By Rachel Crumpler

Just last month, Montgomery County Commissioner John Shaw said, the county experienced four opioid overdose deaths over the span of seven days. While state data show that there are almost 11 opioid deaths per day in North Carolina, four deaths in a week in the central Piedmont county of only 26,000 people was particularly poignant.

Shaw’s best friend was one of the people who died. Another was the father of someone Shaw grew up with.

“Our crisis is great,” Shaw said, noting the potency and increasing prevalence of the synthetic opioid fentanyl in the drug supply. 

Shaw is a relatively new Montgomery county commissioner, having entered public office in 2021. And one of his top priorities, then and now, is to address opioid use in the rural community near the Uwharrie National Forest. That year, the county’s overdose death rate was 69.9 per 100,000 residents — nearly double the state rate of 38.5 per 100,000 residents. 

Since being elected, Shaw has engrossed himself in everything related to opioid use disorder, spending hours in study. In some ways, it has felt like taking a college medical class, he said. He’s now versed in topics like buprenorphine — a medication approved by the Food and Drug Administration to treat opioid use disorder — and naloxone, a medication that can rapidly reverse an overdose.

And Shaw, as a county commissioner, is actually in a position to do something about all those opioid deaths. Montgomery County — along with every other county across the state — has an infusion of opioid settlement funds available to help accomplish that goal.

There are different views across the state about how best to spend opioid settlement funds, and many local governments’ plans are still in formation. At least 12 counties, however, have dedicated a portion of funds to expand harm reduction services, such as naloxone distribution and syringe services programs.

Encouraging investment in harm reduction

Last year, 4,243 suspected overdose deaths occurred across North Carolina, according to provisional data from the state Office of the Chief Medical Examiner — an average of more than 11 fatal overdoses per day. There were also 9,243 opioid overdose emergency department visits in 2022, according to provisional data from the NC Department of Health and Human Services.

“People in our state are struggling. They need harm reduction, treatment and recovery programs that will save their lives — and they need them now,” said North Carolina Attorney General Josh Stein in a statement, referring to how opioid settlement funds can be used to ensure that resources are widely available for people with opioid use disorder. 

Last February, Stein helped finalize a multi-state $26 billion opioid agreement with three pharmaceutical distributors and one manufacturer for their role in creating and fueling the opioid epidemic. North Carolina will receive $750 million of these opioid settlement funds over the next 18 years. And 85 percent of that money — $644 million — will be distributed directly to North Carolina’s county governments to help people and communities affected by the overdose crisis.

Stein said in a statement that an additional $600 million is likely to come to the state as part of another $21 billion in national funds from a different settlement that is still being finalized.

County governments started receiving their first opioid settlement funds in June. The money must be used on opioid abatement strategies outlined under two lists (A and B) in the agreement between county leaders and the Attorney General’s Office. 

It’s up to county commissioners to decide which strategies to support. Shaw said it’s a daunting task.

Among the list of strategies are naloxone distribution and syringe services programs — two priorities for the global public health organization Vital Strategies.

To encourage local governments to invest in evidence-based and life-saving harm reduction services, Vital Strategies offered in October to match county opioid settlement dollars going toward these strategies.

“North Carolina is really far ahead in the opioid settlement relative to all other states,” said Kat Humphries, technical adviser of the overdose prevention program at Vital Strategies. 

She said many counties were unsure what to do. “And I think having a funder say, ‘Hey, we’ll co-fund this with you’ makes people a little bit more comfortable to say, ‘Okay, we’ll allocate to that.’”

To be eligible for the matching funds, local health officials had to convince county commissioners to devote the resources to harm reduction — an approach not everyone is in favor of due to lingering stigma.

Humphries said Vital Strategies received 17 applications representing 21 counties across the state. In January, the organization awarded $1.5 million over three years to eight applicants covering 12 North Carolina counties that are leveraging settlement funds to expand community-based naloxone and syringe services programs. Nearly all plans involved working through peers to reach people with opioid use disorder, Humphries said.

The match funding provided by Vital Strategies particularly allows opioid settlement funds to go further in hard-hit, rural counties that are set to receive comparatively small sums over the coming 18 years. For example, Montgomery County is scheduled to receive $1.46 million over 18 years, while Wake County is set to receive $36.14 million over the same time period.

“With anything, you can only go as far as the dollars will allow you to,” Shaw said. 

And in his view, funding harm reduction will be an effective strategy to start decreasing Montgomery County’s overdose death rate. 

“We can’t just stand on one side of the river and say, ‘Once you come over here — once you accept to come to abstinence-based treatment — we can help you, but until you do that, we can’t do anything for you,’” Shaw said. “We’re just going to watch more and more people die.” 

‘Keeps people alive’

Harm reduction strategies aim to reduce negative consequences associated with drug use. This can include providing naloxone, clean needles, fentanyl test steps, HIV and hepatitis C testing and other resources. 

It’s not an abstinence-based approach. Instead, it’s an approach that meets someone where they are, said Jennifer Greene, health director of the Appalachian District Health Department, which serves Alleghany, Ashe and Watauga counties.

Ignoring drug use will not improve outcomes, Greene added. She believes it’s better to engage those currently using drugs in harm reduction practices.

Humphries agrees. “We know harm reduction keeps people alive,” she said. “And if you’re interested in getting people into recovery, then the only way to get people into recovery is if they’re alive.”

Having a point of contact with individuals currently using drugs through naloxone distribution and syringe services programs is critical. People who have gone through their own recovery journeys are increasingly centered in this work, building relationships with people who use drugs and offering connections to care and resources. 

“Anywhere I can stop the harm being caused is a win for me,” said John Simmons, the peer support specialist team lead at the Appalachian District Health Department. “It’s not necessarily moving them along. It’s giving them resources they may not have known they had.”

Montgomery County similarly knows the value of having peer support in the community. With the opioid settlement and Vital Strategies funding, the county is set to hire its first full-time peer support specialist to serve residents and perform outreach in the community. Before, a peer split time among several neighboring counties. 

Increased naloxone distribution

For Shaw, increased naloxone distribution is key to decreasing the overdose death rate.

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. 

However, for many counties, naloxone distribution has been fairly limited because there hasn’t been a specific stream of funding to purchase the medication.

That’s changing for these 12 counties as they set aside opioid funds to boost their naloxone supply.

In Montgomery County, Roxanne Elliott, policy director at FirstHealth of the Carolinas, estimated that 100 naloxone kits were distributed in Montgomery County last year. This year, the county will have the capacity to distribute 1,200 nasal Narcan kits and additional injectable naloxone doses, significantly expanding the county’s ability to saturate the community with the life-saving medication.

The county plans to provide naloxone to first responders and at-risk populations, such as people leaving jail. A North Carolina study found that people leaving jail are 40 times more likely to die of an opioid overdose within two weeks of their release than are general North Carolina residents. 

Additionally, naloxone vending machines will be installed as a new, hands-off way to distribute the medication in Alleghany, Ashe and Watauga counties. At least one machine will be placed in each county, Greene said, though the locations are still being determined. In recent months, naloxone vending machines have been placed in the public lobbies of seven county jails across the state, and they’ve been found to be an effective distribution method.

“We’re not going to save everybody,” Shaw said. “We’re not going to take all the overdoses away, but we are going to drastically reduce it.”

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