By Taylor Knopf

As North Carolina officials are cracking down on opioid prescribing, some medical professionals weren’t surprised by the concurrent increase in IV drug use and the diseases that come along with it, such as HIV and hepatitis C.

a pair of hands holds several bags containing literature and one containing a nasal applicator for naloxone. One of the pieces of literature reads: Opioid Overdose Prevention and Survival
Madison Substance Awareness Coalition Coordinator Heather Sharp shows a package of naloxone, a medication that either snorted or injected can reverse an opioid overdose in seconds. Photo credit: Taylor Knopf

In Madison County, a rural stretch of mountains northwest of Asheville, the county health director and local sheriff are teaming up to tackle these issues.

Madison County Sheriff James “Buddy” Harwood said when he first took office in 2009, all he saw were “pills, pills, pills.” Now, it’s heroin and methamphetamine.

“Heroin is so cheap,” he said.

The reduction in pill use has occurred, in part, because of systemic changes in the medical community. Madison County Health Director Marianna Daly said local providers have cut down on opioid prescribing in recent years.

“Hepatitis C is indirectly coming from opioids because it was well known and anticipated that when prescribing decreased, that folks would turn to something else,” she said. Something else that would likely require injecting a drug in order to get high.

“The heroin epidemic was anticipated,” Daly said. “It’s a whack-a-mole situation. One thing goes down and then another pops up.”

Lively debates

So, Daly is pushing back against the spread of disease. She applied for and received a FOCUS (Frontlines of Communities in the United States) grant from Gilead Sciences, Inc. to screen more people for hepatitis C. Gilead is one of the pharmaceutical companies that’s manufacturing next-generation cures for the disease.

Daly included jail inmate screenings in her grant application.

The jail is conveniently located right next door to the county medical center. The goal is to screen inmates who will be at the jail for more than three days, and Sheriff Harwood is on board.

photo taken from in front of the jail, shows medical center about 100 yards ahead
Standing in the parking lot of the Madison County Jail, you can see Hot Springs Health Program on the left and the Madison County Health Department straight ahead. Photo credit: Taylor Knopf

He said it would be helpful to screen for hepatitis C, because officers need to know who has contagious diseases before, say, stepping into a fight. Inmates must also be cleared of contagious diseases to work in the jail kitchen.

Harwood just wants to make sure that if he allows screening for hepatitis C, the county will not be responsible for the inmate’s treatment bill. The county usually pays for inmate medical expenses.

Harwood runs a 74-bed facility and said on average, 90 percent of the inmates are arrested on drug charges.

Daly is looking for creative ways to treat inmates without the county picking up the tab. Because hepatitis C often takes years to present symptoms, there is no rush on treatment.

“There is evidence that if you know you’re positive, it may change your behavior,” Daly said. “Even if you start back on some of your bad habits upon release, […] you might not share a needle if you know you’re positive.”

Daly and Harwood are also talking with a local judge to figure out if it’s possible to incorporate screenings and treatment into an offender’s sentence.

The two will have lively debates about disease prevention methods such as a syringe exchange —  Daly sees it as a harm reduction effort, while Harwood sees it as drug enabling — but ultimately they have a healthy respect for one another.

“I think Dr. Daly, with the many hats she wears, has bent over backward to make sure the inmates coming and going from this jail leave here in a much better condition than they come here in,” Harwood said.

Daly smiled.

Reaching the rural community

Daly said her long-term hope is to create a clinic at the health department where she could see and treat people who inject drugs.

Originally from Durham, Daly has lived in western North Carolina for decades. Photo courtesy: Hot Springs Health Program website.

“A clinic where somebody who is using can come and get a regular physical, get birth control, get tests, tell them where to get syringes… whatever.”

She would also like to be able to provide people injecting drugs with naloxone, a medication that either snorted or injected can reverse an opioid overdose in seconds.

Finding a pathway to the population is key though. Daly thinks it boils down to finding one person to trust her and tell their friends.

“So once somebody has a positive experience and feels like they weren’t judged, and it was all above board, I think word would spread very, very fast,” she said. “That’s the big picture of what we are trying to do.”

One way to do that is through the Madison Substance Awareness Coalition, which was started through grant funding at the health department about two and a half years ago.

Coalition coordinator Heather Sharp said it came together because the county officials noticed an increase in overdoses which were affecting the community and families. She said there was also an increase in substance related child abuse referrals at the county department of social services.


The coalition has more than a dozen partners in the community, such as law enforcement, medical and mental health professionals, education, faith, business and rotary.

“Each of us have a population that we serve, but collectively we are all trying to reduce substance abuse in our county,” Sharp said.

The coalition and its volunteers also provide education to all senior centers in the county.

“Not only could they accidentally take too much medication and overdose, but maybe there is a loved one who is struggling and might want to visit their medicine cabinet,” Sharp said. “So we were able to provide lockboxes for all of them to lock up their medications.”

The coalition is heavily involved in the public schools. Volunteers teach elementary kids not to touch other people’s medications. Sharp teaches alcohol, tobacco and drug classes to all middle schoolers in Madison County. And high schoolers are hosting teen town halls and events to teach their peers about substance abuse.

“We start little,” Sharp said. “Our range of prevention is kindergarten through the elderly in the senior centers.”

Because the health department has a good relationship with the sheriff, Sharp and Daly helped bring naloxone, the opioid overdose reversal drug, to all law enforcement in Madison County starting in 2015. Sharp is also working to provide naloxone to citizens who are around people at risk of overdose.

“And if we reach the kids,” she added. “They have to go home, and maybe they will start conversations at home with people we would never reach.”

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Taylor Knopf writes about mental health, including addiction and harm reduction. She lives in Raleigh and previously wrote for The News & Observer. Knopf has a bachelor's degree in sociology with a...

One reply on “Opioids to Heroin to Hepatitis C in Western NC”

  1. I truly believe u r on the right path with this n if we could only get the ppl here n Cherokee county to feel this way we would come so much closer to defeating these issues. I’m a former iv opiod used myself n it is so hard when there is no where to turn for help n even when u try i only get judged n yet they expect u to just magically get better overnight.

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