WHO IS NOT SOMEHOW IMPACTED BY THE OPIOID ISSUE. EITHER THEY LOST SOMEBODY OR THEY HAVE AN EXTENDED FAMILY MEMBER OR A FRIEND STRUGGLING. WE ALL FEEL IT."
“My eyes were really opened with my sons’ addiction,” Fling says. “I just decided that I had to be a part of the solution to the problem we’re facing and figure out what I could do to bring awareness and provide support.”
Though the three counties combined have less than half the population of Baltimore, and stretch more than 120 miles east to west, German has found that, in terms of rallying around the cause, they may be an even more tight-knit community than Baltimore. “There are strong and meaningful social interconnections across the region that really stand out,” says German, who began wondering how else she might contribute.
Her answer came earlier this year when she won a Johns Hopkins Catalyst Award of $75,000 to expand her work in the region in two areas: first, to assess the need for gender-specific services and harm-reduction approaches (some of the issues Kevin Simmers encountered and is addressing); and second, to further explore how social and community relationships might be used as supportive resources for opioid risk reduction.
The drug pandemic—to use Fling’s term—has really spared no one. “I literally feel like now you couldn’t find a person in Cumberland who is not somehow impacted by the opioid issue,” says Hutter Thomas. “Either they lost somebody or they have an extended family member or a friend struggling. We all feel it.”
But how might you empower the harm-reducing capabilities of family, friends, colleagues and acquaintances—especially when naloxone is readily available? “There’s not a lot of guidance out there beyond making sure that everybody has a hotline number or knows how to enroll somebody into a recovery program, which is not always the easiest thing to do,” German says. “But what happens if somebody continues to use or isn’t ready to stop using? In addition to having naloxone on hand, how else can parents and the general public be supportive and help keep someone safe? We’ll be talking to users and nonusers to understand from their perspective what is working and what’s not working or [is] challenging.”
“Professor German exemplifies how careful research can lead to new insights and partnerships that produce effective responses and save lives,” says Joshua M. Sharfstein, MD, director of the Bloomberg American Health Initiative, which aims to tackle challenges to public health, including addiction and overdose. “Her efforts are part of a large number of projects at the School aiming to make progress against one of the most serious public health crises of our time.”
THERE’S NOT A LOT OF GUIDANCE OUT THERE BEYOND MAKING SURE THAT EVERYBODY HAS A HOTLINE NUMBER OR KNOWS HOW TO ENROLL SOMEBODY INTO A RECOVERY PROGRAM, WHICH IS NOT ALWAYS THE EASIEST THING TO DO. BUT WHAT HAPPENS IF SOMEBODY CONTINUES TO USE OR ISN’T READY TO STOP USING? HOW CAN PARENTS AND THE GENERAL PUBLIC BE SUPPORTIVE AND HELP KEEP SOMEONE SAFE?
Rolled-up Sleeves and Resilience
Cumberland’s nickname, “The Queen City,” dates back to its industrial and transportation heyday before protracted economic decline set in after World War II. It was an early stop on the National Road, the first federally funded highway project, and is connected by the Chesapeake and Ohio Canal. It prospered from its proximity to coal mines, and glass, auto tire, brewing and textiles were among the major industries. But what was once the state’s second-largest city after Baltimore has seen its population plunge to below 20,000—half of what it was in 1940.
Cumberland’s mountain-encircled setting remains dramatic, and on a warm summer day, its downtown brick pedestrian mall—with flower boxes overflowing with blooms and sidewalk cafes bustling with diners—can be a pleasant place to visit. But you see things a little differently when your tour guide is Allegany County native Susan Stewart. She’s executive director of Maryland Area Health Education Center (AHEC) West, a Cumberland charity working to improve regional access to health care and one of German’s partners.
“All these buildings used to be department stores, and the upper floors are mostly vacant now," Stewart says, motioning above the diners and the flowers. “We’re the second-largest employer here on the mall, and we only have 21 employees.” The far end of the mall, where the cafes are gone and the storefronts blank, has become a desolate area that draws homeless opioid users. A McDonald’s franchise across a parking lot, Stewart says, is known for having “at least one overdose a week.”
Yet folks here are open to small-scale, alternative approaches to its health challenges, such as Stretching to Empower, an AHEC West program that provides free yoga and stretching classes for women in local public housing. “It’s a means to empower women and give them an alternative therapy to deal with pain or prevent pain,” says Jen Thomas, who coordinates the program. “There is also the whole meditative, calming aspect of it—de-stressing—while also being a source of connectedness among women.”
In Hagerstown and across the three counties, the fight goes on. “We come together and roll up our sleeves out here,” Stewart says. “There is not a distrust of one another or a lot of competitiveness among service providers. When there’s money available, we come together. Some get in the game with no money. I know at least one local lady that lost her daughter to an overdose and she opened her home to help others—all on her.”
For her part, German views her work to date as “foundation building” for an open-ended commitment. She plans to be driving west on I-70 for some time to come. She also continues to be involved with Baltimore’s BESURE project, where research activities also include multiple vans providing mobile services such as on-the-spot HIV testing, counseling and free condoms and health resources. Just what sort of interventions might be put in place in the state’s western half are not yet known.
“I think it’s clear that there’s continued work to be done in both settings,” German says. “I’ve been really loving the engagement in the western Maryland region. It’s a different scale and different scope of work. But it’s hard to imagine pulling out of Baltimore. I think that there is actually quite a lot to learn in parallel.”