By Walker Livingston
In strip malls across rural parts of Western North Carolina, a grassroots harm reduction movement has taken root. In counties from Madison to Macon, volunteers deliver safe supplies to people using drugs, they test substances without judgment and provide things like clothes and food, too.
They are saving lives without stigma, advocates say.
Communities in rural parts of the region have long struggled with methamphetamine usage, while narratives of opioid abuse have swept the whole Appalachian region.
But many individuals who use drugs use multiple substances, which has been underscored by how variable the drug supply is. Rural counties across the state account for about 42% of overdoses, and a lack of resources, including a lack of methadone providers, has worsened the crisis.
Drug landscape in NC
In North Carolina, an average of 6.8 people a day die from a drug overdose, according to 2025 data from the N.C. Department of Health and Human Services. Drug overdoses have been steadily decreasing since 2023 — there were 178 overdose deaths in February of this year, which is down from 226 in February of last year.
About 75% of drug-related deaths were caused by multiple drugs taken in combination by a single user, or polysubstance use, according to the NC State Center for Health Statistics. Fentanyl, a synthetic opioid, has been the leading driver of overdose deaths for the past 10 years. Before that, it was heroin, which is also an opioid.
Across the nation, the drug supply has become increasingly unreliable. Substances like xylazine, a large animal tranquilizer, and medetomidine, another veterinary sedative often mixed with fentanyl, have been showing up during routine drug-checking procedures. Both of these are often mixed with fentanyl, which is a synthetic opioid.
Nabarun Dasgupta, the head of the UNC Street-Drug Analysis Lab, testified before Congress in March about the risks of medetomidine. He said that withdrawing from the drug, which has overtaken xylazine in the supply, can be incredibly dangerous and take weeks in the ICU, per reporting from NC Health News.
Dasgupta, an epidemiologist and advocate for harm reduction, was named a MacArthur Fellow in 2025 for his work at the UNC lab. He was the only North Carolinian to receive the fellowship, known better as the “genius grant.”
Drug-checking has become paramount in reducing overdoses. So has the widespread distribution of naloxone, a medicine that can rapidly reverse opioid overdoses, commonly known by its generic name, Narcan. Syringe-exchange programs have also become commonplace to prevent the spread of infectious diseases. Sharps disposal kiosks, which are publicly displayed boxes where people can dispose of used needles, are in boxes and restaurants across the region, state and country.
All of these are harm-reduction practices — interventions to minimize the negative medical and legal effects of substance use, without total abstinence. At least 65.9% of those who died from overdoses in 2023 had at least one opportunity for an intervention, like a bystander being nearby or a history of drug use, according to data from the National Institutes for Health.
Policing harm reduction
North Carolina legalized hypodermic syringe and needle exchange programs in 2016, which the NC Harm Reduction Coalition helped craft. The NCHRC is an organization dedicated to harm reduction, public health strategies and drug policy change across the state.
Some harm-reduction advocates have had conflicting feelings about legalization, Carolina Public Press previously reported, because it didn’t fund any existing exchange efforts. The legislation that initially legalized these programs was House Bill 972, meant to allow body cameras for law enforcement, with a provision about needles slipped in.
If you get pulled over at a traffic stop in North Carolina, an officer might ask you if you have anything sharp in your pockets, like needles or syringes. Possessing syringes is still technically illegal without that written verification from a syringe program.
So, a person claiming immunity must provide written verification that their needles or syringes are from a syringe service program, or SSP — which can be difficult to regulate. Many law enforcement officials have not received training on safe syringe use, so what happens during these stops can vary by officer and by police department.
“It is difficult to keep large fleets of decentralized law enforcement up to date with all of the minutiae of new legal changes with people they interact with, ” said Jennifer Carroll, an associate professor of anthropology at NC State.
Carroll, who volunteers with different harm reduction groups, said some groups give out small cards that display her name, descriptors like gender and race and a number that is unique to her. She worked on a 2023 study with the NCHRC about law enforcement interactions after the legalization of syringe exchange in North Carolina.
Haywood County was one of the areas mentioned in the study, which surveyed participants in syringe service programs. Some 15% of individuals had negative experiences with law enforcement.
Part of the study’s research goal was to see how racial minorities who use SSPs, especially Black communities, who have been disproportionately affected by drug policing in the past, were interacting with law enforcement. Carroll said the group had to exclude Haywood from some of the conclusions because the county is more than 90% white, but it also reported significant negative interactions with law enforcement.
“I still hear from people that there’s a sentiment from law enforcement of ‘We don’t do that here’ or ‘We don’t follow that here,’” said Phil Dixon, a teaching associate professor of public law and government at the NC School of Government at UNC-Chapel Hill.
‘Imagine how much could be saved and reinvented?’
