Abstract
Our state's motto is “Esse quam videri - To be rather than to seem.” North Carolina struggles with insufficient systems to adequately address the opioid crisis we are experiencing. However, progress is happening. Leaders are making a difference across organizations, partnerships, and communities large and small. Where there is a will, North Carolina people are finding creative solutions to address the opioid crisis and its underlying health issues. We cannot wait. We cannot seem. We cannot be afraid.
You may have heard by now, if you have not experienced it in your own family directly: as a society, we are facing an opioid epidemic, a persistently challenging issue that does not discriminate across age, gender, financial status, employment status, race, culture, or geography. In the United States, death from opioid overdose now takes more lives each year than car accidents [1]. Sadly, we know this to be true in every region of North Carolina, too. Like the rest of the nation, we have seen a dramatic increase in overdose death in recent years [1]. The majority of drug overdose deaths (66%) involve an opioid. In 2016, the number of overdose deaths involving opioids (including prescription opioids and heroin) was 5 times higher than in 1999. From 2000 to 2016, more than 600,000 people died from drug overdoses. On average, 115 Americans die every day from an opioid overdose [2]. There are countless public agencies in counties across the state that are affected by opioid addiction and abuse: hosptials, health departments, foster care services, adult care services, nursing homes, law enforcement… the list is unending.
Communities are charged with solving persistent, expensive, and deadly challenges—so far, in large part, on their own. Providers are charged with educating, prescribing properly, and following up for harm reduction and patient safety. Together, providers, county commissioners, law enforcement leaders, public health workers, and social service workers are doing what they can to be responsive and responsible to the unintended consequences of this crisis despite a lack of financial resources and difficulty accessing recovery and treatment centers from rural areas of our state. Communities across the state are working tirelessly and creatively to help people find hope, treatment, and lasting recovery.
Part of the crisis we are experiencing has developed because, in some cases, those who followed a medical provider's instructions have developed a dependence on opioids to the point they continue to seek the medication and its effects. When the opioids are no longer available by prescription, some seek alternative options to prevent the pain and illness of going into withdrawal. This is where heroin, an illicit and synthetic form of the drug, can enter the picture and become a problem in communities like it has in many of our North Carolina counties. Heroin, since its origin varies, is often laced with other synthetic opioids like fentanyl and overdoses of these different combinations of drugs are becoming more and more common. Heroin overdose death among women tripled between 2010 and 2013 nationally [3].
The Federal Government's Role
The federal government also has a role in addressing this issue. Last year, President Trump formed the Commission on Combating Drug Addiction and the Opioid Crisis. Governor Roy Cooper is one of 6 members of the Commission, led by former New Jersey Governor Chris Christie. The Commission submitted its report outlining recommendations to the president on November 1, 2017, just days after he declared the opioid crisis a national public health emergency under federal law. In the 138-page report, Governor Christie writes, “It is time we all say what we know is true: addiction is a disease. However, we do not treat addiction in this country like we treat other diseases. Neither government nor the private sector has committed the support necessary for research, prevention, and treatment like we do for other diseases [4].” There has never been a truer statement. Recognition and acceptance that addiction is a disease and needs to be treated as such is an important first step in making real progress toward tackling it.
The National Association of Counties has also done its part to shed light on this issue by issuing a joint report with the National League of Cities called A Prescription for Action: Local Leadership in Ending the Opioid Crisis. The first page of the report includes this statement: “It has been said that in every crisis lies the seed of opportunity, and the opioid crisis presents an invaluable opportunity for city and county officials [5].” It is in this spirit that North Carolina counties have coalesced around this issue and made significant progress in turning the tide on what feels like an overwhelming problem.
Inspiring Local Action
In North Carolina, we are working across partners, leaders, families, and providers in diverse and new ways to address this issue as not just one of individual choice or chance, but as a community health challenge that needs attention at many different levels across a continuum from primary prevention to harm reduction.
One major issue is that local elected officials rarely have an opportunity to come together to learn about the unique challenges facing their counties. Creating just such a learning and sharing opportunity was the impetus for the North Carolina Association of County Commissioners' (NCACC) 2017 initiative, the County Leadership Forum on Opioid Abuse. As 2016-2017 president of the NCACC, Fred McClure, who is also commissioner for Davidson County, worked with the association staff to develop a meeting model, including all the requisite materials, and to provide these materials to every county.
