By Rachel Crumpler
Amanda Clark knows the word is getting out that there’s a way to stop an overdose using a medication available at the Forsyth County jail.
That’s because of a story told to Clark, who leads the Forsyth Regional Opioid & Substance Use Team, by someone from the county emergency medical services.
In September, a passerby in downtown Winston-Salem noticed someone who was unresponsive on the street. That passerby had heard about a new vending machine in the lobby of the county jail that had free naloxone administration kits for anyone to use. The drug is used to reverse an opioid overdose.
They ran inside, got one of the kits, then ran back to the person who had overdosed to give them the naloxone. By the time EMS workers arrived, the person was awake and talking.
Likely, that passerby’s knowledge saved a life.
Within the past three months, these new vending machines have been added in the lobbies of six other county jails across North Carolina, along with the Forsyth location.
Brad Ray, a senior justice and behavioral health researcher at RTI International, estimates that there are about 80 naloxone vending machines nationwide, and he’s helped facilitate numerous machines in the Midwest and in North Carolina over the past two years.
It’s a recent emerging strategy for naloxone distribution at a time when drug overdoses continue to be on the rise nationally and in North Carolina.
Need for naloxone
Over 100,000 people nationwide died from drug overdoses in 2021, according to data from the Centers for Disease Control and Prevention. In North Carolina, 3,759 people died from a drug overdose last year according to the state’s Opioid and Substance Use Action Plan Data Dashboard. This amounted to a state overdose death rate of 35.8 per 100,000 residents in 2021, more than 10 overdoses every day, on average.
It’s especially important to have naloxone accessible to justice-involved populations who are at greater risk of overdose. A North Carolina study found that people leaving jail are 40 times more likely to die of an opioid overdose within their first two weeks after release, and overdose is the leading cause of death among persons who are returning from incarceration.
Naloxone — also known by the brand name Narcan — is a safe, non-addictive drug that rapidly reverses an opioid overdose. It can restore normal breathing within minutes in a person whose breathing has slowed or even stopped as a result of an opioid overdose.
In fact, 4,154 overdose reversals using naloxone were reported by community members in 2021, according to the state’s Opioid and Substance Use Action Plan Data Dashboard.
Ray wants to see the numbers of lives saved with naloxone continue to climb and believes the vending machines are a novel, low-barrier way to get naloxone into more hands.
“It’s just about reducing overdose deaths — that’s it,” Ray said. “It’s through the roof, the number of people dying right now. People don’t know what is in this supply. Everybody needs to have naloxone on hand.”
Making naloxone widely available is a key component of North Carolina’s Opioid Action Plan.
A new strategy
The National Center for State Courts provided the naloxone vending machines to detention centers in Buncombe, Cumberland, Forsyth, Guilford, Orange, Pitt and Wilkes counties at no cost. In addition to North Carolina, other states that are part of the Regional Judicial Opioid Initiative also received vending machines aimed at addressing overdose among justice-involved populations.
The North Carolina Harm Reduction Coalition helped identify counties interested in installing vending machines in their county jails. The coalition used relationships with some jail officials and community groups formed through years of providing overdose prevention education, said Melissia Larson, the former law enforcement program manager at the coalition who helped with the vending machine placements before her departure in August.
“We knew that this was not going to be an easy project because of stigma, so we really wanted to find jails who were willing to stand up and say, ‘Yes, I am willing to put this naloxone vending machine in my lobby,’” she said.
Larson, now a public safety and harm reduction specialist at RTI International, said the timeline of implementation was fast so placement came down to counties that demonstrated eagerness about the idea. Those sheriffs’ departments also had community partnerships in place to manage the machine long-term, such as who would restock the machine and pay for the naloxone kits.
Larson said the vending machines are a hands-off, judgment-free way to distribute naloxone that does not put any additional burden on jail staff.
“We want to make sure that people exiting the jail who are at high risk for overdose have immediate access to naloxone upon exit,” Larson said. “They can walk to the public area of the jail as they're exiting, and for free, they can hit the button and get a naloxone kit. Also, their visitors and their loved ones who may be coming for visitation can get a kit too. You don't have to give your name. You don't have to pay for it. We just want it to be there and to be readily accessible.”
In her position on the regional opioid and substance use team, Clark jumped at the opportunity for Forsyth County to get a naloxone vending machine.
“We wanted to make sure we're doing everything we can to prevent deaths from overdoses in our community,” Clark said. “One of the easiest ways to do that, and one of the most cost-effective ways to do that is to increase community access to naloxone.”
She was excited about the vending machine’s potential, but as a new distribution strategy, she didn’t know how much it would be used. She thought it could very well sit there for months and only have a handful of kits gone. But in actuality, it’s been driving an infusion of naloxone into the community as she hoped.
Since the machine’s installation on Aug. 24, Clark said nearly 600 naloxone kits have been distributed through the machine. Demand was so great, she needed to refill the machine for the first time less than a week after it was put into use.
In less than three months, this machine has already matched the number of kits she gave out during all of last year at various community events.
“The number of people carrying naloxone and knowing how to use it is just as beneficial as people knowing CPR and knowing first aid,” Clark said. “The more people we have in our community that know those things, the better off we're gonna be.”
The naloxone vending machine in Cumberland County’s detention center was installed on Aug. 25. Ashley Curtice, Cumberland County’s deputy health director, has also seen many people use the machine. She said about 600 kits have been distributed to date.
Due to the jail setting, all vending machines have seven-days a week accessibility to the life-saving medication. Educational information is also provided on the vending machine about how to administer the doses.
While Clark acknowledged that people may have mixed feelings about going to a jail for naloxone, she said it is not as scary as it seems, especially since the jail staff is in support of the machine and no human interaction is required to get the medication.
However, Curtice said if the jail setting makes anyone uncomfortable, then a person should find a different way to get the medication such as the county public health department, or a pharmacy.
While these seven counties received their vending machines at no cost, Clark said other counties interested in using this distribution strategy could use opioid settlement funds to purchase a machine.
In Forsyth County, based on the current success, Clark said there have already been conversations about the potential to get more machines for other locations such as near homeless shelters. And ever since the machine has been installed, Clark said she has been fielding questions from others wanting to learn from Forsyth’s experience.
“I've been contacted by other counties — both in and out of North Carolina,” she said. “I've had counties from as far away as Washington state call me and say they saw one of the news pieces on it and said, ‘Hey, how can we do that here?’”
Ray, who provides technical assistance on setting up naloxone vending machines, said every week he has hours of meetings about the vending machines with people wanting to know more about the innovative distribution strategy or requesting help getting one up and running.
Some places are taking the vending machines a step further by providing other harm-reduction safety supplies in addition to naloxone, supplies such as fentanyl testing strips and syringes.
“I would love for the machine to be a hub or a resource in which people maybe come in and they learn that they can get naloxone there,” Larson said. “Maybe they're also getting information like a resource card that may be attached to the machine, or just that link or that QR code that maybe then opens them up to other options if they're interested in treatment or recovery.”