By Taylor Knopf

Proposed state legislation filed in response to a years-long feud between an Asheville neighborhood and a local needle exchange could threaten syringe exchanges across North Carolina. Senate Bill 607 seeks to ban mobile exchanges, require engraved needles, background checks, forced treatment and more. 

Meanwhile, opioid overdose deaths are at an all-time high.

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A neighborhood group in west Asheville has tried for several years to put restrictions on the Steady Collective, which runs syringe exchanges for people who use drugs at several locations in Buncombe County, including a bookstore in West Asheville once a week. Based on comments on the group’s Facebook page, they are concerned about used needles in community spaces.

“West Asheville started experiencing an increase in crime and litter that was new to the community in 2017,” reads the group’s About section on Facebook

Steady Collective Director Hillary Brown says what really changed in 2017 was the neighbors, not the drug use. In 2017, Asheville was ranked number two in the nation on a list of fastest gentrifying cities. Brown said their harm reduction organization serves people in this area because the need has always been there. In fact, there were underground needle exchanges in Asheville long before the state legalized them. 

Screenshot of a post in the west Asheville neighborhood Facebook group

Asheville city officials looked into the issue and determined in 2019 that the syringe exchange could continue operating out of the bookstore in West Asheville. Brown believes that since the city didn’t shut their operation down, the neighborhood group has worked around local officials, going directly to the state legislature to fight this battle. The Substance Use Disorder Safety Act, introduced by Sen. Check Edwards (R- Flat Rock), has similar language to proposed restrictions presented by the neighborhood group to city officials. 

A representative of the West Asheville neighborhood group declined to give an interview or statement to NC Health News.

However, Senate Bill 607 wouldn’t just apply to the Asheville needle exchange, it would have implications for all of North Carolina’s syringe exchanges. Edwards didn’t respond to NC Health News’ multiple requests for comment by phone and email.

shows a group of people wearing facemasks standing in front of an ambulance that now acts as a mobile needle exchange outlet. The words "Steady Collective" are painted on the side with a logo of two crossed syringes
Dr. Bayla Ostrach, Kim Roney, Hillary Brown and Reid Getty take part in a Steady Collective community syringe pickup in April 2021. Photo courtesy of Hillary Brown

Leaders in North Carolina’s harm reduction community say they were not consulted about this bill which would greatly alter or eliminate some needle exchanges. 

“In short, if this bill were passed as written it would probably end all syringe exchange programs in the state,” the NC Harm Reduction Coalition, which runs dozens of exchanges, wrote to supporters in an urgent email.

Mandatory substance use treatment

The proposed legislation would require needle exchanges to carry $1 million in liability insurance and to operate out of a facility offering substance use treatment. The bill would require those coming to needle exchanges for clean drug use supplies to enroll in substance use treatment. 

Requiring treatment flies in the face of harm reduction philosophy which seeks to lessen the damage caused to a person by their use of drugs and “meet people where they are.” Harm reduction organizations offer people who use drugs clean needles and supplies so they don’t reuse or share needles, therefore reducing the spread of HIV and hepatitis C infections. Many also provide free testing for these bloodborne infections, and they are a major distributor of naloxone, an overdose reversal drug.

While harm reduction workers will link people to substance use treatment if they ask for it, it’s not a requirement. Forced substance use treatment has not been shown to improve health or treatment outcomes for people who use drugs and can lead to higher rates of overdose death.

“The point of harm reduction is to respond to what the person is asking for,” the Steady Collective’s Brown said. “You don’t come with an agenda.”

If this bill passes, the Steady Collective could not continue to operate, they said. 

“The requirements are absurd, and I’m not going to make people go to treatment. So if I’m made to violate all of my values and the principles of harm reduction, I’m not going to do the work,” they said. “That’s not fair to participants.”

“I don’t feel like I will be able to support them and advocate for people effectively with these requirements, and that will result in a dramatic increase in hepatitis C and HIV infections. And it will result in a great deal of death. We are the most effective way to get naloxone into the hands of people using drugs,” Brown concluded.

Engraved needles, background checks and no mobile exchanges

Harm reduction workers say some provisions in Senate Bill 607 would be impossible to comply with — such as a requirement to engrave sterile needles with the program logo. By definition, sterile needles come in sealed packages. 

Another bill provision requires all needle exchange workers to pass a background check. This would make many ineligible to work because many people working in harm reduction have a history of substance use, which often includes past encounters with the criminal justice system. Their experience makes them effective at relating in a non-judgmental way to people seeking clean drug use supplies.

