A suspected case of measles. A rabid fox on the loose. A recall of a dye used in tattoos. A drug epidemic that's claiming hundreds of lives.
Those are just a few of the problems that Dr. Leana Wen confronts in a typical week as the Baltimore City Health Commissioner. While they all have to be dealt with, it's clear that heroin is among Wen's gravest concerns. Right now, she's focused on stopping overdoses and saving lives.
There were 104 overdose deaths in Baltimore during the first quarter of 2015, a 49 percent increase over the 70 reported during the same period in 2014.
As chair of a committee that has a state mandate to review every fatal drug and alcohol overdose, Wen hears about each and every overdose victim in the city. Each month, the health department, police department, and other agencies that are part of the committee conduct a detailed examination of every death.
"These are difficult meetings to attend," Wen says. "You're literally hearing about a person's life, seeing their spiral downward, seeing how they did fall through the cracks ... fell through our fingertips and now is dead."
The committee's examinations show that many of the victims are people who had sought care in hospital emergency rooms, some as many as 50 times. Many are repeat drug offenders who had been in and out of central booking and may have been to jail as many as a dozen times.
Wen sees those points of contact as opportunities to reach people and, in particular, to educate them about a lifesaving drug: naloxone.
Naloxone, also known as Narcan, is a medication that essentially reverses an opioid overdose long enough for a person to get medical attention. Many cities now equip police officers and other first responders with the drug. And a growing number of places around the country are working to make it widely available in the community. Early studies show that naloxone programs do reduce overdose deaths.
Wen wants to blanket Baltimore with naloxone, and she's starting with those drug users themselves.
The health department conducts naloxone training for inmates at the Baltimore City Detention Center. The department also offers naloxone training and a naloxone kit to every person who visits one of the city's needle exchange vans.
This summer, Wen herself led the very first naloxone training inside the Baltimore City Circuit Court, for participants in the city's drug treatment court program.
Health workers have also taken to the streets, setting up tables at spots around the city known for drug activity. The trainers are often familiar faces in the community and easily draw a crowd for the five-minute naloxone demonstration. There is a glass vial with the medication, a syringe, and an atomizer. Uncap the various parts, screw them together, and spray half the medication up one nostril and half up the other. At the trainings, there is always a doctor on hand to write prescriptions, which Medicaid recipients can fill for $1.
On Aug. 31, to mark International Overdose Awareness Day, outreach workers had a new version of naloxone to give out. At a spot in Sandtown, eight blocks from where Freddie Gray was arrested, veteran health worker Nathan Fields demonstrated Evzio.
"It's an auto-injector," Fields says. "It's very simple."
Similar to an EpiPen, Evzio comes in a cartridge smaller than a pack of cards. Once activated, the device talks, telling you to remove a red safety guard, place the device against the thigh and press firmly for five seconds. Fields demonstrated the educational version on Dr. Wen before distributing kits to bystanders.
The wholesale price for an Evzio kit, which include two doses of naloxone plus a trainer cartridge, is $575. There's no chance the health department could afford to buy Evzio at that price. Kaleo, the pharmaceutical company behind it, has just donated more than 3,000 kits to the city.
The donation is a boon to the city, which has faced a price surge in the nasal spray version of naloxone. The price has nearly doubled since February, from about $20 a dose to close to $40.
On the streets, Evzio gets rave reviews for its convenience.
"This one is much better and easier to follow," says Andrea Towson. "I think this is a plus."
Towson, whose street name is Teacup, has used heroin on and off for 33 years. She tells us, she's known in the community as someone who can help others get high, hitting veins they cannot. And she says she's known as someone who carries naloxone. She's used the antidote more than a dozen times, saving the lives of drug users around her.
"I couldn't sleep if I thought I couldn't save someone's life. I just can't," Towson says. "An addict is going to be an addict, but it's still a certain kind of addict that still has morals and principles, and I like to pride myself and say I'm one of them."
Wen says she knows that many will question whether giving naloxone to people like Towson promotes drug use. If there's no danger to overdosing, why wouldn't people continue to use?
