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Home / Health / D.C's Opioid Epidemic: As the overdose of African American skyrocketed, the city ignored strategies to save lives

D.C's Opioid Epidemic: As the overdose of African American skyrocketed, the city ignored strategies to save lives



Over the last four years, the US capital has witnessed the worst public health crisis since the arrival of AIDS: an explosion of fatal drug overdoses in African Americans.

The death toll caused by heroin degradation with the deadly synthetic opioid fentanyl is similar to the worst ravages of the opioid epidemic in rural and suburban parts of the United States. In the district, more people died of opioid overdoses than murders last year.

However, the overdose victims of the city are different from those in areas of the country more commonly associated with opioid abuse. Many are black men who have been addicted to heroin for decades. And unlike drug users, they were often left by their government without any basic help.


D.C. has the highest increase in

overdose deaths in

urban areas

percent change in age-adjusted overdose

death rates since 2012 for large urban

and [19456501] other counties.

Cabell County,

W. Va. + 435%

fentanyl-related

overdoses were more common

during this period

Source: Centers for Disease Control and Prevention

KATE RABINOWITZ / THE WASHINGTON POST [19659]] DC has the highest increase in overdose

Deaths in urban areas

Percent change in age-matched overdose death rates

since 2012 for large municipalities and

other counties .

Cabell County,

W. Va. + 435%

fentanyl-related

overdoses were reported

more frequently during this period

Source: Centers for Disease Control and Prevention

KATE RABINOWITZ / THE WASHINGTON POST [19659030]] DC has the highest increase in overdose deaths in

urban areas

The percentage change in age-related overdose death rates since […]

[17659010] and other counties.

Cabell

County, W. Va.

+ 435%

fentanyl-induced overdoses

accumulated during this period

Source: Centers for Disease Control and Prevention [19659041] KATE RABINOWITZ / THE WASHINGTON POST

DC has the highest increase in overdose deaths in urban areas

Percent change in age-related overdose death rates since in large urban districts

and other districts.

Cabell

County, W. Va.

+ 435%

Overdoses Related to Fentanyl

Amassed

Source: Centers for Disease Control and Prevention

KATE RABINOWITZ / THE WASHINGTON POST

DC has the highest increase in overdose deaths in urban areas

Percentage change in age-adjusted overdose death rates since 2012 for large urban districts and other districts.

Cabell

County, [Va

+ 435%

fentanyl-related overdoses

were more common during this period

Philadelphia, Pennsylvania

+ 120%

Source: Centers for Disease Control and Prevention

KATE RABINOWITZ / THE WASHINGTON POST

The district has given fewer and fewer answers to the number of opioid victims millions of federal dollars have been wasted and those in other countries have seen widespread rescue strategies ignored

D.C. Officials distributed naloxone – an overdose remedy that allows laymen to prevent fatalities – at a far lower rate than other cities with comparable opioid problems. When deadly overdoses reached their peak last year, Baltimore distributed more than four times as many naloxone kits per capita as the district; and Philadelphia, according to the city more than three times as many. Civil servants working with the district in their Naloxon Campaign called it "unfortunate enough" and "catastrophic."

The city also failed when it conducted a government-sponsored initiative to connect long-term heroin users to treatment. Although DC officials began receiving $ 4 million from the US Department of Drug Abuse and Mental Health Services (SAMHSA) in 2017, many of the programs the city announced were never introduced. Officers in the district's majority federal agency said that not a single patient had been referred for addiction treatment.

"It's just pure incompetence," said Larry Gourdine of the Medical Home Development Group (MHDG), which received nearly $ 1.5 million from the city grant. "It's not that hard. I mean, that's direct health care. "

In a city where growing wealth hides deep differences between race and class, the damage done by heroin and fentanyl has fallen directly on the African Americans. Of the 860 people who have died of opioid overdoses since 2014, four out of five were blacks, according to the head physician. In 2017, the most recent year in data for Disease Control and Prevention Centers, the rate of fatal overdose was higher among African Americans in the district than whites in West Virginia, Ohio or New Hampshire.

