By Taylor Knopf and Liora Engel-Smith

Though attention has shifted to combating the coronavirus pandemic, the opioid crisis in North Carolina has not gone away. The stressors caused by COVID-19 — such as homelessness and job loss — have contributed to an increase in drug overdoses in the last year.

North Carolina saw a spike in overdoses in the spring and early summer months of the pandemic. When fewer people were going to the emergency room as the virus took hold in the state, the number of overdose-related visits shot up. Preliminary state data from 2020 shows a 23 percent increase in overdose-related emergency room visits over the previous year.

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Though still elevated, the number of overdose emergency room visits are coming down as more naloxone — an opioid overdose reversal drug — has been pushed out into communities.

Nationally, more than 81,000 Americans died from drug overdoses between May 2019 and May 2020, according to the Centers for Disease Control and Prevention. The CDC noted that this was the highest number of overdose deaths ever recorded in a one-year period.

On Thursday, NC Attorney General Josh Stein announced a $573 million multi-state settlement with consulting firm, McKinsey & Company, as a result of the group’s alleged role in advising opioid manufacturers on how to promote their drugs. North Carolina will receive $19 million from that settlement, which Stein said will be used to address the consequences of opioid addiction in communities across the state.

More fentanyl, more overdoses

Meanwhile, the street drug supply has become more contaminated and more dangerous. Fentanyl — a synthetic, highly potent drug often added to street drugs — was the “primary driver of the increases in overdose deaths,” the CDC said.

Nearly everyone NC Health News interviewed for this story said fentanyl became an even bigger problem over the course of the pandemic. Those who work with people who use drugs say that fentanyl is being cut into all street drugs — heroin, cocaine, marijuana and even pressed into pills disguised as drugs such as Xanax.

“Anecdotally, 2019 and 2020 were pretty rough in terms of reversals and overdose deaths,” said Jesse Bennett, executive director of the NC Harm Reduction Coalition, the largest network of syringe exchanges in the state.

Harm reduction strategies aim to lessen the damage caused to a person by their use of drugs by providing naloxone, clean needles and other drug use supplies, HIV and hepatitis C testing and other resources. In 2020, the coalition distributed 25,062 naloxone kits across the state. Bennett said there were 3,241 successful overdose reversals and 30 unsuccessful attempts reported to the coalition.

man with heavily tattooed arms puts a box into a plastic bag to build a naloxone kit, which helps treat opioid overdoses, as others stand around hime, looking on.
Jesse Bennett, now director of the NC Harm Reduction Coalition, demonstrates how to assemble a naloxone kit to a group of volunteers. Photo credit: Taylor Knopf

“These are primarily drug user to drug user reversals, which indicates that PWUDs [people who use drugs] can perform reversals successfully even while using drugs,” Bennett said.

He added that people using drugs reported fentanyl in the drug supply throughout N.C. And harm reduction workers themselves have reversed more overdoses than past years. Several participants using drugs told the coalition that they needed to use four or more doses of naloxone to reverse an overdose, a result of the extreme potency of the added fentanyl.

Health workers on the front lines of North Carolina’s drug epidemic share stories about how the pandemic has impacted people using drugs across the state.

Want to help?

To maintain social distancing, the NC Harm Reduction Coalition suspended its monthly naloxone kit assembly events. The group has scrambled to keep up with the demand for kits and needs volunteers who are willing to do some remote work. If interested, email to receive the volunteer newsletter.

Wilmington and Fayetteville: fighting evictions 

Many people who use drugs have been unable to find work and pay their bills, and they’re facing eviction.

“Because of the evictions, the tent cities have grown exponentially,” said Becca Rose, who oversees Wilmington and Fayetteville syringe exchanges for the NC Harm Reduction Coalition.

Rose’s clients have worked with legal aids who have been successful at pushing off housing evictions for a time, but usually only a few weeks or months. Due to these added stressors, people who had previously been in recovery from drug use or had manageable drug use have been using drugs more chaotically, she said.

“There’s just not enough resources for people to pay their bills. So if you’re a drug user or have substance use disorder, and you lost your job or you don’t have housing, it can trigger a substance use disorder,” she said. “People are looking to self medicate. And because of fentanyl and how strong the opiates are nowadays, they’re overdosing very easily.”

At the beginning of the pandemic, the syringe exchanges were mobile only. Now brick and mortar sites have opened back up with masks, sanitizer and capacity restrictions. Rose said participants are very willing to take COVID-19 prevention supplies and are careful and considerate. One day when Rose was delivering clean supplies to one house, she found a note on a door warning her that someone inside had COVID.

