With $1.5 billion from opioid settlements, NC counties tasked with reversing epidemic

Since the start of the opioid epidemic, 3 million Americans have suffered with opioid use disorder in the United States. Longtime Fayetteville resident Betty Davis was one of them.

After experiencing "heavy addiction," she sought help at the Carolina Treatment Center in Fayetteville six years ago. While there, she overheard a conversation about North Carolina Harm Reduction Coalition and its LEAD program: Law Enforcement Assisted Diversion. Through the program, low-level offenders avoid prosecution by participation in recovery services.

"I heard someone talk about the program and I thought, 'I'm going to give it a try,'" she said.

Right away, she felt something different from other treatment programs she had attended.

"They don't treat you like a number," she said. "They check up on you. If they don't hear from you for a little while, they're going to find you, and they're going to make sure you're OK."

The program helped her find housing, which she said was a key part of her recovery. 

Not treating participants like a number means caring about the details. When Charlton Roberson, eastern regional coordinator for N.C. Harm Reduction, visited Davis, he noticed that she had very little furniture.

"Don't worry Miss Betty, we'll see about getting you some furnishings," he told her.

Roberson said it's "very rewarding work" to connect people with services to help their recovery.

"Whether it's medical attention, whether it's housing, whether it's mental health or substance abuse treatment, we are right there to help them navigate and provide low threshold access to these resources," he said.

Finding funding to aid recovery

On average, nine North Carolinians die every day from opioid overdose. It's a sobering figure, and courts found it is directly related to drug companies pushing doctors to prescribe more pain medication. 

Litigation to hold these drug makers accountable led to $50 billion in national settlements, from which North Carolina will receive $1.5 billion over the next two decades. The funds are intended to help people that now suffer from the effects of taking these strong opiates.

Nearly $1.3 billion of the funds to N.C. will flow through local governments where city and county officials will decide how to best spend their part of the pie. The remainder will be allocated by leaders at the state level.

A collaborative of five public radio stations across the state asked every county government how they intend to use the funds. Of the 100 counties, the collaborative received responses from 72, of which 34 had allocated funds. Other counties say they want to set up a task force or study commission to best decide how to use their funds. Some counties have spent money from other sources outside of settlement funds on opioid treatment projects.

North Carolina Attorney General Josh Stein helped secure the settlements and said counties may use the money in four broad categories.

"Either prevention, to keep people from becoming addicted to opioids in the future. Harm reduction, which is all about keeping people who are struggling with addiction alive and healthy. Treatment, obviously, that's core. And then the fourth is recovery. And recovery is all about sustaining that healthy lifestyle," Stein said.

Stein said the epidemic is felt most acutely at the local level, whether it's county jails, hospital emergency rooms, or local health departments.

"And it also differs from community to community in terms of the nature of the problem, and also that community's assets to respond to the crisis," he said.

Forsyth County will receive nearly $20 million over the next 18 years. 

So far, $1.3 million has been dispersed, and the lion’s share went to Twin City Harm Reduction Collective (TCHRC), a syringe exchange program headquartered in Winston-Salem. The group provides supplies including clean needles and fentanyl testing kits to anyone who requests their help, mostly via their mobile van unit. 

TCHRC has been doing this work since before syringe exchange programs were even legal in North Carolina. TCHRC Executive Director Rachel Thornley says that’s because they recognized a critical need in the community – a need that has only increased.

“Everything — I mean, the amount of syringes that we're getting back, the amount of syringes that we're distributing, the Naloxone that we're distributing definitely, the overdose reversals that are reported to us, everything has gone up tremendously, just in the last few years.”

The settlement money will allow them to operate their mobile unit for an extra day every week. 

Greg Berry, a certified peer support specialist with N.C. Harm Reduction Coalition in Fayetteville, said these kinds of programs can help lead to recovery because they don’t require someone with substance use disorder to quit using drugs cold turkey. 

"People who engage in syringe service programs are five times more likely to get connected to treatment than people who don't," he says.

In a harm reduction model, patients can receive medicines like Suboxone or buprenorphine to help wean off heroin. 

While some N.C. counties are using these methods, others are taking a different approach to use the settlement funds.