An invisible opioid epidemic in the capital of the country

The American drug epidemic is often associated with rural cities and suburbs. However, in the district of Columbia, more people died of opioid overdose than homicides last year when local government officials looked the other way. Read how a few experienced users struggle for survival.

But these deaths, which have concentrated in the historically black neighborhoods of southeast and northeastern Washington, have not been noticed by many residents of the national capital. Only a handful of elected officials took prompt action to tackle the crisis. Frustrated advocates and physicians say the district's lackluster response has never been tolerated in whiter and more prosperous areas.

"People are not accepting the severity of our opioid epidemic because older, African-American men who have used heroin in the long term are dying," said Kaitlyn Boecker, a citizen of the DC Office of the Drug Policy Alliance , an organization that works to change drug laws. "There simply does not seem to be any urgency in dealing with the crisis."

D.C. Mayor Muriel E. Bowser said in a statement that the district's strategies are "working and saving lives". (Jabin Botsford / The Washington Post)

D.C. Officials defended their response to the rising deaths from opioids and said the past few years had been a learning phase. Looking ahead, they plan to plan a comprehensive response to the epidemic with $ 21 million in new funds for opioid programs that the district will receive from the federal government.

Mayor Muriel E. Bowser (D) refused repeated requests for an interview for this article. In a written statement, Bowser said the district's strategies "work and save lives". She noted that more than 700 cases of naloxone overdose were reported by the city.

"We will tirelessly seek the best possible tools and data to stop preventable overdose and death," Bowser said in the statement.

There are bright spots in the city's opioid reaction. At the end of last year, the district began with $ 1.7 million in local grants to increase the number of doctors and nurses trained in addiction treatment. However, according to the city and the federal government, there are no corresponding peaks in the number of patients registering for treatment.

After three consecutive years of increasing numbers of opioids, the number of projected deaths is projected to decline this year, although the number of projected deaths will still be twice as high as 2014, according to the district's chief physician. Some city officials say the decline is due to their prevention efforts.

However, some medical experts believe that the trend – reflecting a decline in fatal opioid overdoses in other cities and federal states – could have other causes. One theory is that chronic consumers are beginning to adapt to fentanyl-contaminated heroin by using it more carefully and in smaller doses.

Another is that four years after the district opioid crisis, many of the most vulnerable addicts are already dead.

(André Chung for The Washington Post)

"The only tools we have"

Outreach employee Kenneth Poge embraces a customer in the Service Exchange Service Van (FMCS) of Family and Medical Counseling Service. FMCS was one of two nonprofit groups shaken to disperse the district's overdose of the life-saving naloxone antidote, but one manager said the program had become "catastrophic" when the city was not providing enough medication.

Maurice Abbey-Bey stepped in from a minivan in the DC General shelter for homeless families, he opened the trunk and announced that he was shouting syringes, condoms and Narcan, a brand of Naloxone Nasal Inhaler, in a hoarse cry would. Among the dozens lined up in a row was Renee Jones-Collins, a resident of Southeast Washington.

Jones-Collins said she no longer uses heroin, but has friends who do. Last month, she said, she used Narcan to revive someone who had "failed" or overdosed. She said that while fentanyl-laced heroin was "everywhere" in the district, naloxone was relatively scarce.

"It's not enough," she said.

Abbey-Bey was selective with his 30 Narcan kits, but quickly got away. He soon returned to the Helping Individual Prostitutes Survival (HIPS), where naloxone, provided by the city, was carefully rationed.

"I do not want to cling to that stuff as it is a sweet life," he said. "But that's exactly what I'm doing."

The US Department of Health began its campaign with Narcan in the spring of 2016 to saturate overdosed residential areas. The department collaborated with HIPS and the Family and Medical Counseling Service (FMCS), another non-profit organization offering needle exchange services, to buy Narcan in the city to distribute it.

