Levels of Care for Baltimore City Hospitals Responding to the Opioid Epidemic

On April 30, 2018, Baltimore City leadership along with the leadership of Baltimore City's 11 acute-care hospitals, launched the Levels of Care for Baltimore City Hospitals Responding to the Opioid Epidemic initiative. This program provides a shared, evidence-based framework for hospitals to implement best practices in addressing the crisis. Through strong partnerships, almost all emergency departments in the city screen patients for substance use disorder, offer immediate treatment for those who screen positive, and employ peer recovery specialists to ensure continuity of care.

The Central Role of Hospitals

Opioid-related emergency department visits have been steadily increasing over the last few years, with a 20% increase from 2016 to 2023. (Data sourced from the Maryland Department of Health Overdose Data Portal, which was last updated in August 2024.) According to an article published in the Journal of Hospital Medicine, up to one-quarter of hospitalized patients have a substance use disorder (SUD).

Given these trends, opioid-related policies and protocols in hospitals continue to be crucial. Evidence supports various effective interventions:

  1. Naloxone Distribution: Hospitals can prescribe or dispense naloxone, a medication that reverses opioid overdoses. One study found that nearly one-third of emergency patients who received naloxone used it to save someone during an overdose.

  2. Treating Opioid Use Disorder: Initiating addiction treatment in the emergency department significantly boosts patient engagement in treatment after 30 days (78% vs. 45% when referred to community providers). Another study reported a 75% reduction in opioid use six months after inpatient-initiated addiction treatment.

  3. Addiction Consult Services: These services effectively diagnose addiction, start treatment, and connect patients to ongoing care. Peer recovery specialists, who are in recovery themselves, also enhance treatment effectiveness.

Preventing new cases is as important as treating existing ones. Strategies to reduce opioid prescribing, such as following guidelines, have been effective. This approach is particularly relevant in Baltimore, where opioid use disorder is prevalent.

Building on Progress through Levels of Care

Baltimore City hospitals participating in the Levels of Care initiative are assessed based on various evidence-based criteria, such as a hospital's ability to provide treatment to patients who screen positive for substance use disorder, distribute naloxone, connect patients with peer support services or other forms of assistance, and ensure responsible opioid prescribing practices among physicians. By meeting these criteria, hospitals demonstrate their commitment to providing effective treatment, reducing harm, and supporting patients on their path to recovery. Hospitals can be classified as level 3, 2, or 1, with level 1 hospitals offering the most comprehensive response to the opioid crisis.

The initiative takes inspiration from a successful program in Rhode Island. In Rhode Island, all hospitals have successfully attained the level one designation established by the Rhode Island Department of Health.

Levels of Care for Baltimore City Hospitals Responding to the Opioid Epidemic 

Level of Care Action

A Level 3 hospital:
  1. Screens emergency department (ED) patients for at-risk substance use and substance use disorder (SUD)
  2. Has an ED discharge protocol (as required by state law) that includes a referral to community-based treatment for patients with SUD
  3. Prescribes naloxone to ED patients at high risk for opioid overdose
  4. Maintains capacity to initiate medication-assisted treatment for ED patients with opioid use disorder (OUD)
  5. Promulgates guidelines for judicious prescribing of opioid analgesics across the hospital system
  6. Provides information about safe storage and disposal to patients who are prescribed opioids

A Level 2 hospital meets the criteria of Level 3 and:
  1. Offers peer recovery specialist services or similar support services to ED patients
  2. Screens directly admitted patients for at-risk substance use and SUD
  3. Prescribes naloxone to admitted patients at high risk for opioid overdose
  4. Maintains capacity to initiate medication-assisted treatment for admitted patients with OUD
  5. Monitors fidelity to prescribing guidelines and addresses cases of injudicious prescribing

A Level 1 hospital meets the criteria of Levels 3 and 2 and:
  1. Maintains capacity to initiate medication-assisted treatment for admitted patients with OUD with at least one formulation of each medication approved by the U.S. Food and Drug Administration for that purpose
  2. Offers peer recovery support services or similar support services to admitted patients
  3. Dispenses naloxone to ED patients and admitted patients at high risk for opioid overdose
  4. Screens patients in hospital campus outpatient clinics for at-risk substance use and substance use disorder (SUD)
  5. Offers ongoing medication-assisted treatment in the appropriate hospital campus outpatient clinics, including clinics that do not specialize in the treatment of substance use disorder

Current Levels of Care Designations

Baltimore City Hospitals

Levels of Care

Johns Hopkins Bayview Medical Center
Johns Hopkins Hospital
University of Maryland Medical Center
University of Maryland Medical Center Midtown Campus

 1

MedStar Good Samaritan Hospital
MedStar Harbor Hospital
MedStar Union Memorial Hospital
Mercy Medical Center

 2

Ascension Saint Agnes Hospital
Sinai Hospital of Baltimore 

 3

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