Former Baltimore health commissioner, Maryland health secretary testifies in city’s opioid trial: ‘We were on the right track’

Dr. Joshua Sharfstein took over as Baltimore City Health Department in 2005, at a time when heroin overdose deaths were declining. One of his key responsibilities under then-Mayor Martin O’Malley was to further reduce the number.

Sharfstein was the driving force behind an initiative to expand access to buprenorphine, an opioid used to treat heroin withdrawal. Overdose deaths dropped to about 100 in 2009, the year Sharfstein stepped down as city health commissioner after being appointed by former President Barack Obama to head the U.S. Food and Drug Administration.

From a peak of 312 heroin deaths in 1999, Baltimore reached a low of 76 deaths in 2011, when Sharfstein returned to the city, this time as Maryland’s health secretary, again under O’Malley, who had been elected governor.

But shortly after his return to Maryland, Sharfstein testified Thursday in Baltimore Superior Court, he and other health officials noticed a troubling trend. Under his leadership, the state Department of Health and Human Services sent a letter to all Maryland physicians on Dec. 7, 2012, asking for their help.

“Over the past decade, a growing epidemic of prescription drug abuse has led to a significant increase in overdose deaths involving pharmaceutical drugs, often involving physician-prescribed opioid painkillers,” the letter, which was shown in court, said. “Enhanced controls on these medications and improved prescribing practices have been implemented to combat this trend.”

While deaths from prescription drugs were declining at the time, deaths from heroin were rising again, the letter continued.

“One possible explanation is that people who find it increasingly difficult to obtain prescription drugs for non-medical use are turning to heroin,” it said.

Sharfstein was the first person to take the witness stand in Baltimore’s long-awaited civil trial against drug distribution companies McKesson and AmerisourceBergen. The city alleges that those companies alone shipped hundreds of millions in addictive painkillers into Baltimore from 2006 to 2019, with little regard for the havoc they allegedly caused.

A city attorney described the crisis in Baltimore as “the worst opioid epidemic in America” and accused drug distributors of overlooking “suspicious orders” from “pill mill” doctors.

According to Bill Carmody, the companies created a new generation of addicts, people who died in unprecedented numbers as their subscriptions expired and they turned to an illegal drug market flooded with deadly fentanyl, a synthetic opioid even deadlier than heroin.

Sharfstein’s testimony bolstered the city’s case and provided a preview of the strategies the companies are using to combat the problem.

“We were on the right track,” Sharfstein said, “until something happened and threw us off course.”

In opening statements, attorneys for McKesson and AmerisourceBergen said their companies supplied opioids and other drugs only to licensed pharmacies that filled doctors’ prescriptions. They blamed cartels, gangs and drug trafficking organizations for bringing heroin and fentanyl into Baltimore, and pointed to the criminal element as the source of the overdose crisis.

“As health commissioner, have you looked at who was selling illegal drugs?” Timothy C. Hester, an attorney for McKesson, asked Sharfstein.

“Not really,” said Sharfstein.

Hester pointed out during his questioning that the vast majority of opioid-related deaths included in a Department of Health chart that broke down such deaths from 1995 to 2006 were attributable to heroin rather than prescription opioids. He also asked whether Sharfstein, when he was health minister, was concerned about doctors overprescribing opioids.

“I was concerned about the prescription drug epidemic in Maryland, which included overprescribing,” said Sharfstein, who now works at the Johns Hopkins Bloomberg School of Public Health and serves part-time as a health policy advisor to Baltimore Mayor Brandon Scott.

City attorneys also asked Sharfstein about a Jan. 31, 2014, press release from the health department that warned of a “potent and deadly drug combination” discovered during autopsies. The announcement raised alarms about heroin being contaminated with fentanyl.

“That was a huge concern for us. … We knew at the time that there were a lot of people with opioid addiction,” Sharfstein recalled.

The city alleges that the distributors’ actions amounted to a public nuisance that deprived residents of their right to health and safety. In order for the jury to find the companies liable, Judge Lawrence P. Fletcher Hill told jurors Thursday, the city must prove that “one or both of the defendants” created the public nuisance.

To further support her cause, the city invited Yolanda Cason, from the Public Works Department’s Solid Waste Bureau, and Rania Mohamed, from the Public Health Department, to testify about their work in keeping the city clean during the opioid crisis and helping those trapped in the vicious cycle of addiction.

Cason, who has worked for the public works department for 31 years, says she didn’t see many signs of addiction growing up in Baltimore, but “now you see it everywhere.”

“It’s really hard to keep the city clean,” Cason said, noting that her team deals with dirty mattresses, drug-related items and human waste on a daily basis.

She said it had become such a problem that her agency had to hire a biohazard company and purchase puncture-resistant gloves to prevent workers from being stabbed by used needles.

“You see drug use in those areas,” Cason said, “there’s a lot more trash.”

Mohamed, meanwhile, spoke about the Department of Health’s syringe service and opioid reversal programs, which have distributed 17.6 million clean syringes in the past 30 years, and reversed over 7,000 overdoses in the past 20 years, respectively.

She testified about the health department’s efforts to help people with opioid addiction, including setting up mobile clinics specifically designed to provide resources and wound care, and building partnerships to help people with substance abuse and provide additional resources, such as housing assistance.

“It is very important that we do not ignore and abandon people because they suffer from an illness,” said Mohamed.

Megan L. Rodgers, an attorney for McKesson, suggested in her questioning of Mohamed that syringe services were only meant for people who used illegal drugs. She also confronted Mohamed with a Department of Health and Human Services strategic plan to address Baltimore’s opioid epidemic.

“Wholesalers aren’t mentioned, right?” Rodgers asked.

“They are not directly mentioned,” Mohamed replied, “but that does not mean there is no connection.”