Terrence Cooper, a needle-exchange coordinator at Family and Medical Counseling Service, monitors clients on Minnesota Avenue and Clay Place in the northeast. FMCS was one of two nonprofit organizations participating in the district's troubled naloxone distribution program. (André Chung / for The Washington Post)

The city administration of the program was "catastrophic," said Diane Jones, a social worker who oversaw the initiative of the FMCS. In an interview in May, she estimated that the approximately 150 kits FMCS received each month from the city were half the need. She said that her organization routinely faced painful decisions about which customers earn the most.

"These are the only instruments we have in this crisis at this time," Jones said. "And we have to ration them."

Similar complaints date from the first days of the city's naloxone initiative. On July 12, 2016, about two months after the program began, former HIPS employee Andrew Bell warned health officials that Narcan's offer was exhausted and the demand for medication could not be met.

"There is not a day when we have no customers asking for Naloxon," Bell said in an e-mail.

The Health Department eventually increased HIPS 'Narcan offering. The nonprofit organization, however, still had bottlenecks. In May of this year, HIPS launched an online fundraiser when it was about to leave Narcan and the city rejected it nine days earlier.

"We are tired of the city's inadequate response to fatal overdoses in D.C.," the group wrote in its appeal. "Please donate today and help HIPS buy our own materials so we can do the city for them."

HIPS Executive Director Cyndee Clay said other local governments are more aggressive in ensuring that naloxone reaches drug users.

"There are places where this is done well," she said. "D.C. just is not one of them. "

Other municipalities have launched far more robust Narcan distribution campaigns, as shown by a post-analysis of the data provided by these cities.

In 2017, Baltimore distributed an average of 178 kits per month per 100,000 population and Philadelphia 141. Boston distributed 87 kits per month per 100,000 population, San Francisco 86 and New York City 59.

D.C.s Figure: 38.

D.C. Health Ministry director LaQuandra Nesbitt said complaints about naloxone deficiency had provided valuable feedback in a two-year trial. "I want to emphasize that it's a pilot, so we wanted to hear from them what worked and what did not work," said Nesbitt.

She said the health department overhauled the program so that HIPS and FMCS would receive funding to buy their own naloxone instead of relying on the city, a move that she explained should resolve disputes.

Nesbitt said it was wrong to judge the effectiveness of the district program in terms of the number of narcan kits given without tracking other measures, such as For example, if medical help or long-term addiction treatment was offered after an overdose victim life was saved.

"It's not just about whether Naloxone was given or not – did you inject something into the nostrils? It's what happened as a result, and these things are vital to us to understand, "said Nesbitt.

She added, "I do not determine the success of a program based solely on the number of kits distributed."

This view contradicts best practices for naloxone distribution, according to Eliza Wheeler, national strategy for overdose response at the Harm Reduction Coalition.

"To measure the success of a naloxone program, it must depend on how much naloxone gets into the hands of people who are taking drugs," said Wheeler. "The analogy we use is thinking about a flu shot in the community." These efforts are judged by how many flu patients are vaccinated, not what happens afterwards.

The district has also been an outlier in increasing the availability of naloxone: a government policy that allows anyone to buy medicines in a pharmacy without a doctor's prescription. In January 2018, according to the National Alliance of State Pharmacy Associations, such policies existed in more than two dozen states, including neighboring states Maryland and Virginia.

The DC Council passed a law that would allow residents of the district access to medicines in pharmacies in 2016. Nesbitt, however, rejected the implementation and said that the legislation gave the pharmacists too much authority and did not protect the pharmacists who did not want to decide Naloxon from legal liability. It did not do anything to make Naloxone available until this month, when the Council approved changes it had requested to the Directive.

