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Proportions of Drug Crisis Incalculable
'60,000 addicts' is cited to show the size of the city's drug problem and to seek funds.
But the number can't be trusted.

 
Alec MacGillis; Baltimore Sun; 2005-03-28
[Identifier: http://www.doctordeluca.com/Library/WOD/BaltimoreODsFell05.htm]
[Related resources: http://www.doctordeluca.com/Library/LibPages/WODjournalism-lib.htm]
[See also: “Why Drug Reporting Sucks. Still.” Jack Shafer; Slate; 2005-08-10]
[See also: “City [Baltimore] Overdose Deaths Fell by 12% Last Year” Alec MacGillis; Baltimore Sun; 2005-03-28]

 

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AN OPTIMIST could take heart in signs that Baltimore's huge drug problem might just be on the decline. The numbers of fatal overdoses and emergency room visits are trending downward, drug treatment has expanded in the past decade, and surveys suggest there might be a generational shift away from hard drugs.

But it is impossible to seriously assess the course of the city's struggle with drugs. And because of that, the city is stuck with a number that has hung around its neck for two decades: 60,000 addicts.

That number has been invoked, over and over by countless media and government officials, as shocking shorthand for the city's many ills. It has prevailed, like a broken gauge on a gas tank, through four mayors, a large drop in the city's overall population and major changes in the narcotics trade.

In truth, the number is almost certainly wrong. It was, at best, a hit-or-miss guess to begin with.

The 60,000 estimate has been built on hazy projections and on misinterpretations of researchers' findings, a review of its sources shows. Those who produced it acknowledge its shakiness and say they're uneasy about the way the number is bandied about. Without a prohibitively costly survey, they say, there's no reliable way of keeping score in the fight against addiction.

Yet the figure has been repeated often by the national media, this newspaper, and boosters and critics of the city. The city's Baltimore Believe Web site proclaims: "The epidemic of illegal drugs has turned 60,000 city residents into addicts enslaved by chemical substances." Last month, The New York Times stated that "almost one in 10 people" in the city is addicted to drugs.

The number has at times been used to benefit Baltimore. Public officials and other advocates have wielded the figure to dramatize the city's problems in bids to obtain treatment funding or win approval for initiatives such as needle exchanges.

At the same time, use of the 60,000 figure has helped to propagate a perception of the city as an urban wasteland beyond repair, thereby demoralizing residents and potential visitors, businesses or homebuyers. "You can't help but have a gray cast over things when you're constantly getting inundated with [the number]," said Tracy Gosson, director of the Live Baltimore Home Center, an organization that promotes city living. "It's very damaging."

Questions about the estimate's validity have further implication. In the absence of more solid data, one expert says, the city will need to battle its drug problem without being able to know for sure to what degree it is succeeding.

"We know it's a huge problem. The precise number will never be known and does not need to be known," said Eric D. Wish, director of the Center for Substance Abuse Research (CESAR) at the University of Maryland, College Park, which has produced some of the estimates. "What's important is that the problem is overwhelming the resources that are available."

There is no doubt that Baltimore continues to be awash in illegal drugs and debilitated by the narcotics trade to a greater degree than almost any other large American city. There were 278 homicides last year, the vast majority of them drug-related, according to police, and 261 fatal drug overdoses. There are lengthy waiting lists for drug treatment, a sign that whatever the number of addicts, there are more than the city can help.

But researchers trying to quantify the addict population have few reliable guideposts. For instance, the numbers of people arrested for possessing drugs are heavily influenced by how aggressive policing is, and the number of those overdosing is driven partly by drug purity.

There's also the challenge of defining what is meant by an "addict." Is a former heroin user on methadone an addict? Is someone who uses cocaine every few weeks addicted?

"It's just a nightmare to try to really do those estimates," said William T. Rusinko, director of research for the state Alcohol and Drug Abuse Administration, which has made some of the projections to help guide state treatment funding. "My approach is to downplay those estimates, but then again it's always something people like to look at, that they want to know."

First citation in 1986

As near as researchers in the field can tell, the 60,000 estimate first appeared in 1986, in a study done for the state by an outside researcher. The study said there were 60,700 people in the city who were "dysfunctional" because of illicit drug use, including 29,065 whose main problem was heroin and 20,484 whose main problem was cocaine.

Within five years, the number had gained public currency: in 1991, a Sun columnist referred to the city as "home to 60,000 drug addicts," the first of many mentions of the figure in the paper.

But the 1986 estimate, like several others that would follow, was based on a method that practitioners concede is efficient but far from conclusive: Researchers tally those seeking treatment for various drugs, as well as the frequency of return treatment visits in a given year by addicts, and extrapolate from that an estimate of the total number of addicts needing help.

This method has obvious shortcomings. It requires making an educated guess about the number of addicts who aren't getting treatment. Also, it doesn't account for changes in treatment availability. If a city increases the number of slots and thereby draws more addicts into treatment, that doesn't necessarily mean the city's drug problem has grown in scale.

"It's a very crude way of estimating," said Dr. Robert Schwartz, a psychiatrist specializing in substance abuse who has overseen local drug treatment initiatives.

The estimate got new life in a 1998 study by researchers at the Center for Substance Abuse Research, who produced four different estimates for substance abusers in Baltimore, the largest of which was about 60,000.