"But that would be just as flawed as saying that we can't give somebody an EpiPen for their allergic reaction, because that's going to make them eat peanuts or something else they're allergic to," Wen says. "There's just no evidence behind that at all."
Wen's ambitions for naloxone extend beyond the city's drug corners. Earlier this year, she sent a letter to all doctors in Baltimore, urging them to prescribe naloxone any time they prescribe opiate pain killers. She's since heard from doctors worried about liability and the message they'd be sending to patients.
On Oct. 1, a new Maryland state law takes effect that allows for standing orders of naloxone. That means a doctor won't have to be on hand at every naloxone training session to issue individual prescriptions, as is the case now.
Wen plans to issue a citywide standing order for naloxone, essentially giving everyone in Baltimore a prescription for the medicine. She hopes that will make it easier to get the anti-overdose medicine into people's hands.
In addition, a broader good Samaritan law takes effect in October, extending immunity to anyone who administers naloxone to someone who is believed to be experiencing an opioid overdose.
Still, Wen recognizes that naloxone has its limits as a public health tool.
"For everything that we're talking about with naloxone, as big a fan as I am obviously for it, that we're about to prescribe 620,000 people in our city with it, we know that we're just going to be treading water unless we have treatment that immediately follows saving someone's life."
NPR and All Things Considered will continue reporting from Baltimore in the coming months, checking in with Leana Wen and her team periodically. Stay tuned for future stories.
AUDIE CORNISH, HOST:
All summer, I've been listening to an audio diary.
LEANA WEN: It is almost midnight on Tuesday - what day is...
CORNISH: This is the voice of Dr. Leana Wen, the Baltimore City Health Commissioner.
WEN: I am just exhausted.
CORNISH: It's her first year on the job, and we're following her as she juggles everything from the routine...
WEN: I'm still actively investigating our likely measles case getting...
CORNISH: ...To the surprising...
WEN: A recall of a particular dye in tattoos...
CORNISH: ...To the seemingly impossible.
WEN: What are we going to do to step up in this epidemic?
CORNISH: She's speaking there about substance abuse, specifically heroin. Baltimore has been wrangling with it for decades. The city saw more overdose deaths than murders last year. Leana Wen hears about every overdose victim in the city because by law, she has to. She heads a monthly meeting with the health department, police, social services and other agencies called the overdose fatality review, and it's grim.
WEN: We spend so much time focusing on the gruesome detail. And there is a lot of gruesome detail because you're literally hearing about a person's life, seeing their spiral downward, seeing how they did fall through the cracks and fell through our cracks, fell through our fingertips and now is dead.
And then we look at the details of the cases, and people could get fixated on the detail and start talking about well, this type of drug paraphernalia was found, these five substances, these empty pill bottles were found. This is exactly where the patient was found with their pants down in a bathroom stall. And I mean, all these details may be important in some ways, but we still have to put the focus squarely on what could've prevented this patient's death that may apply to future cases?
CORNISH: So Dr. Wen and her team launched an awareness campaign with a not-so-subtle title - Don't Die. The message is plastered everywhere on bright, yellow billboards and bus shelter ads. And they're going all in on Naloxone, a medication that reverses an opioid overdose long enough to get the person medical attention. Dr. Wen wants to blanket the city with this antidote. And to start, she's targeting the people most likely to end up in an overdose fatality review - addicts who are repeat visitors to emergency rooms and jails.
UNIDENTIFIED WOMAN #1: Affirmation on one - one.
UNIDENTIFIED CROWD: I believe in myself today and every day. I am a woman who thinks before she acts.
CORNISH: That's how we ended up at the city jail, watching two dozen women in pink jumpsuits recite an oath. They're in a special treatment program for nonviolent drug offenders. They get counseling, acupuncture and basic education. Today, the health department is here to teach them how to use Naloxone.
THOMAS CLEMONS: Good morning, everyone. My name is Thomas.
CORNISH: A man named Thomas Clemons runs the session. He asked what they've heard about how to treat an overdose victim.
CLEMONS: What are some of the older street remedies and myths that we do in terms of overdose?
UNIDENTIFIED WOMAN #2: Inject them with saltwater.