(André Chung for The Washington Post)

"It just fell apart"

Dr. Edwin Chapman has treated hundreds of heroin users in his office in northeast Washington. Chapman's practice was to participate in a program for the recent overdose victims at the district public hospital, one of several government-funded initiatives that were not carried out by the city.

Victor Williams, a 56-year-old heroin user, was discharged on the morning of September 28 from the United Medical Center (UMC), the district's public hospital, where he had been overdosed. On the same day, just before midnight, his younger brother Phillip Williams received a call he had long feared.

Victor had gone to the bathroom of Phillip Williams, according to a friend, and did not react to beatings. The friend called 911. Phillip came home in time to see his brother, with whom he played for a long time, play Domino and Pinochle, even though heroin had damaged the relationship, carrying the door in a body bag.

An injection was found in the bathroom. The coroner's office later found that Fentanyl had killed Victor Williams.

Phillip Williams, herself a recovering heroin user, said he believes his brother could have been persuaded to undergo professional contact treatment. "When people who need help offering help, they can not get help – they return to what they used to know," he said, explaining his brother's relapses.

Victor Williams, shown with his great-granddaughter. Williams was treated for an overdose in the district public hospital and died on the day of his discharge from another overdose. (Courtesy of The Williams Family.)

The forensic surgeon's office has determined that Fentanyl killed Victor Williams pictured with his granddaughter. (Courtesy of the Williams family.)


Victor Williams, shown with his great-granddaughter. Williams was treated for an overdose in the district public hospital and died on the day of his discharge from another overdose.
(Courtesy of Williams Family)

The coroner's office found that Fentanyl had killed Victor Williams, who was pictured with his granddaughter.
(Courtesy of Williams Family)

What Phillip Williams did not know until recently was that an outreach program for overdose victims like Victor should have taken place at UMC more than a year ago – one of several government-funded initiatives that DC officials did not were carried out.

Along with each state and four US territories, the district received money to combat the opioid epidemic under the 21st Century Cures Act signed by then-President Barack Obama in December 2016. The city's eligibility for the grant – $ 2 million a year for two years – gave it an edge over communities that have no direct access to federal funds for anti-opioid campaigns.

This advantage has led to few results. Initiatives to promote heroin users for whom the grant was earmarked have never been realized. At the height of the epidemic last year, district officials did not spend the $ 620,000 of their federal money, or about one third of the amount allocated to the city in the first year of the grant.

The grant was overseen by the D.C. Department of Behavioral Health, which manages Opioid strategies in the district with the Department of Health. In its application, the agency described a comprehensive roadside action with a group of ten peer counselors – former drug users who were trained to advise others on treatment options – and visited places where heroin users gathered.

However, in a Strategic Plan of August 2017 submitted by the Department to the Federal Government, they stated that they had difficulty recruiting outreach staff. A first training session in May did not have enough participants for the peer outreach program as originally planned.

Instead, the agency said it would launch a more targeted outreach campaign in a location where peer counselors could safely target drug users: an emergency room at a hospital. According to the city administration, two consultants are to be stationed at the UMC. The victims of the overdose were treated locally with buprenorphine, a drug that reduces the craving for opioids.

Similar programs have been launched in several cities based on a 2015 study at the Yale-New Haven Hospital, which shows that users who start buprenorphine during the emergency department are often more successful at recovery.

"We really have the opportunity to see many of these patients in this awakening moment," said Ali Raja, a doctor who overseen the introduction of a buprenorphine program at the Massachusetts General Hospital in Boston last year.

UMC was an ideal location. Last year, there were 400 opioid overdose patients, far more than any other hospital in the country's capital, according to the city. The Medical Home Development Group, the city-contracted provider of buprenorphine treatment, hired two floors above the hospital emergency room in anticipation of the program.

But the city's promised outreach workers never came. The office will not be used for the treatment of overdose victims from the emergency room, but for other patients, said Edwin Chapman, chief physician of MHDG.