At a September county commissioners meeting in Jackson County, Pazia Harbin, who works with the North Carolina Harm Reduction Coalition, spoke about these issues during a public comment segment.
While some in the county, which is in the state’s far west, are wary about the safety and costs of syringe exchanges and safe drop boxes, Harbin said these resources save lives and money. Spending $5 on a dose of naloxone will save more than $20,000 that an emergency room visit to treat the overdose would have cost, Harbin said.
“This is hundreds of thousands of dollars saved by harm reduction workers doing their jobs,” Harbin said. “Imagine how much could be saved and reinvented with county-backed initiatives?”
Drug overdose death rates in rural Jackson are more than 40% higher than those of the rest of North Carolina. In neighboring Swain County, they’re more than 70% higher. In these counties with just tens of thousands of residents, these numbers are striking.
In Western North Carolina, there are nine syringe exchange programs. Most of the programs are operated by community groups, though the Buncombe County Health Department also operates one. Most of these do not receive government dollars and rely on grants and donations.
Hushabye Sinn is the organizational director of Holler Harm Reduction in Madison County, which serves the towns of Marshall, Hot Springs and Mars Hill. Holler delivers supplies to residents who don’t have the time or money to travel to the nearby cities of Asheville and Johnson City, Tennessee.
A large number of people who use drugs in the area tend toward stimulant use, they said, and the organization has a lot of folks coming over the border from Tennessee, too.
Tennessee offers less immunity from prosecution for overdoses. Areas like Unicoi County, which is just across the state line from Madison County, have fewer harm-reduction resources for people who use drugs. Sinn said North Carolina has some of the most lenient harm-reduction laws in Southern Appalachia.
Sinn previously worked with the Steady Collective, which is a harm reduction organization based in Asheville. The group distributes naloxone and provides syringe exchange services and wound care, traveling around Buncombe County with a mobile unit.
“Harm reduction seeks to make sure that if people are going to use, because we’re autonomous adults who make our own decisions, they do it as safely as possible,” Sinn said. “The drug supply itself is not always safe, and the circumstances around it are not always safe.”
People should think about harm reduction for illicit drugs like taking precautions with firearms, Carroll said. While everyone has a different level of comfortability with firearms, it’s paramount that they are used in a safe manner.
Raymond Velasquez-Turner, the organizing director for the Western North Carolina AIDS Project, said syringe exchange programs can limit the spread of HIV, Hepatitis C and other needle-borne illnesses. He said harm reduction isn’t just about drug use, it’s about safe sex and other ways of keeping people healthy.
Groups can also send samples of drugs to the Street Drug Analysis Lab at UNC-Chapel Hill, which is entirely mail-based. Sinn and Harbin said they have sent samples to the lab and been surprised with the results. Once, a sample that was thought to contain fentanyl came back as nearly pure cocaine.
Sinn and Velazquez-Turner also said people come into harm-reduction organizations with questions about testing hormone replacement therapy and research peptides that can be bought online. Sometimes, organizations will help older individuals coming in who need help injecting their GLP-1 medications for weight loss.
“There’s this weird idea that harm reduction is this nefarious thing that is happening,” Sinn said. “In reality, we will test your peptides, we will test your HRT, we’ll test you for Hep C and HIV.”
Funding the future of harm reduction
North Carolina is receiving $1.6 billion in funds from opioid settlements with major pharmaceutical companies, but that money will be spread out over the next 18 years. In 2024, Jackson, Macon and Swain counties considered pooling money together to create a regional care center, but there hasn’t been any recent motion.
Because of the broad nature of the funds and their slow disbursement, communities have waited to decide how they will use the money to combat the opioid crisis. Places that have already disbursed their installments have given them to things like paramedics, treatment strategies or law enforcement.
Stephanie Almeida hopes some of the Macon County funds will go to harm-reduction efforts. Syringe services are an allowed use of the funding, as well as naloxone distribution. Macon has not yet distributed any of its dollars from the settlement.
She is the founder and director of Smoky Mountain Harm Reduction in Franklin, which is in Macon County, a thinly populated area deep in the mountains. The area is a big gap for resources, Almeida said. Franklin is just 10 miles from the border with Georgia. Her office, which is a strip mall neighbor to a treatment center, is a refuge for people who need food, naloxone, personal hygiene supplies or really anything.
Hers is one of the few organizations providing support to people experiencing addiction in the four westernmost counties in the state. COVID-19 and Helene were devastating to people who use drugs and those who face housing insecurity, she said. Most of her work is self-funded, or assisted by donations, but still, she loves it.
“My job is to keep people alive and healthy,” Almeida said. “Doesn’t matter if they use drugs today, last week or if they’re abstinent.”
Editor’s note: This article has been updated to include more recent statistics about deaths from overdoses in North Carolina.
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