Maryland's Opioid Epidemic: Understanding the Crisis in Baltimore and Beyond

Maryland does not fit the national narrative of the opioid crisis as a “rural” or “suburban” phenomenon. The state’s overdose death rate has long ranked among the highest in the United States per capita — and the epicenter has been Baltimore City, one of the most densely populated urban areas on the East Coast. But in recent years, the crisis has spread well beyond Baltimore’s rowhouses into suburban counties like Prince George’s and Montgomery, into rural Western Maryland, and across the Eastern Shore.

Understanding Maryland’s opioid crisis — its history, its current shape, and where help is available — is essential for residents, families, and communities trying to respond to it effectively.

By the Numbers: Maryland’s Overdose Toll

The Maryland Department of Health (MDH) publishes overdose data through its Behavioral Health Administration (BHA). The numbers tell a devastating story:

• Maryland consistently records more than 2,000 drug- and alcohol-related overdose deaths per year
• The opioid-specific overdose death rate in Maryland has ranked among the top five in the nation in recent years, according to data from the Centers for Disease Control and Prevention (CDC)
• Fentanyl and other synthetic opioids are involved in the overwhelming majority of opioid overdose deaths statewide
• Baltimore City has historically had among the highest per-capita heroin use rates of any city in the United States, a distinction rooted in decades of social, economic, and structural factors

The Substance Abuse and Mental Health Services Administration (SAMHSA) includes Maryland in its analyses of states with the most severe opioid crises, and federal opioid response funding has consistently targeted Maryland as a high-need state.

How Maryland Got Here: A Historical Overview

The Heroin Foundation

Baltimore’s heroin problem predates the current opioid epidemic by decades. Heroin arrived in significant quantities in Baltimore in the 1950s and grew through the 1960s, 1970s, and 1980s. By the time the nationwide “crack” crisis of the 1980s drew national attention, Baltimore was simultaneously experiencing a heroin crisis that the rest of the country largely ignored.

The reasons are structural as much as they are circumstantial. Baltimore’s industrial economy collapsed in the latter half of the 20th century, leaving large swaths of the city in concentrated poverty. Disinvestment, segregation, and the mass incarceration policies of the War on Drugs era devastated communities already struggling with limited economic opportunity. Heroin filled a vacuum.

By the early 2000s, Baltimore had approximately 60,000 heroin users — an astonishing number for a city of approximately 640,000 people, as documented by researchers at Johns Hopkins Bloomberg School of Public Health, one of the nation’s leading institutions for addiction research and public health.

The Prescription Opioid Wave

Maryland was not spared the national prescription opioid crisis of the 2000s. Opioid prescribing increased dramatically throughout the state — in suburban and rural areas as well as Baltimore — and pill-based addiction took hold among populations with no prior heroin history. When OxyContin and other opioids became harder to obtain, many transitioned to heroin, which was cheaper and increasingly available.

The Fentanyl Transformation

Beginning around 2015–2016, fentanyl began appearing in Baltimore’s heroin supply in increasing quantities. At first it was mixed with heroin; over time, the drug supply shifted to the point where most of what is sold as heroin in Baltimore and throughout Maryland is now primarily fentanyl. The CDC identifies this shift as one of the key drivers of the dramatic increase in overdose deaths nationally.

Fentanyl is 50 to 100 times more potent than morphine by weight. A quantity invisible to the naked eye can be a lethal dose. The contamination of the drug supply with fentanyl — and more recently, fentanyl analogs like carfentanil, which is 10,000 times more potent than morphine — has made using any street drug an act of profound and often unknowing risk.

The Geographic Spread: Beyond Baltimore

While Baltimore City remains the crisis’s epicenter, MDH data shows alarming overdose death rates throughout the state:

Prince George’s County: The Washington suburb has experienced significant increases in overdose deaths, driven partly by demographics — a large young adult population with increasing fentanyl exposure — and partly by geographic proximity to both Baltimore and Washington, DC supply networks.

Montgomery County: Maryland’s most affluent county has not been immune. Overdose deaths have increased here too, and the demographics increasingly include professionals, young adults, and people with no prior substance use history who are exposed through contaminated substances.

Western Maryland: Garrett, Allegany, and Washington counties have high rates of substance use disorder relative to population, limited treatment infrastructure, and significant social and economic stressors.

Eastern Shore: Rural counties like Wicomico, Somerset, and Dorchester face the dual challenges of high substance use disorder rates and limited treatment access.

The Role of Co-Occurring Conditions

Baltimore’s opioid crisis cannot be understood apart from the social determinants that amplify it. The National Institute on Drug Abuse (NIDA) and SAMHSA both identify poverty, trauma, lack of educational opportunity, housing instability, and untreated mental health conditions as major risk factors for substance use disorder.

Baltimore City has some of the highest rates of childhood trauma exposure (adverse childhood experiences, or ACEs) in the nation. Poverty is concentrated in specific neighborhoods — the same neighborhoods where heroin and fentanyl use have historically been highest. The intersection of addiction, mental illness, poverty, and housing instability creates needs that no single system — treatment, housing, mental health, or employment — can address alone.

Maryland’s Response: Harm Reduction and Treatment Expansion

Maryland has invested significantly in evidence-based responses to the opioid crisis:

Naloxone access: Maryland law allows naloxone to be dispensed without a prescription, and the state has funded extensive naloxone distribution through harm reduction programs, pharmacies, and first responders. This has prevented thousands of overdose deaths.

Fentanyl test strips: Maryland decriminalized fentanyl test strips, allowing people who use drugs to test their supply for fentanyl contamination — an important harm reduction tool.

MAT expansion: Maryland has expanded access to medication-assisted treatment (MAT), including buprenorphine and methadone, through additional Opioid Treatment Programs and an increased number of physicians authorized to prescribe buprenorphine.

Drug courts and diversion: Maryland’s drug courts and Law Enforcement Assisted Diversion (LEAD) programs aim to divert people with addiction from incarceration into treatment.

Behavioral Health Crisis Centers: Maryland has invested in crisis center infrastructure to provide immediate stabilization and treatment connections.

The Maryland Behavioral Health Administration (BHA), within the Maryland Department of Health, is the primary state agency coordinating the opioid response. SAMHSA grants — including State Opioid Response funding — have significantly expanded Maryland’s treatment capacity.

Warning Signs of Opioid Use Disorder

The CDC and NIDA identify these warning signs:

• Using opioids in larger amounts or for longer than prescribed or intended
• Inability to control or reduce opioid use
• Spending excessive time obtaining, using, or recovering from opioids
• Strong cravings or urges to use
• Failing major role obligations at work, home, or school
• Continued use despite social or interpersonal problems it causes
• Withdrawal from social activities
• Use in physically hazardous situations
• Tolerance and withdrawal symptoms

If you recognize these signs in yourself or someone you love, treatment works — and it is available in Maryland.

Get Help Today

Maryland’s opioid crisis is severe, but recovery is real and it happens every day across this state. If you or someone you love is struggling with opioid use disorder, our Maryland Addiction Hotline can connect you with treatment programs, verify insurance coverage, and help you take the first step.

Call our Maryland Addiction Hotline now. Confidential, free, and available 24/7. Help is closer than you think.