Dr. Peter Beilenson, M.D. M.P.H. is Baltimore City’s former Health Commissioner.

Q: Is it fair to say drug policy is a priority for Baltimore?

It is probably the top priority along with universal health care for the health department.

If we are going to get to an absolute no drug use policy, I don’t think people should be arrested for possession. I think talking about legalization really marginalizes the issue. What former Mayor Schmoke and I have been talking about is medicalizing the problem. For those who are non-violent, drug-related offenders, by far the most important thing is getting them into good, long term treatment.

Q: Do you have role model cities? Where do your ideas come from?

It’s not rocket science. Back in 1994 I asked the mayor, or maybe he asked me, to put together a Mayor’s Working Group and we had drug policy reform minded people come, just for a summer, two or three times, and we came up with a consensus document. The bottom line is that they decided we should shift toward a public health model for non-violent drug offenders and that we need treatment on demand, which we define as having appropriate treatment available within hours of someone seeking it, within 24-48 hours. We really started putting our money where our mouth was around 1997, 1998.

Back then, we had 4,000 treatment slots treating 11,000 people a year. This past year we were at 9,000 slots treating 26,000 people. Our best estimate is that for treatment on demand we need to serve about 40,000 people in a given year, so we are about two-thirds of the way there. Our funding has gone from 22 million in 1997 to around 70 million. We think for treatment on demand we would need about 100 million.

Q: How would you characterize the role of needle exchange in Baltimore?

It’s us. We are the largest city-run needle exchange program in the country. Most other places, they are run by advocacy groups. Our tenth anniversary is this year. We are now at eight sites with two vans, having served 15,000 clients and we exchange 4 million syringes. We get thousands into treatment. To do it, we had to get an exemption from the paraphernalia law for the city within city borders. We went to the legislature and the governor supported it as well. The mayor and I threatened to start exchanging ourselves and we got the governor to flip. We exchange one for one.

There were two priority issues. One is a reduction in the spread of AIDS obviously. Johns Hopkins has been doing all of the studies with us and has shown overwhelming success. Of newcomers to the exchange, there is a 40% reduction in the spread of HIV for their non-attending peer group. It has clearly done its job at reducing HIV.

Secondly, it is to be a bridge to treatment. Typically, we reserve about 400 treatment slots for our needle exchange clients. We have gotten 3,000 in now. And these are the hardest to reach addicts in the city.

Q: How would you respond to lawmakers who doubt the legitimacy of your studies?

You hear lawmakers saying that? Are you playing devil’s advocate?... We do, we have studies, peer reviewed from Johns Hopkins. We have a built in control group. We look at live study clients who are matched demographically by age, sex, frequency and length of drug use, etc. The only variable is needle exchange. We have very good proof. Go on our website.

BSAS is very useful in that it doesn’t run any treatment programs. It only funds, monitors, analyzes, and holds accountable all of the treatment programs. It is not in the dual business like some health departments of running and funding programs.

Q: Are you aware of other cities doing things you would like to bring to Baltimore?

The Delancey Street model is a treatment model that trains people for jobs, but also runs businesses out of the residential center- a restaurant, auto mechanics, carpentry… As you progress through the system you start cleaning bathrooms, but then you pick a company to work for. You are trained like an apprenticeship. And it is all coupled with substance abuse treatment.

We just started a model like Delancey Street, called Jobs Housing and Recovery. It houses people while they are in recovery and we have a pest control business, catering, and a demolition type business. It is a residential treatment program and the goal of course is for them to move out of residential treatment as they recover, get housing, and have a job.

Q: Can women bring children?

We are just about to take on a women’s and children’s center which will have daycare for the women and help them line up with one of these companies.

This is one I am involved with outside of the health department, but there are programs in the city for women with children.

Q: What is going on with Narcan right now?

It is very cool. Chicago told us about it. It is also going on in New Mexico and San Francisco now and maybe the lower east side.

We have been having a lot of overdose deaths in Baltimore. There are actually more overdose deaths than homicides each year. And most of the homicides are related to drugs. We have done tons of outreach, but it has been a stubborn number, around 300 a year. These other places seem to have dropped overdoses around 20% a year with Narcan. Almost all of our overdoses have heroin involved.