Chapman, treating Phillip Williams at his Benning Road NE practice, said Victor Williams was just one of many patients whose lives could have been saved if the city had survived.

Medical Home Development Group Chief Medical Officer Edwin C. Chapman said that D. C.'s officers could have saved lives if they had implemented a plan to overdose victims at the city's public hospital. (André Chung / for The Washington Post)

"It just fell apart," said Chapman. "They have renounced everything."

Tanya Royster, who until two weeks ago was the director of the Department of Behavioral Health in D.C. said in an interview that she could not provide any information as to why the city had never run the program at UMC. "I can not answer that," she said.

In a later e-mail, department spokeswoman Jasmine Gossett denied that the program had ever been planned. Having been shown the federal government's plan presented by the department, Gossett confirmed the proposed UMC project, but said it was part of an interim plan rather than an "official proposal."

Other initiatives outlined as part of the city's grant documents also made little progress. Efforts to convince 125 elderly patients in the city's methadone clinics to switch to buprenorphine treatment – which, unlike methadone, is fully covered by Medicare – went nowhere.

Over time, when the city did not take action or instructions for the funding programs, the MHDG used the paid federal money to provide basic care to patients at the Foundation for Contemporary Mental Health, a Foggy Bottom methadone clinic.

Attention was greeted by men and women who, after decades of addiction, often have serious health problems, but it was not a treatment for substance abuse. Although the MHDG received $ 1.46 million in city grants totaling $ 4 million, it did not treat any single patient for opioid addiction in the context of the grant.

Officials from the Department of Behavioral Health have acknowledged problems with granting a July report to the federal government. They said that the district spent $ 1.38 million on the $ 2 million awarded in the first year of the scholarship, stating that it was "unclear" to communicate their roles and responsibilities to sub-fellows and "unexpected Sales "in the department that oversees opioid programs.

Royster had a more positive assessment. She told the post office that it was normal that federal grant money was not spent in the first year, and pointed to the use of the money she said had been successful: about $ 200,000 spent on posters, warned drug users of fentanyl and promoted naloxone.

She admitted that her agency did not apply proven strategies that other governments had adopted, but said that this was more of a strength than a weakness. The city's approach was tailored to the particular population of older, African-American heroin users.

"We are not behind the curve. I'd say we're in front of the curve, "Royster said," and you can rest assured we're not just doing what everyone else is doing, we're doing what's important to D.C. "

In response to The Post's questions about the district's use of subsidy funds, SAMHSA spokesman Brian Dominguez said beneficiaries of grants are "flexible enough to design their systems and plans."

On November 30, after her interview with The Post and before this article was published, Royster was dismissed from office by the mayor. An official from the Bowser administration who talked about the condition of anonymity to discuss a personnel issue said the mayor was frustrated at the slowness of the agency's responses to various issues, including overdoses of drugs.

Bowser selected Nesbitt, who will continue to run the Ministry of Health while temporarily overseeing the Behavioral Health Department.

(André Chung for The Washington Post)

Just Another Day

Heroin user Eugene Short, 47, strips copper wire outside the FMCS pinwheel. Proponents say that four years after the increase in overdose deaths among African Americans, the recent improvements in the city's opioid response have come too late.

There is at least one precedent for a more successful opioid program managed by city authorities. Last year, the Ministry of Health began with $ 1.7 million to help clinics hire and train medical staff for buprenorphine programs. Five clinics have been funded with Howard University Hospital.

The money was a factor in the rapid expansion of addiction treatment providers in the district. According to SAMHSA data, the federal government has certified at least 150 new buprenorphine prescribers with a capacity to treat 5,550 patients in the last two years.


D.C. extended opioid addiction

treatment options, but

patient growth is delayed

Additional treatment capacity and

Medicaid patients in the last two years

132 more Medicaid patients

5.550 added

Treatment Capacity

Note: The new capacity is based on the maximum number of patients

new physicians can accept. The capacity may be underestimated

because in rare cases doctors expand their capacity limit

. Patient increases are calculated by subtracting

the quarterly averages of the current year from the previous year.

