The federal Health Resources and Services Administration awarded the Franklin-based Full Circle Recovery Center $100,000 to purchase and distribute naloxone, which reverses the effects of heroin overdose, and to provide training in how to use it.

By Taylor Sisk

Heroin users are 20-something professionals. They’re somebody’s grandma.

They’re male and female, rich and poor, have post-graduate degrees and GEDs. They’ve done some federal time. And they had never done any hard stuff until that herniated disc.

Rural Rx: NC Health News coverage of rural health issues. This week: Macon County and Western North Carolina.
Rural Rx: NC Health News coverage of rural health issues. This week: Macon County and Western North Carolina.

No longer confined to a stereotype – the all-in, emasculated, no-exit junkie – the face of heroin must now be acknowledged as someone who looks like you.

In 2002, 214,000 people in the U.S. reported a heroin dependence; in 2012, the number had risen to 467,000.

Heroin addicts live in rural areas – increasingly so. They’re your neighbors to the east and west. More than three of four heroin users surveyed in a 2014 study published in JAMA Psychiatry reported living in small urban or non-urban communities. Heroin use challenges already inadequate health care services, and with it comes spikes in Hepatitis C, among other heightened health risks.

Some communities are mobilizing.

A community-based network of concerned officials and citizens in Franklin, the county seat of Macon County in the rural southwestern corner of the state, is aiming to get people to the treatment they need. On Set.17, Full Circle Recovery Center was awarded a federal Health Resources and Services Administration Rural Opioid Overdose Reversal grant to support this network, called the Macon Overdose Prevention Coalition.

The grant provides $100,000 to be used to purchase and distribute naloxone, which reverses, almost instantly, the effects of heroin overdose, and to train health care professionals and emergency responders in how to administer it.

Full Circle and the Granville-Vance District Health Department in Oxford, northeast of Raleigh, were the only North Carolina agencies among 18 selected nationwide.

The harm reduction movement

“I can tell you that I’ve never met a family in Macon County that hasn’t been touched in some way, either from a kid or a parent or a grandparent who had pain medication after a hip replacement,” said Stephanie Almeida, Full Circle’s founder and CEO, of opioid overdose.

People are dying. The number of confirmed heroin overdose deaths in North Carolina in 2010 was 38; in 2013, it was 170.

Stephanie Almeida is founder and CEO of the Full Circle Recovery Center in Franklin. Photo credit: Taylor Sisk
Stephanie Almeida is founder and CEO of the Full Circle Recovery Center in Franklin. Photo credit: Taylor Sisk

Communities, urban and rural, are responding to what is now widely termed the “heroin epidemic.” They’re responding on a number of fronts, including reducing harm among drug users. A harm reduction movement has been gaining traction across the country in general and in the South in particular.

Movement advocates focus not on getting users to quit drugs immediately, but on keeping them alive and as healthy as possible until the day they decide to quit and can follow that decision through. Among their primary tools is naloxone.

EMTs are required to carry naloxone. And Project Lazarus, which operates in all 100 of the state’s counties through the Community Care of North Carolina network, also now distributes it in Macon County to people coming out of treatment. They also give it to senior citizens.

Macon County Commissioner Ronnie Beale, who until this summer served as president of the state Association of County Commissioners, said that because naloxone is new to rural counties, law enforcement administrators still had some questions about its use – about storing it at the proper temperature, for example – but that “as they become more acquainted, more comfortable, and receive the training,” he’ll support officers carrying it.

Beale believes the outreach Full Circle will offer with the federal grant money will provide that education.

“We are excited to get the grant,” he said. “We wish the grant wasn’t necessary, but it is.”

Saving lives and money

The 2015-16 state budget, signed last month by Gov. Pat McCrory, allocated $50,000 for naloxone; $25,000 will be made available to law enforcement agencies that want to buy it and $25,000 will go to the N.C. Harm Reduction Coalition‘s community distribution program.

Contents of a naloxone reversal kit distributed by the NC Harm Reduction Coalition.
Contents of a naloxone reversal kit distributed by the N.C. Harm Reduction Coalition include naloxone, syringes and needles for administration, directions for use and information about getting clean. Photo credit: Rose Hoban

NCHRC reports more than 1,100 naloxone overdose reversals statewide between August 2013 and the end of last month – 276 in Asheville alone. Franklin had three reported reversals, while the community of Otto, located eight very rural miles south, had four.

The vast majority of NCHRC’s naloxone kits are given out at medication-assisted treatment centers. Clients of the clinics then carry them back to their communities. NCHRC staff also regularly visit clinics to pass out kits.

Robert Childs, NCHRC’s executive director, said that a two-dose kit of injectable naloxone sells today for about $50, the nasal-spray version for $90 to $140 and the auto-injector EVZIO for a couple of hundred.

In contrast, the Agency for Healthcare Research and Quality reports that the average cost in 2008 for inpatient treatment for opioid overdose poisoning was $16,970.

‘Laying out flat’

Stephanie Almeida speaks of the ripple effects heroin has throughout a community: “I see lots of people unable to hold jobs, unable to take care of their family, unable to maintain their household,” she said. “I see a lot of people with a lot of promise that are really stuck in a place that without realistic interventions are going to be stuck there for a long time.”

Harm reduction, she believes, is an intervention that allows people who’ve gotten in deep time to get back to a more productive place.

Judy Johannsen has conducted research on substance abuse and solutions in Macon County. Photo credit: Taylor Sisk
Judy Johannsen has conducted research on substance abuse and solutions in Macon County. Photo credit: Taylor Sisk

Judy Johannsen is a Franklin resident and drug-treatment activist who’s been in recovery from drug and alcohol use for 25 years. She recently completed a master’s in social work degree at Western Carolina University. Her last semester, she and her research partner, Ward Price, authored a study titled “Reducing Harm in Macon County, NC: Providing Lifesaving Tools for Opiate Users in Rural Appalachia.”

In the course of her research, Johannsen discovered that substance abuse wasn’t even mentioned in Macon County’s 2013 Community Health Improvement Plan. She began writing to potential allies and asked if she could speak to them about harm reduction.

On her first pass, she received but one response, from Scott Marion, chief medical officer for the Macon County Detention Center. Marion recognized that naloxone could save lives under his watch.

“People would get busted for drugs and ingest everything they had, and nobody would know,” Johannsen said. “And then all of a sudden, they’re laying out flat in his custody.”

Marion now offers naloxone.


Over time, Johannsen came to see that the abstinence-based treatment that had helped her get and stay clean, and that she and others had worked so hard to get implemented in Macon County, “was part of the problem.”

The general public stigmatizes harm reduction, she said, and it’s no better received in the abstinence community. It’s hard for many to accept that there can be a path to recovery other than a 12-step program.

In fact, she said, there are many such paths. “Yours doesn’t have to be like mine.”

“But you go to one of those [12 step] meetings and say you’re on methadone, and you won’t be well received.” That’s got to change, Johannsen said, “and I talk it up all the time.”

“Until we change some attitudes,” Franklin Mayor Bob Scott said, “and that is to realize that we’ve got a problem – recognizing the problem rather than demonizing the problem – until we do that, we’re not going to get a handle on the drug thing.”

Almeida agrees: “It’s the beliefs and the perceptions of the community that have to change, the stigma. If we don’t change the perception of what we think of when we think of a heroin addict, then we’re never going to reach them. There’s a human in there who’s suffering, and they deserve help if they want it.

“Now where do we get it for them? There’s the challenge.”

[box style=”2″]This story was made possible by a grant from the Winston-Salem Foundation to examine issues in rural health in North Carolina. [/box]

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