I am actually the prescribing physician in this program. In other cities, they are often run outside of the health department. So it is under my license. We have a three hour training program for the individual and their shooting partner. They are often identified through needle exchange. They are taught CPR, how to identify an overdose, what to say when they call 911 because there is a fear they will be arrested, and then I come in and prescribe a vial of Narcan. In the first month we already had three saves. A couple other physicians rotate with me each Wednesday. In the first two months, we have already trained over 100 people.

We have an opinion from the Attorney General that as long as there is a relationship between the doctor and client it is legal. So far, it has been hugely successful. Narcan has no side effects unless you are allergic to it, which is very rare.

Q: Has there been community opposition to this?

None. We always work with the grassroots. Same with needle exchange, I did a lot of speaking before we introduced the bill. By that time, I had 60 letters of support from community groups. For our sites, we have always required any new community we go to, to unanimously support it. In ten years we have had eight phone calls, none of them in the last seven years.

Our needle exchange staff is fabulous. Two of the leaders have been there from the very beginning. The staff has grown from three people to fifteen and they are very good at doing community work. They are also the staff for the narcan program and the Directly Observed Therapy program for AIDS patients. We go seven days a week, twice a day and give them medications. We are one of two cities that have this kind of program. We have found that CD4 levels, among our 25 clients with two exceptions, have just shot up and the viral load has gone to zero in many. We would like to expand the program, but it is very expensive.

Q: What would you say to other health officials?

As long as you get community support and have grass roots support before you launch programs, it is clearly possible to offer a comprehensive and appropriate system of both drug treatment and harm reduction.

All of our programs have worked pretty effectively. They are very cost effective, 40:1. For every dollar we spend, we save forty.

Q: What has been the biggest hurdle while you have been here?

The single biggest has been, and still is, getting adequate funding. The cost effectiveness is so well shown. The RAND Corporation shows a seven to one benefit for drug treatment. Eighty-five percent of crime in our city is drug related and it is far cheaper to treat than incarcerate, yet we are still only two-thirds of the way there.

And the cost effectiveness is immediate- within that given year. Treatment works within six months. Cigarette smoking prevention programs save Medicare costs thirty years down the road, we can save incarceration costs right now. You’d think people would be willing to spend $30 million in order to save several hundred million the same year.

There are four different modalities: methadone, outpatient, residential, and adolescent. The executive directors are required to come to Drug Stat. If they are not meeting goals, they get decreased funding and possibly defunded. We have defunded six of our forty programs. We can show legislators the programs are highly accountable.

Q: Do you work with the police at all?

All the time. They have been extremely supportive. I go to roll call and talk to the police officers. The Commissioner has been supportive all along, but the real issue is how the street officers feel. They can do things to make it hard on addicts. As we hear about that from time to time, we will say something.

Q: What is addiction?

Addiction is using substances to a point where it so significantly affects your life that it affects your family relationships, job, ability to be housed. That is not an official definition, but to me, that’s what it is. I’ve never used anything. I haven’t even used cigarettes, but that being said, just because someone uses something once or occasionally, doesn’t mean they are addicted. We shouldn’t focus our resources on that and we clearly shouldn’t focus our law enforcement resources on that. I would define addiction as causing dysfunction.

Q: If someone develops an addiction it means they have broken the law, shouldn’t they be sent to jail?

Generally, if it is non-violent… no. Almost always no. It is a huge waste of time. The average cost for someone arrested for breaking and entering- an actual non-violent crime- and they need money for heroin, let’s say they stole six cell phones out of cars. They might plead out a three year sentence to one year. It costs $25,000-$30,000 for the bed alone in tax payer expense. That doesn’t cover police costs, court costs, prosecution costs. They almost never get treatment. There is a little treatment behind the wall, but not much. They are exposed to AIDS at very high rates, drugs and needles are brought in, they meet nasty, hardened criminals. Coming out a year later, you probably have the same drug addiction problem and you have a greater probability of having AIDS. Plus, you probably got some ideas from people you met about committing crimes and it is harder to get a job because you have a record now. As opposed to residential treatment that costs around $12,000 a year which has a success rate over 50%. It depends on how you define success though. At discharge, about 98% are clean, 55% or so have jobs, around 60% are housed. As for recidivism a year later, it is very hard to track, but I would say 50-60% are still not using.

It is as successful as any other chronic disease treatment- and has much more pro-social outcomes than incarceration. And all of these outcomes are much less expensive.