The decision of the state medical examiner to rule the overdose death of a 24-year-old heroin addict as a homicide has rekindled questions about whether city and state officials are routinely under-reporting Baltimore's number of annual murders. Homicide statistics are generally considered to be a reliable measure of crime simply because they leave so little room for interpretation, but as the case of Amber Brown illustrates, there is still judgment involved. Circuit Court Clerk Frank Conaway and others have long argued that many of the city's overdose deaths should be considered homicides if we are to get a true picture of Baltimore's problems.
Their complaints are baseless and potentially dangerous. Medical Examiner David R. Fowler's reason for declining to state a cause of death in most overdose cases is reasonable from a criminal justice perspective and crucial for Baltimore's successful efforts to treat overdoses as a public health problem.
Without knowing the specifics of what happened in the moments before a fatal dose was taken, it's impossible to say for sure whether a death was a homicide, accident or suicide. Most importantly, Dr. Fowler is consistent. His office has been operating in the same way since at least 1993, which means the statistics for homicides and overdose deaths are comparable from one year to the next. That may contribute to the difficulty of comparing Baltimore's statistics with other cities', but it preserves the most valuable and reliable use for the data, which is to gauge long-term trends.
If the medical examiner were to routinely treat overdose deaths as homicides, it could have precisely the opposite of the desired effect. If addicts become fearful that they could face criminal charges — which is a possibility for Ms. Brown's companion who helped her inject drugs the day she died — they may become less likely to call for help when they see someone overdose. That could threaten one of the most encouraging trends in Baltimore in the last decade: a rapid decline in the number of people who are dying from overdoses.
The annual count of Baltimore overdose deaths declined by nearly 60 percent in the decade that ended in 2009, and researchers say the trend has continued. Though it's impossible to say for sure what has caused the drop in deaths, the change has coincided with a number of targeted efforts to tackle drug abuse as a public health problem rather than as one of criminal justice.
Opiate substitutes for heroin addicts have become more widely available in recent years, and in particular, the advent of buprenorphine since 2002 may have had a significant effect. Unlike methadone, buprenorphine does not typically require daily visits to a clinic and is thus easier to prescribe and to use. As a result, when he was city health commissioner, Joshua Sharfstein was able to convince a number of treatment programs that had previously not offered drug replacement therapy to begin doing so.
Another factor in the decline in overdoses was a program started by Dr. Sharfstein's predecessor, Peter Beilenson, that trained addicts in recognizing the signs of overdose and provided them with training — and in some cases, opiate antagonists — to help treat overdose victims before an ambulance can arrive.
The expansion of Medicaid eligibility under Mr. O'Malley's administration as governor has also transformed the nature of drug treatment in the state. Now that tens of thousands of childless, low-income adults are eligible for coverage under the program, far more addicts are able to pay for drug treatment. As a result, waiting lists for treatment programs have all but vanished, and the number of Marylanders receiving drug treatment through Medicaid has more than doubled in the last four years.
But just as the homicide count is an imperfect proxy for the level of crime in Baltimore, so too is the number of overdose deaths insufficient to gauge the extent to which the city has reduced its problem with drug addiction. Researchers have not been able to conclusively determine the extent to which the drop in deaths corresponds to a decline in drug use. Nonetheless, it is encouraging that deaths like Ms. Brown's are becoming less and less common. Routinely treating them as homicides, however, might stall or even reverse that progress. Dr. Fowler's approach over the last 20 years has been sound; he should stick to it.