Two glass vials that say "Naloxone HCL" and two wrapped syringes rest on a metal shelf at a needle exchange facility. In the background is a paper instructions on using the medication to reverse an opioid overdose
Full Circle, based in Franklin, distributes naloxone kits along with fresh syringes, sterile water and toiletry items. Credit: Liora Engel-Smith

By Liora Engel-Smith

Roughly three years after syringe exchange programs became legal in North Carolina, more people than ever are receiving clean needles and kits to help them reverse an overdose.

Collectively, North Carolina’s syringe exchange programs — operated by local health departments, as well as faith-based and other community organizations — had more than doubled their number of participants from just under 4,000 people in 2016-17 to more than 9,600 in 2018-19.

During that same three-year period, the number of clean syringes the programs distributed soared from 1.15 million in 2016-17 to 3.3 million syringes in 2018-19.

Distribution numbers for naloxone, a drug that can reverse an opioid overdose almost instantly, have shown a similar pattern. In 2018-19, needle exchanges distributed roughly 35,000 kits of the overdose reversal drug. In 2016-17, the number was approximately 5,700.

Infographic of growth of syringe exchange programs
Data source: N.C. DHHS. Graphic credit: Liora Engel-Smith Credit: Illustration by Liora Engel-Smith

Syringe exchange programs hand out clean injection equipment, opioid overdose reversal kits that include naloxone, and sharps containers to those who use drugs. These programs also collect used needles for disposal. Though some consider exchanges controversial, the practice has a robust track record in reducing the spread of HIV and other blood-borne infections that stem from using and sharing dirty needles.

The actual number of syringes and naloxone kits that organizations gave away this year is likely to be even higher, as the state is awaiting for 2018-19 data from a handful of exchanges. According to the N.C. Department of Health and Human Services, 31 active needle exchange programs were registered with the state as of July, but the state’s 2018-19 data, obtained earlier this month, aggregates data from only 29.

Despite the growth in distribution, many counties in the state remain without a syringe exchange. The 31 registered exchanges cover 45 of North Carolina’s 100 counties, according to the N.C. DHHS.

“Expanding syringe exchanges access in North Carolina is a long-term effort,” a state health department spokeswoman said in an email Wednesday.  “And since 2016 the state has been able to support this work through technical assistance, program development, and education and outreach. Progress has been possible through invaluable partnerships … . “

The state will continue to focus on expanding access to these programs in the future, the statement said.

A map of North Carolina with 45 counties in blue, showing needle exchange programs, including areas in the western, middle and northern sides of the State as well as smaller pockets in the East and South.
As of July, 31 needle exchange programs registered with the state of North Carolina. Graphic credit: N.C. DHHS Credit: N.C. DHHS

The news comes as the Tar Heel State is grappling with an opioid crisis that killed nearly 1,900 North Carolinians in 2017. But North Carolina’s exponential rise in needles and naloxone kit distribution may not necessarily reflect an overall increase in drug use across the state, staff from needle exchange programs said.

“That huge number [of syringes and naloxone] … doesn’t mean that all of a sudden these hundreds more people are suddenly injecting drugs and need services,” said Loftin Wilson, rural program coordinator at the North Carolina Harm Reduction Coalition. “These people have been in need of services and the services have not existed.”

The Harm Reduction Coalition operates six syringe exchange programs, three of which run in  rural areas. All six, he said, have grown either because existing staff is better at building trust with participants or because the coalition has devoted them more resources, such as staff time. Between the six programs — located in New Hanover, Wake, Durham, Vance, Haywood and Cumberland counties — the coalition distributed nearly a third of the needles the state logged in 2018-19, a recent news release from the coalition said.

What Needle Exchange Programs are Available in North Carolina?

To find the needle exchange nearest to you, zoom in on the map to your area. If you click on the icon, the information for the needle exchange will pop up.

Note: Organizations notated with a star either don’t have a permanent address or that address was unavailable. In those cases, we used the addresses of local county offices. Data source: NC DHHS. Map credit: Liora Engel-Smith.