At least four southeastern counties have so far allocated funds to reserve beds at The Healing Place, a detox and residential recovery center that uses Alcoholics Anonymous and Narcotics Anonymous strategies instead of medication-assisted treatment. The center originally planned to ban anyone on medically-assisted treatment from an outside provider but relented after pressure from the U.S. Department of Justice.

Unlike harm reduction programs, The Healing Place uses a non-medical detox prior to a peer-led approach to recovery. 

Detoxing without medication can be painful and risky. After the effects of a strong opiate wear off, a person can experience severe withdrawals that can include vomiting, muscle aches, excessive sweating and more; with alcohol withdrawal, the effects can also include seizures, which can be fatal in extreme cases.

Medicines like buprenorphine for opioids and benzodiazepines or barbiturates for alcohol can reduce these withdrawal symptoms and evidence has shown the approach helps people on the road to recovery.

Although Stein has said that medication-assisted therapy, like with buprenorphine, is the standard of care, centers like The Healing Place are acceptable uses of funds, according to Stein.

Orange County, on the other hand, has embraced a harm reduction model, even using opioid settlement money to get people started on medication-assisted treatment while in jail. Caitlin Fenhagen, head of the Orange County Criminal Justice Resource Department, said this model is another tool to help people with substance use disorder.

"And that's because people who are coming out of prison who came in with an opioid use disorder are disproportionately likely to overdose," she said. "Like 40 to 50 percent more likely than the average person two weeks out of coming out of incarceration."

Orange County law enforcement agencies have signed on to this model as well. Fenhagen said the agency made Narcan, a medication used to reverse an overdose, and test strips to check for drug impurities available at the jail.

"We have a vending machine in our detention facility to give out free Narcan and fentanyl test strips and that is in the lobby so when people leave our jail they can literally go and get those materials as they walk out," she said. "Family members can walk in and get it."

Millions flowing directly to local governments

While many counties have yet to allocate funds, in far western N.C., the delay isn’t about inaction. Instead, a local commission is designing a plan for seven counties to work together to spend their collective $20 million, Southwestern Commission Executive Director Russ Harris said.

"There's just not as much leverage doing this by yourself as there is if they come together, and there may be some pretty big ticket items that nobody needs to do on their own," he said. "So it's worth looking at, is there an opportunity to have more impact if you work together as a region?" 

The collaboration is still in its early days. Harris said preliminary discussions started last year, and the commission recently hired a consultant, Omni Institute, to work on the regional plan. The counties’ first official meeting will be July 26.

“The counties have agreed to plan together as a region, so there's no agreement on implementation at this point in time. They have not agreed to pull their money together as a region. They just have agreed to do a planning process working together on that,” Harris said. 

One of the things that bubbled up as a top priority was an opioid treatment facility. 

“We do not really have enough, anywhere near enough beds in the region,” Harris said. 

The work is not the first collaboration of this kind in the area. Six of the far western counties are part of a housing consortium with the Southwestern Commission to fund affordable housing projects. 

Harris said the total amount of $20 million in settlement funds might sound like a lot of money, but it is a challenge for the counties to create the type of change needed for the area’s more than 200,000 residents. 

The current efforts by the state’s 100 counties are just the start of an 18-year process. More than $250 million will flow to local governments over the next five years. Nidhi Sachdeva, director of opioid initiatives for the North Carolina Association of County Commissioners, said the long time horizon gives counties the opportunity to make lasting change.

"We need to do both. We need to save lives today. We need to invest in direct services, keeping people alive with Naloxone, connect them with harm reduction services," she said. "And also, think about how we can provide care and services in a much more holistic, comprehensive way."

While plans are preliminary in many parts of the state, North Carolina is ahead of many other states, according to a KFF Health News investigation which found other states have not been so transparent. North Carolina is one of only 15 states to pledge public disclosure of the expenditures, according to a KHN study. Detailed information about how much each county receives is already posted online in North Carolina.

Local governments are required to keep opioid settlement money in a unique fund that can be easily audited. The Attorney General’s office also requires annual financial and impact reports, and a public dashboard showing how funds are being used.