Source: Substance Abuse and Mental Health Services

Administration; Department of Health Care Finance

KATE RABINOWITZ / THE WASHINGTON POST

But the rate at which patients at highest risk go into treatment has not lasted. Since 2016, the number of Medicaid beneficiaries receiving buprenorphine has increased by 1%
132 people, according to the Department of Health Financing at D.C.

Nachdem die Suchtklinik im Mary’s Center in Adams Morgan neue Buprenorphin-Vorreiter ausgebildet hatte, kann sie nun etwa 500 Menschen behandeln, sagte der leitende Arzt Daniel Smith. Derzeit habe es etwa 135 Patienten, sagte er.

"Wir wachsen und wir wachsen jeden Monat um fünf oder zehn Prozent", sagte Smith. "Aber wir sind nicht nahe an unserer Kapazität."

Der Distrikt wird in den nächsten zwei Jahren reichlich Gelegenheit haben, seine Behandlungslücke zu schließen, da er jährlich 21 Millionen US-Dollar an neuen Bundesmitteln für die Kommunen zur Bekämpfung der Opioidkrise erhält.

Die Abteilung für Verhaltensgesundheit, die die Bewilligung beaufsichtigen wird, hat in ihrem Bewilligungsantrag Dutzende neuer Programme skizziert, von denen einige auf unerfüllte Initiativen der letzten zwei Jahre eingehen. Die Stadt plant die Durchführung von Outreach-Programmen für Überdosis-Patienten in mehreren Krankenhäusern, wobei sowohl die neuen Bundesgelder als auch die ungenutzten Mittel aus der früheren Bewilligung übrig bleiben.

Der FMCS-Nadelwechselspezialist Tyrone Pinkney, Mitte, und sein Kollege Terrence Cooper befragen Marlon Brando Robinson, 53, im Mobile-Services-Van der Organisation. (André Chung / für The Washington Post)

Vier Jahre nach der Opioidkrise des Bezirks beginnen die Beamten der Stadt, andere Maßnahmen zu ergreifen, die von den Befürwortern seit langem gefordert werden.

D.C. Gesundheitsbeamte sagen, dass sie einen umfassenden Plan für die Reaktion auf die Opioid-Epidemie abschließen, der von einer Arbeitsgruppe von Regierungsangestellten, Behandlungsanbietern und Befürwortern geschaffen wurde. Im August begann die Gesundheitsabteilung, Naloxon über Obdachlosenunterkünfte zu verteilen.

In diesem Monat genehmigte der DC-Rat ein Paket von Änderungen, die von den Behandlungsanbietern an der Opioid-Politik des Distrikts angestrebt wurden, einschließlich der Aufhebung der Einschränkungen bei der Erstattung von Medicaid für Suchtbehandlungen. Die Gesetzesvorlage wurde ursprünglich 2017 eingeführt und dauerte fast 15 Monate, um zur Abstimmung zu kommen.

Einige an der Front der Epidemie sagen, dass diese Entwicklungen willkommen sind, aber nach unentschuldbaren Verzögerungen kommen.

"Sie hätten eine Menge Leben retten können", sagte Robert Keisling, ein Arzt, der eine der aktivsten Suchtmedizinpraxen der Stadt leitet. „Es ist spät dran. Aber spät ist besser als nie. "

In Marvin Gaye Park, einem berüchtigten Treffpunkt für Heroinkonsumenten im Nordosten von Washington, versammelte sich eine kleine Gruppe am 31. August – dem International Overdose Awareness Day -, um sich an diejenigen zu erinnern, für die Hilfe nicht früh genug kam.