But more than half of the addicts included in the estimates were people who were dependent on alcohol, not on illicit drugs. The most reliable estimate for illicit drug addiction, the study found, was only 20,711. That distinction never made it into the public debate.

The CESAR researchers argue that their much lower estimate of drug addicts is more reliable than the higher one based on the number of people in treatment, because it is based on a more time-consuming approach: the results of a telephone poll of about 5,000 city residents, and the results of urinalysis tests and interviews with 1,190 arrestees in the city jail.

But Rusinko, the state researcher, counters that this method undercounts, because not every addict regularly passes through the jail, so using arrestee figures to make up for people missed in the phone poll is inadequate.

Rusinko's office has adopted the approach used in the 1986 study, making estimates based largely on the number of people receiving treatment, which has produced estimates for Baltimore that exceed even 60,000. The state's projections of treatment need in each county determine the allocations for a fifth of the state's treatment funding, so Rusinko's very high estimates of addiction in Baltimore have helped bring money to the city.

Rusinko said his office had looked at factors other than the number of people receiving treatment, such as HIV infection levels and drug overdoses. That way, he said, it wasn't relying exclusively on the doubling of treatment rosters in the city since 1998, which was driven more by an increase in funding than a surge in need.

Still, he noted, the very treatment data that the estimates are based on are not entirely reliable, because the city has been undergoing a "difficult transition" between two systems to track clients. It is likely, he said, that duplicate counting of clients "may be contributing to an inflated estimate," which is why he urges people not to place too much weight on the numbers.

'Mythic proportions'

Despite all the researchers' qualifications about the 60,000 estimate, it has been repeatedly cited with all the assurance of established fact. "The number has taken on mythic proportions," said Peter Luongo, head of the Alcohol and Drug Abuse Administration.

In 2000, the federal Drug Enforcement Agency assessed the city's drug problem at the request of then-police Commissioner Edward T. Norris. The DEA made no attempt to quantify the addict population.

But after local news reports mentioned the 60,000 estimate in their reports on the DEA study, ABC and CBS national news stated in reports that the DEA had found that there were 60,000 addicts in the city - a false citation that gave further weight to the number.

A year later, in Washington, the former co-chairman of a congressional drug task force cited the number at several Capitol Hill hearings to argue that Baltimore's approach to the drug problem had failed.

"You can use the Baltimore example, which went from a few thousand heroin addicts to 60,000 - one in eight [adults] in the city of Baltimore, because of a liberal philosophy, tolerant philosophy, lack of law enforcement philosophy, is now an addict," said Rep. John L. Mica, a Florida Republican.

Political weapon

The 60,000 figure has been used most often by those seeking resources to attack the city's drug problem. Mayor Martin O'Malley started citing the number in his first year in office, using it to argue for more substance abuse treatment in a 2000 letter to business leaders. Also that year, then-city Health Commissioner Peter L. Beilenson cited the number in an interview on CNN.

"Politically, it's been used as a great weapon in showing the magnitude of the problem," said Michael M. Gimbel, head of substance abuse education at Sheppard Pratt Health Systems and the former director of drug treatment in Baltimore County. But, he said, there might be a cost in the effect on the city's image. "They have created a campaign [for funding] that's based on those numbers, and those numbers are now passed as gospel," he said.

Beilenson, who left his job last month to run for Congress, said in a recent interview that he cited the 60,000 figure for years because it seemed the best estimate available. He acknowledged that the figure was not airtight, but he rejected the suggestion that officials have used it simply to get more money to fight the problem. State funding for drug treatment in the city doubled between 1999 and 2002 but has leveled off since.

"I can tell you categorically that the last thing we'd want to do is overestimate. That would make it look worse," he said.

In the past year or two, Beilenson has, without fanfare, started using a lower estimate of drug users in his public remarks: 45,000. He says this is based only on his conjecture that expanded drug treatment might have reduced the ranks of users by at least 10,000.

Hints of declining use

There are signs that drug use in the city might be on the decline. Fatal drug overdoses fell to their lowest level in five years last year, though the city attributes the drop in part to the distribution of an anti-overdose medication. A national survey that tracks drug-related visits to hospital emergency rooms showed a decrease of 45 percent in heroin-related visits and a 33 percent decline in cocaine-related visits in Baltimore between 1995 and 2002.

The city could also find encouragement in the findings of researchers at the Johns Hopkins Bloomberg School of Public Health who have been tracking two groups of East Baltimore residents from birth. When researchers checked in with the younger group five years ago, when the subjects were in their early 20s, they found such low levels of heroin and cocaine use, especially among blacks, as to be virtually negligible.

While researchers have found that many blacks in the city use only marijuana in their teens and don't start using heroin until their 20s or 30s, Howard Chilcoat, a professor at Hopkins' Bloomberg school, said such extremely low reports of hard drug use could be a sign of a possible generational shift.

Researchers agree that if the city wanted to reliably quantify its drug problem, it could conduct an exhaustive survey. But they question whether that would be worth the high cost, because the surveys would have to be repeated to detect trends. The money, the researchers say, would be better spent on treating the drug problem, whatever the size.

And if city officials use less-than-solid estimates to try for that funding, well, that's politics.

"If you're needing to get resources, you say the problem is as bad as possible," said Chilcoat. "But the issue isn't that we don't know how many there are. The issue is we don't have enough resources for the ones we have."

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