“It’s nice that my participants are at least making efforts to keep each other safe,” she said.

Never Use Alone

Because people are isolated during the pandemic and still using drugs, harm reduction workers are encouraging folks to call (800) 484-3731. Someone from the Never Use Alone initiative stays on the line with the person using drugs to make sure they are OK. If there is no response after they use drugs, someone calls EMS.

Hyde County: heightened demand for needles, supplies

Further up the coast, in rural Hyde and surrounding counties, demand for syringe exchange services ballooned with the pandemic, health department spokeswoman Anna Schafer said in an email.

“We know that almost all of our clients have overdosed at least once — almost half having overdosed three or more times.” But the majority say they have not gone to a hospital or called for help after overdosing, she said.

“We know overdoses are occurring regularly, but ‘the data’ does not always accurately depict the true extent of the issue,” Schafer said.

The health department staff check-in with most clients by phone or online. But many clients need that in-person support, she said, so department staff decided to continue with some face-to-face support in the pandemic.

Wake County: Navigating recovery, racial injustice and COVID-19

The rapid response team with the addiction recovery program Healing Transitions in Raleigh has been a lot busier during the pandemic, reporting a 64 percent increase in referrals from 2019 to 2020.

The team is responsible for making contact with people who overdosed the day before, referred to them by the Wake County EMS system. Alex Peacock, a graduate of the Healing Transitions program, joined that team last April. His job is to go out with EMS to check-in on these folks and offer support, presenting them with recovery options, detox, medication-assisted treatment, harm reduction supplies or simply a listening ear.

A grab bag with cottons, cookers, alcohol wipes, syringes and a list of treatment resources put together by North Carolina Harm Reduction Coalition to help people who use opioids reach all available resources.
A grab bag with cottons, cookers, alcohol wipes, syringes and a list of treatment resources put together by North Carolina Harm Reduction Coalition. Photo credit: Taylor Knopf

“Just so they can have someone in their life who is in recovery, and we can just be there for them,” he said. “If they eventually decide to get recovery, we can be there.”

Peacock, who is three years into recovery, said many people are more interested in seeking help immediately after a life-threatening overdose. He says it’s best to “strike while the iron is hot.”

“We’ve also seen an increase, not just in people needing substance use treatment, but needing a lot of help with mental health,” he said. “A lot of people are really struggling with being furloughed and being at home, having this unemployment money and a lot of time on their hands.”

Peacock said the need peaked in May and leveled off, seeming to subside a little in the fall. However, overdoses and the need for services spiked again during December, he said. Holidays are always harder as people return to family and old friends, and sometimes old habits.

As the virus swept across the country this summer, so did the movement to end racial injustice which emerged after George Floyd was killed by police. As a young Black man, Peacock said he felt “anger and sadness” at the former president’s “lack of support for the African American community.”

As Peacock worked to process his own emotions in response to the death of Floyd and others who died at the hands of police, he wondered how Black men who were just starting their recovery journey were doing. So he formed a support group for Black men at Healing Transitions.

two men wearing masks talking next to an EMS vehicle
As part of his job on the rapid response team with Healing Transitions, Alex Peacock, left, goes out with EMS workers to the homes of people who overdosed the day before to offer them peer support. Photo courtesy of Healing Transitions

“What that looks like is guys sitting around talking about their feelings and relating and talking about what we can do,” Peacock said.

They’ve had discussions on how to talk to their children about these issues. They read and discuss literature and share experiences. After the pandemic, Peacock hopes to invite leaders in the local African American community to talk with the group.

Piedmont Region: Tainted drugs, shuffled priorities and prolonged stress

The clearest sign of the pandemic’s impact on opioid use came to Louise Vincent when two people overdosed right in front of her organization’s Greensboro headquarters.

Vincent, herself in recovery, is the executive director of North Carolina Urban Survivors Union, an advocacy organization that seeks to represent the interests of drug users and alter policies that affect them. The organization serves hundreds of people from Guilford, Alamance and Mecklenburg County.

Before the pandemic, Vincent would have been able to invite people into the building. And if they had overdosed in the bathroom, she would have been ready with naloxone nearby.

But the office is empty. Staff at the Guilford County organization can’t let anyone in because of coronavirus restrictions. Indoor gathering restrictions were a huge blow to people who use drugs who might have sought help, Vincent said.