Lewis Blakeney, ein 62-jähriger Heroinbenutzer, der zwei Überdosierungen überlebt hatte, schätzte, dass ein Dutzend älterer schwarzer Männer, die einst neben ihm auf den Parkbänken eingenickt hatten, nun tot waren. Durrell Gray, 55, erinnerte sich an seinen Cousin, der im Park an einer Überdosis Heroin gestorben war. Alvin Wynn, 62, erinnerte sich an seine vor einigen Jahren verstorbene Ex-Freundin und an einen Freund, den er erfolglos versucht hatte, mit Narcan wiederzubeleben.

Seitdem Fentanyl-verunreinigtes Heroin den Bezirk traf. Im Jahr 2014 sagte Wynn: "Ich ging zu 50 Begräbnissen."

In Baltimore, 35 Meilen nördlich, hielten ein Bürgermeister, ein Kongressabgeordneter und der Gesundheitskommissar der Stadt eine Pressekonferenz im Rathaus ab und versprachen, die Drogentodesfälle der Stadt zu reduzieren.

Der Nadelwechsler Maurice Abbey-Bey, links, und der Heroinbenutzer Alvin Wynn nahmen an einer Veranstaltung im Distrikt Marvin Gaye Park am International Overdose Awareness Day teil. (André Chung / für The Washington Post)

Aber die Mahnwache im Distrikt war informell und wurde organisiert, indem Heroinkonsumenten und Nadeltauscharbeiter geborgen wurden. Der Bürgermeister erschien nicht und die Gesundheitsbehörden der D.C. hosten keine Veranstaltungen. Für den Großteil der Landeshauptstadt war der Internationale Tag der Überdosierung nur ein weiterer Tag.

Peter Jamison schreibt über Politik und Regierung im District of Columbia. Seit 2016 arbeitet er bei der Washington Post.

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Über diese Geschichte

In den US-amerikanischen Städten sind tödliche Überdosierungen bei afroamerikanischen Heroinkonsumenten stark angestiegen, auch wenn die Diskussionen über die Opioid-Epidemie häufig auf Weiße in ländlichen und vorstädtischen Gebieten abzielen. Die Washington Post untersuchte dieses Phänomen im District of Columbia – dort, wo schwarze Einwohner heute an Überdosierungen sterben, schneller als die Weißen in West Virginia, Ohio oder New Hampshire – und untersuchte das Versagen der lokalen Regierungsbeamten, die Krise nicht zu bewältigen. Die Post verwendete Daten aus dem D.C.-Büro des Chief Medical Examiner zur Untersuchung tödlicher Opioid-Überdosierungen in der ganzen Stadt. Auf nationaler Ebene verwendete The Post Überdosisdaten aus den Zentren für Seuchenbekämpfung und Prävention. Die beim Vergleich von Landkreisen und Bundesländern verwendeten Sterbeziffern sind altersangepasst und umfassen alle Überdosierungen von Medikamenten. Die opioidspezifischen Sterblichkeitsraten von CDC sind aufgrund der inkonsistenten Berichterstattung durch die Kommunen weniger zuverlässig.
        

Der jährliche Anstieg der Buprenorphin-Behandlungsprovider wurde am 12. Dezember 2018 von der Behörde für Drogenmissbrauch und psychiatrische Versorgung erhalten und ist möglicherweise eine Unterschätzung, da die Behörde keine neuen Zertifizierungen nachverfolgt. Die Zunahme von Medicaid-Patienten, die Buprenorphin erhielten, wurde berechnet, indem der vierteljährliche Durchschnitt der Patienten des Vorjahres vom Durchschnitt des laufenden Jahres abgezogen wurde. Die durchschnittliche monatliche Naloxonverteilung pro 100.000 Einwohner wurde anhand der von den Städten bereitgestellten Daten berechnet. Im Jahr 2017 lagen für Philadelphia nur sechs Monate und für den Distrikt nur neun Monate vor.
        

Grafiken von Chris Alcantara und Kate Rabinowitz. Fotobearbeitung von Mark Miller. Design und Entwicklung von Jake Crump.
        

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