The Vance County program, for example, saw an uptick in dispensed syringes and overdose-reversal kits after the coalition dedicated more staff time to the program in 2018. The program has also been reaching more people because it gradually expanded to serve neighboring Granville, Franklin and Warren Counties, Wilson said.

Even as the harm reduction coalition grows its programs, he said the exchanges aren’t reaching everyone who needs it.

“Every single one of our programs is enrolling new people constantly,” he said. “And I don’t think any of our programs has reached (everyone) … we’re not reaching everybody we need to in any of the areas.”

To help more people, Wilson said, the organization would need more of everything — staff who can tap into communities of people using drugs, more needles and naloxone, as well as vehicles for mobile programs. Expanding the programs, he said, is predicated not only on securing the funding to do so, but the time and energy to maintain quality as exchanges grow.

Supplies and stigma

Staff at Full Circle Recovery Center, a Franklin-based organization that serves seven counties in western North Carolina, expressed similar sentiments. Nestled in a faded strip mall, the center has served 526 participants since its needle exchange program began in 2017, said founder and CEO Stephanie Almeida. In these two years, the organization handed out roughly 93,000 syringes. Staff handed out almost half of that amount — about 46,000 — in 2019.

“We didn’t have access to as much (supplies) as we needed or (these distribution numbers) would have been much higher,” Almeida said.

Staff at Full Circle hands out 7,000 to 8,000 needles a month on average, but for at least three months of the year, their supplies drop below that level for lack of funding. To adequately serve the area, Almeida said, the organization would need at least 10,000 syringes a month, or “even closer to a half a million needles a year.”

Fear and stigma also limit the organization’s reach. Though the 2016 law protects participants from being arrested for possessing injection supplies from a needle exchange, some participants tell Almeida they’re scared.

“Clients believe that the police are in the parking lot watching and that when they leave, they are going to be arrested,” she said.

Though Full Circle delivers syringes and gives participants supplies to share with others who aren’t coming in, seeing people face-to-face can be valuable, Almeida said. It’s an opportunity to build relationships, discuss safer practices and perhaps link people with the recovery resources down the line.

‘Not in transformation land’

As director of the Steady Collective, an Asheville-based exchange, Hillary Brown had witnessed trauma: participants with abscessed wounds and other untreated illnesses, and homeless people with little to no access to the resources they need.

And then there’s an ever-growing list of those who didn’t make it.

Hillary Brown wears an "I Carry Narcan So Can You" top and in the background are syringe exchange supplies such as red sharps containers
Hillary Brown of the Asheville-based Steady Collective needle exchange program said the organization served 1,259 participants in the first six months of 2019, compared with 1577 people in 2018. Photo credit: Liora Engel-Smith.

Brown said Steady has distributed 100,017 needles in the first six months of 2019, compared with 129,079 syringes for all of 2018. Participant numbers also appear to have grown. In 2018, Steady served 1,577 participants, compared with 1,259 people in just the first six months of 2019.

One of three organizations that operate exchanges in Asheville, Steady operates a mobile exchange at a West Asheville bookstore. That mobile exchange was the subject of a months-long zoning struggle with the city, who said the bookstore isn’t zoned to host a needle exchange. Steady had to hire a lawyer, and after some negotiations, city officials agreed to let the organization operate the mobile exchange with registered nurses on the premises. At least one other exchange in the state, in Winston-Salem, also ran into zoning barriers.

But Brown said working through these challenges is important because the help that Steady provides helps people who use drugs to stay alive. That objective comes with its share of heartbreak, Brown knows.

“There’s a lot of watching things you can’t do anything about and understanding that your job is to ensure survival. …We’re not in transformation land, we’re in the land of, like, looking at somebody and saying ‘I want to see you tomorrow.’”

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Liora Engel-Smith joined NC Health News in July 2019 and covers policies, programs and issues that affect rural areas. She has previously worked for the The Keene Sentinel in New Hampshire and the Muscatine...