“Addiction is the opposite of connection,” she said. “Connecting with people and being connected, that’s all of what harm reduction is about.”

That loss of community also coincided with a shift in the local drug supply. As travel restrictions tightened, dealers had fewer drugs to sell. That, in turn, created a scarcity that led to some of the overdoses.

“For a minute, everything was insane,” Vincent said. “The price rose, it was a dog-eat-dog kind of world … just horribly contaminated drugs.”

That chaos seemed to have settled down, she said, but many people’s lives remain unstable, making it difficult for people seeking recovery to get help or support that will keep them alive.

Vincent said the pandemic compounded some of the barriers that face people who use drugs. Though attention shifted from the opioid crisis, it didn’t go away. HIV and other STD outbreaks brought on by drug use also didn’t go away.

“We weren’t out of the woods there,” she said. “But yet, when we had the pandemic we were focused on [that].”

shows a bin with plastic bags filled with naloxone and other supplies
Naloxone kits at North Carolina Harm Reduction Coalition. Photo credit: Taylor Knopf

Elsewhere in the region, Karen Lowe, co-founder of Olive Branch Ministries, a faith-based harm reduction organization that spans several counties, said as the pandemic wears on, people’s resilience is waning. Lowe said some of the services they’re accustomed to, such as peer support, groups, just face-to-face conversations with sponsors are no longer there.

“You had people who, because they had jobs or because they had activities, were able to disguise the fact that they were dealing with addiction issues.”

In some cases, employment and other activities may have also kept the addiction from escalating, but when these activities stopped, some people turned to drugs for comfort.

“We’ve seen an increase in overdoses,” she said. “We’ve seen an increase in people needing supplies. It wasn’t like it was rocket science. People knew that it was going to happen. … Two weeks [of social distancing] was bad enough and then it stretched on.”

Western North Carolina: Peaks and valleys 

Blake Fagan, a family physician at Mountain Area Health Education Center in Asheville, oversees the organization’s office-based treatment program for substance use disorders. Between Fagan’s practice and MAHEC’s telehealth and other initiatives, such as the program for pregnant women, the organization treats roughly 500 people with substance use disorders.

Providers stand around a bed in a training about opioid use disorder at MAHEC in Asheville last year.
MAHEC opioid educators Dr. Blake Fagan and Dr. Shuchin Shukla, far right, train North Carolina physicians to treat opioid use disorder at a statewide trainer-the-trainer event in June 2019. Shukla is part of an initiative that will create a ‘hub and spokes’ network for opioid use disorder treatment. Photo credit: MAHEC.

In the first stages of the pandemic last spring, Fagan noted, some patients responded to the isolation, job loss and uncertainty by returning to drug use. Following that first wave of coronavirus, some — but not all patients — have stabilized, he added. That overdose spike coincided with a nationwide increase in diagnoses of depression and anxiety and an overall erosion in mental wellness.

“When [people] have time on their hands, and they’re anxious or scared, they unfortunately return to use,” he said. “And when some of them did.”

At the same time, providers across the state and the country have worked to transition most of their support services online and the advent of telehealth in the region has been a boon for the recovery community.

With fewer overdoses in recent months, especially compared with last spring, Fagan said these virtual support services appear to be working.

Macon County: Homelessness and isolation

Outside of Asheville in rural Macon County, Stephanie Almeida, founder and CEO of Full Circle Recovery Center, has a different take. Almeida works with people who live in their cars or in the woods, offering basic necessities such as socks, blankets and coats alongside syringe exchange services.

A woman with black wavy hair and reading glasses on her hair is looking at the camera. She is sitting on a black chair and her hand is resting on a wooden table.
Stephanie Almeida, founder and CEO of Full Circle Recovery Center in Franklin. Photo credit: Liora Engel-Smith

She noted that it’s almost impossible to remain clean while living outdoors, adding a hurdle to a long list of barriers that prevent homeless people from seeking recovery.

“For people who are unsheltered outside and freezing, they would rather be high than to be suffering,” she said.  But even people with stable housing have ramped up their use.

Almeida, whose organization is one of two syringe exchanges in the mountainous county, also contracted coronavirus and had to shut down services for roughly two weeks right after Christmas.

Two weeks later, two volunteer construction workers who helped with renovations at Full Circle also got coronavirus, forcing the center to close yet again for 10 days.

In the meantime, Almedia does what she can.

“I help keep them alive,” she said, “and I help keep them healthy and I make sure they know they are loved and that they have a place in this world and that they don’t have to die just because they use drugs.

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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...