CLEMONS: Inject them with salt water.
UNIDENTIFIED WOMAN #3: Slapping them.
CLEMONS: Slapping them around.
UNIDENTIFIED WOMAN #4: Just taking them out in the backyard.
CLEMONS: I've heard people say that.
CORNISH: This is why he's here - getting these women while they're clean and clearheaded to learn something that actually works.
CLEMONS: It's called an intranasal spray, so it's going to go right into the nostril.
CORNISH: There's a glass vile with the medication, a syringe and an atomizer. You screw it all together and spray half up one nostril, half up the other.
CLEMONS: Person's going to wake up feeling nauseated and sick. They're going to be cussing everyone out - tell him where his drugs at and where his money at
CLEMONS: But that's OK too.
CORNISH: At the end of the jailhouse training, Clemons can't just give the women Naloxone kits while they're incarcerated. The best the health department doctor on hand can do is write prescriptions for when the women are released. So Clemons makes a final plea.
CLEMONS: Please, once you get this prescription, please take it to get it filled immediately so you can have this ready and available. We would hate for somebody to overdose and die and then you be like, oh, well, I was I had - I should've, could've - and it be a little bit too late.
CORNISH: It's one thing to have a captive audience. It's another to try to get an entire city on board. A few places have tried a big push like this - San Francisco and Massachusetts. Many others now have police or first responders carrying Naloxone.
Leana Wen has bigger ambitions. She sent a letter to all doctors in Baltimore urging them to give patients Naloxone when they prescribe opiate painkillers. And there was pushback from doctors worried about liability and the message they'd be sending. Still, that hasn't stopped Dr. Wen and her team.
NATHAN FIELDS: This is an anti-overdose medication. It works on any opioid, heroin, OxyContin, Percocet, Dilaudid. Come on over, man. Come on over
CORNISH: We're outside a subway station in the neighborhood of Sandtown, eight blocks from where Freddie Gray was arrested and an area where addicts hang out. Nathan Fields is a health worker. He gives the street version of that jail training. They've been at it all summer. Fields shows people how to use Naloxone. Doctors stand by with free kits and prescriptions for more. Today, his gray card table is toppling with kits, and the doctor at his side is the boss.
WEN: Hi, I'm Dr. Wen. Nice to meet you, I'm the health commissioner.
FIELDS: This is Dr. Wen. This is the health commissioner for Baltimore city.
WEN: Nice to meet you, sir. How are you?
CORNISH: Wen's brought a small army of chipper workers in lemon yellow t-shirts, a congresswoman and extra volunteers. It's a special effort because they've brought something new - a version of Naloxone that's much easier to use than the nasal spray.
FIELDS: So the first thing, real quickly - if you pull it out.
COMPUTER-GENERATED VOICE: This trainer contains no needle or drug.
UNIDENTIFIED WOMAN #5: Oh, it talks to you?
UNIDENTIFIED WOMAN #5: Tells you what it is.
CORNISH: This brand of Naloxone called EVZIO not only talks to you. It comes in a cartridge smaller than a pack of cigarettes, works like an epipen.
COMPUTER-GENERATED VOICE: Pull off red safety guard.
FIELDS: Red safety guard...
UNIDENTIFIED WOMAN #5: Red safety guard.
CORNISH: Place on the thigh, and inject. Dr. Wen offers up her arm for the demonstration.
WEN: You can use it on me if you want.
UNIDENTIFIED WOMAN #5: Just right there, not on your thigh?
FIELDS: OK, OK.
WEN: Well, on the thigh, but I don't want to lift up my skirt right now (laughter).
CORNISH: She does a little role-playing for the crowd craning their necks to see.
COMPUTER-GENERATED VOICE: Injection complete.
UNIDENTIFIED WOMAN #5: OK?
FIELDS: Jump up.
WEN: So you do...
UNIDENTIFIED WOMAN #5: That's it?
WEN: That's it.
FIELDS: You jump up. That's it.
UNIDENTIFIED WOMAN #5: Oh, that's better. That's much better.
FIELDS: Yeah (laughter).