Shows five people gathered around the back of a van, the hatch is open, showing supplies inside.
Mike Page and Hyun Namkoong meet a group of people in their neighborhood to hand out syringes and other supplies as part of NCHRC’s mobile syringe exchange in 2017. Photo credit: Taylor Knopf

Both Brown and the director of the NC Harm Reduction Coalition Jesse Bennett have prior criminal records. Bennett said the government cannot tell private organizations not to hire people with criminal backgrounds. 

The bill would also require needle exchange programs to be located outside of a three-mile radius of schools, which would give them few options. For example, the three needle exchanges currently operating in Asheville — including one located at the county health department — would be in violation of this buffer.

The proposed legislation aims to eliminate mobile needle exchanges, which harm reduction workers say is one of the only ways to reach the homeless, along with rural residents and those without access to transportation. 

“This is just more war on drugs policy. It’s attacking the most vulnerable and coming after homeless people,” Bennett said. “There’s nothing based in science in any of the provisions in this bill.”

Pandemic increased overdoses

These proposed restrictions on needle exchanges come on the heels of a pandemic that has fueled overdoses and the prevalence of contaminated street drugs, making them more deadly. Harm reduction workers across the state said that pandemic-related stressors — such as job loss and homelessness — drove increases in drug use, overdoses and a return to drug use for some. 

In 2019, even before the pandemic struck, an average of six North Carolinians died each day from drug overdoses. Illegal opioids such as fentanyl and heroin made up 78 percent of overdoses in that year. 

Though 2020 drug death data isn’t finalized, the state health department says that all indicators — particularly emergency room data — point toward an increase in overdoses. 

There was a 24 percent increase in overdose-related emergency room visits in 2020 over the previous year. North Carolina data shows an 89 percent increase in EMS responses to opioid overdose from February 2020 to February of this year. 

Due to the increase in drug use and overdoses, last week HepConnect, an initiative funded by pharmaceutical drugmaker Gilead, pledged an additional $5 million to fight hepatitis C infections in Appalachia. In the past, HepConnect funds have flowed through multiple harm reduction groups in North Carolina, including the Steady Collective, and four surrounding states.

New national data shows that synthetic opioids, such as fentanyl, are driving up overdoses in the U.S., and the number of deaths surged even higher after the pandemic lockdowns began.

More than 87,000 Americans — a record high — died from a drug overdose in the 12-month period ending in September 2020, according to new provisional data from the Centers for Disease Control and Prevention. That’s a 27 percent increase over the previous 12-month period.

Data behind needle litter

In order to address concerns about used needles in the community, Brown said Steady Collective is one of the few exchanges in the state that requires the needle return. In 2019, Brown said program participants insisted on this policy change because they didn’t want to lose the program.

To combat low needle take-back rates, Bennett said the NC Harm Reduction Coalition is piloting a new biohazard takeback program by giving participants who bring back used needles swag, such as backpacks, sunglasses, etc. 

In a comparison study of a city with syringe exchange programs and one without, researchers found eight times more improperly disposed syringes in the city without exchange programs. Another study looked at the prevalence of used needles in Miami, Florida before and after the implementation of syringe exchange programs and found a 49 percent reduction after the exchange programs began.

Many law enforcement officers also support syringe exchanges because needlestick injuries on the job are not uncommon for them. In a 2014 survey of North Carolina law enforcement officers, the majority said that contracting HIV on the job from used needles was a big concern for them and that they believed needle exchanges would be good for the community and law enforcement. Syringe exchange programs have been shown to reduce these incidents among law enforcement, reducing their risk of exposure to HIV or hepatitis C. 

Spokesmen for the NC Sheriffs’ Association and NC Association of Chiefs of Police told NC Health News via email that they do not have a position on Senate Bill 607. However, North Carolina law enforcement agencies put their support behind the original bill that legalized syringe exchanges in 2016

Advocates push back

Bennett said the NC Harm Reduction Coalition has been trying to build and expand its linkage to care program. They opened a health hub in Wilmington that offers classes and more support for people who use drugs, as well as a food bank in Raleigh, he said.

He added that retention rates for treatment are already low, and in light of that, forcing more people into treatment who don’t have a desire to go won’t lead to better outcomes. 

“What’s even more insane is the fact that this General Assembly won’t pass Medicaid expansion, but yet want all these people to go to treatment,” he said. “I don’t understand how that’s going to be paid for.”

A recent analysis by Health Affairs shows people who use drugs are referred to substance use treatment much more frequently in states that expanded Medicaid. 

Data and graphic courtesy of Health Affairs

Bennett said there is no way to make Senate Bill 607 good legislation, and that he will make no concessions. He and others in the harm reduction community are nervously watching a similar bill move through the West Virginia legislature. 

“We feel like if it gets too watered down or convoluted it could be more dangerous, they might get Democrats to sign on and it would be harder to veto,” he said. 

Bennett said he believes Gov. Roy Cooper would veto Senate Bill 607 as written.

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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...