How do the opioid epidemics in Maryland and California differ regarding demographic characteristics, mortality trends, and the impact of interventions like naloxone distribution and buprenorphine access?

Comparison of Maryland and California Opioid Epidemics

Maryland's opioid epidemic is substantially more severe than California's, with Maryland experiencing one of the highest age-adjusted opioid death rates in the nation (37.2 per 100,000 in 2017), while both states face critical barriers in buprenorphine access, though California has taken more aggressive policy steps to reduce treatment barriers. 1

Mortality Trends and Severity

Maryland's Disproportionate Impact

• Maryland ranks among the top three states nationally for opioid overdose deaths, with an age-adjusted death rate of 37.2 per 100,000 in 2017, placing it third highest in the United States behind only West Virginia (51.5) and Delaware (43.8). 1
• Between 2018-2022, Maryland documented 11,455 opioid overdose deaths, with 80% occurring among employed individuals, indicating the epidemic's penetration across working populations. 2
• Fentanyl and heroin have disproportionately impacted Maryland's urban Black population, with Black opioid death rates exceeding White rates by four- to six-fold in Baltimore and other major urban centers. 3
• Baltimore's opioid death rates were elevated two-fold over all other regions of Maryland, with this urban concentration pattern intensifying through 2020. 3

California's Relative Position

• While specific California mortality data is not provided in the evidence, the state was not listed among the highest-mortality states in 2017, suggesting lower per-capita death rates compared to Maryland and Appalachian/Northeastern states. 1
• The national epidemic disproportionately affected ages 25-54 years, with highest death rates in ages 25-34 (38.4 per 100,000), 35-44 (39.0 per 100,000), and 45-54 (37.7 per 100,000), a pattern likely reflected in both states. 1

Demographic Characteristics

Maryland's Unique Patterns

• Maryland demonstrates stark racial disparities, with African Americans experiencing four- to six-fold higher opioid death rates compared to White residents, particularly in urban areas like Baltimore. 3
• Occupational analysis reveals construction and extraction workers (291 deaths per 100,000 workers), transportation and material moving workers (137 per 100,000), and installation/maintenance workers (133 per 100,000) face highest risk. 2
• Males account for 72% of Maryland's opioid deaths, with significantly higher incidence rates than females across all occupational categories except those not in the labor force. 2
• Non-Hispanic whites comprise 55% of Maryland's opioid deaths, though they experience lower rates in military-specific occupations compared to other racial/ethnic groups (IRR=0.53). 2

Geographic Distribution Differences

• Maryland's epidemic is concentrated in urban centers, particularly Baltimore, representing a pattern distinct from the initially rural-focused national narrative. 3
• The hardest-hit states nationally were concentrated in Appalachia and the Northeast, with Maryland positioned as a Northeastern hotspot. 1

Treatment Access and Interventions

Buprenorphine Access Barriers

Both states face critical buprenorphine access limitations, though California has implemented more progressive policy reforms:

• California has only 7 physicians with buprenorphine waivers per 100,000 residents, representing severe treatment capacity constraints. 4
• Nationally, less than 4% of prescribers (approximately 37,000 physicians) had buprenorphine waivers as of August 2016, with many waivered physicians not actively treating patients. 4
• Barriers include lack of institutional support, insufficient mental health and psychosocial support, time constraints, lack of specialty backup, lack of confidence in managing opioid addiction, and resistance from practice partners. 4

California's Policy Innovations

• California's Medi-Cal program eliminated the Treatment Authorization Request requirement for buprenorphine treatment of opioid use disorder, representing a significant access improvement. 4
• This policy change directly addresses insurance-related barriers that many Medicaid programs maintain due to concerns about cost and safety, despite evidence showing buprenorphine has similar mortality rates to methadone with lower mean annual spending. 4

Naloxone Distribution

• By August 2016, both California and Maryland (as part of the District of Columbia region) had adopted legal immunity laws protecting individuals who use naloxone or call 911 for overdose assistance. 4
• Thirty-seven states and DC had immunity protections for laypeople, while 47 states and DC granted immunity to medical professionals prescribing or dispensing naloxone. 4
• Naloxone price increases from $120 to $330 for prefilled syringes and $690 to $4,500 for auto-injectors (2014-2016) created access barriers affecting both states. 4

Polysubstance Involvement

• Benzodiazepine co-involvement occurred in 62.6% of all opioid deaths nationally in 2018, increasing death rates 3- to 10-fold compared to opioids alone. 1
• This polysubstance pattern likely affects both Maryland and California, though Maryland's higher overall mortality suggests potentially greater polysubstance involvement. 1

Critical Clinical Implications

Treatment Recommendations

• Medication-assisted treatment with buprenorphine demonstrates an 80% reduction in illicit opioid use along with significant increases in employment and recovery indices. 4
• Buprenorphine outcomes are similar to methadone, with the advantage of office-based treatment rather than clinic-based delivery. 4
• Daily buprenorphine dosages of 16 mg are sufficient for most pregnant women, though doses can range from 4-24 mg daily, with higher and more frequent dosing potentially required during pregnancy. 4

Common Pitfalls

• The insistence on buprenorphine/naloxone combination products over monoproduct can foster stigma and mistrust, creating barriers to care despite naloxone's theoretical low sublingual bioavailability. 5
• Providers must recognize that adverse effects from the naloxone component may be less benign than generally accepted, potentially affecting the provider-patient relationship and treatment adherence. 5
• Switching from methadone to buprenorphine requires careful monitoring due to withdrawal precipitation risk, while switching from buprenorphine to methadone can be done immediately in the absence of sedation. 4