CORNISH: The wholesale price for EVZIO kits with two doses each - $575 a pop - way too expensive for health department giveaways. But the pharmaceutical company behind it has just donated more than 3,000 kits to the city. That's a good thing for the health department because the price they're paying for the nasal spray version has doubled since February. This donation and this photo op with Wen and the company CEO nearby means for today, at least, Naloxone is free.
FIELDS: We're going to give you this today.
CORNISH: But really, it's having a guy like Nathan Fields, who's known on the streets, that draws people in. At least that's what Teacup tells me.
ANDREA TOWSON: He's the reason why I got involved with the needle exchange and everything. So when seen him, I really came over here. He just started smiling when he saw me.
CORNISH: Teacup is Andrea Towson. She happened to walk by and pick up a kit. She's a 51-year-old grandmother and tiny, almost wiry. She's got a nose ring, short, wavy hair. Her slim brown arms are laced with scars.
TOWSON: I'm an active heroin user, I am. I'm 33 years, as a matter of fact. I've been in treatment a few times. I've stayed clean 8 years and just recently relapsed. Well, I ain't going to say I relapsed. I changed my mind.
CORNISH: And that's not totally a surprise. Towson says the drug scene in Baltimore has made it harder to stay clean.
TOWSON: An addict has more choices of where to go to now than they ever did when I first started getting high because it was a (shushing) back then. Now it's everywhere you go. You make a left; you make a right; you keep straight; it's right there.
CORNISH: She waves her arms around the intersection as though there are drug dealers everywhere, but I'm not seeing it.
CORNISH: Am I missing a corner right now that would be a good place to get it?
TOWSON: Actually, they're giving y'all respect.
Teacup says everyone here knows she carries Naloxone. She says she's used it more than a dozen times, partly because of her unique reputation on the street.
TOWSON: A lot of people that may be first-time users will come to me because I can hit them, and that means I'm a doctor in street language - where I can hit veins that most people can't. So like I said, I'm not glorifying it, but they come to me because they know I ain't going to let you die. And you're going to be OK. If you do go out, I'm going to bring your [expletive] back, and I'm going to call the ambulance afterwards.
I couldn't even sleep if I thought I couldn't save somebody's life. I just can't. But you have people that'll take a person and put them in the alley and just leave them - rob them for they clothes, they jewelry. I mean, it's just - how about an addict is going to be an addict, but it's still a certain type addict that still have morals and principles. And I like to pride myself and say I'm one of them.
CORNISH: So if people come to you for a hit 'cause they know you're going to hit a vein...
CORNISH: ...They know you know what you're doing...
CORNISH: ...Is that one of the reasons why you try and have the overdose kits around?
TOWSON: Absolutely. Not one of the reasons - the only reason.
CORNISH: There's going to be people that listen to this and think, why should I keep...
TOWSON: Oh, my (laughter). Hey, people (laughter).
CORNISH: Why should we keep paying for Andrea to have a kit? She needs to get clean.
TOWSON: I absolutely do. Can you help me please? Actually, that's my next thing. I'm finally realizing that it's more mental. It's like, if you don't get therapeutic help with this, you're bound to do it again.
CORNISH: I leave, not sure what to make of Teacup, so I share her story with Dr. Wen.
There was something kind of off-putting about knowing that she wasn't changing her behavior but now felt she just had a kind of other tool in her toolkit of surviving as an addict, not ending her addiction.
WEN: We need both. We have to be able to save people's life at the moment they're overdosing or else there is no chance - there's zero chance that they will make a different choice to get into treatment. Many of our patients will overdose not just once, but several times. And it's our duty to save their life, or else there's not going to be a better future.
CORNISH: On October 1, a new Maryland state law will clear the way for Leana Wen to issue a citywide standing prescription for Naloxone. That'll make it easier to get the anti-overdose drug into people's hands. In addition, a broader Good Samaritan law also takes effect to give legal immunity to anyone who administers Naloxone in good faith. Eventually, Dr. Wen wants Naloxone to be just another household drug. For now, she reminds me this is only the first step towards reducing that grim toll of overdose victims. Transcript provided by NPR, Copyright NPR.