Working with a team of partners from the North Carolina Division of Mental Health, the North Carolina Local Public Health Directors Association, North Carolina State University Cooperative Extension Services, and the North Carolina Council of Community Programs, NCACC created a common meeting design, developed sample program content, and established an online resource page with materials to use for the meetings. Davidson County hosted a pilot forum in May 2017, which allowed the work group to fully evaluate the program model and county support needed to make the meeting a success, and in June, 100 individual county packets were developed and delivered to all counties [6].
To date, nearly 40 counties have held opioid forums, and many more have extensive resources dedicated to tackling the issue. As part of the initiative, counties were asked to submit a follow-up report to the NCACC outlining the ideas generated at the forum, including next steps and the challenges and opportunities identified by the group. From Pender County in the east to Macon County in the west, counties across the state are generating ideas and implementing prevention, education, and treatment strategies to combat the opioid epidemic.
County efforts were bolstered with the passage of the Strengthen Opioid Misuse Prevention (STOP) Act, which was signed into law by Governor Roy Cooper on June 29, 2017. It provides more state funds for opioid and substance abuse management, and importantly, restricts the prescribing of opioids and requires additional reporting by physicians and pharmacists. Measures like the STOP Act are critical to reinforcing and accelerating the grassroots efforts counties are undertaking.
Martin, Tyrrell, and Washington counties held a joint forum on October 26, 2017, attended by 115 people who discussed what the counties are doing and can do to address the opioid crisis in their communities. A significant next step coming out of the forum is for the 3-county District Health Department to research and develop a position for a public health educator.
New Hanover County has been one of a handful of counties at the forefront of taking steps to address the opioid epidemic. The county's largest city, Wilmington, has been called “ground zero” for the nation's opioid crisis, as it was rated number one in the nation for opioid abuse, according to a report by Castlight Health. The county's Communications and Outreach Department has produced a number of public service announcements (PSAs) aimed at raising awareness of the local opioid epidemic and its impact on the entire community. The first PSA showcases a series of powerful messages delivered by the district attorney, sheriff, chief of police, mayor, chairman of the board of commissioners, health care professionals, superintendent of public schools, public defender, and chief district court judge, all ending with a statement: “This matters. I'm going to be part of the community solution.” Other PSAs share stories of people formerly addicted to opioids and the heart-wrenching struggle of family members whose loved ones could not overcome their addiction. These messages go a long way in educating the public about the dangers of these drugs and how to avoid becoming addicted.
Cabarrus County is focusing on the drug courts' Law Enforcement Assisted Diversion (LEAD) program (see sidebar, pages 172-173) and notes communities in its forum report that are pursuing the program, including Fayetteville and Wilmington (in operation); Waynesville (launching); Gastonia, Dare County, Durham, Orange County, and Hickory (exploring); and Statesville (department with a LEAD Set Up Committee). LEAD is a pre-booking diversion pilot program that allows police and sheriffs to redirect low-level offenders engaged in drug or sex work activity to community based programs and services, instead of jail and prosecution.
Much of what counties are doing to address this issue draws on the concept of community coalitions, which is an evidence-based best practice, meaning that it has been validated through professional research, data, and findings, according to the Substance Abuse and Mental Health Services Administration of the United States Department of Health and Human Services. Having county commissioners and other county leaders use their positions to convene these forums and shepherd these projects is an effective step toward opioid abuse prevention, treatment, and intervention in North Carolina.
In-Depth: Granville Vance Public Health
Granville Vance Public Health (GVPH), with offices in Henderson and Oxford, North Carolina, has worked since 2016 with the North Carolina Harm Reduction Coalition (NCHRC) to make a difference in a place where a lethal combination of factors exists to make opioid dependence common. In January 2016, GVPH offered primary care in 2 locations of the health department with a family physician, Shauna Guthrie, MD, MPH, who was willing to address all the health needs of her patients including substance use disorder. Dr. Guthrie participates in the University of North Carolina at Chapel Hill School of Medicine's Ethnicity, Culture and Health Outcomes (ECHO) project, a hub-and-spoke model for providing patient care in medication-assisted treatment (MAT), combining counseling and behavioral therapies with FDA-approved medications. Individual provider-patient relationships deepen and evolve as needs are identified in substance use disorder, Hepatitis C treatment, and counseling, but the health department has also addressed the crisis at a population level.
Through funding from the Health Services and Resources Administration at the federal level and locally from the Triangle North Healthcare Foundation, GVPH was able to start a local coalition effort in 2015 called Project VIBRANT—Vance Initiates Bringing Resources and Naloxone Training. VIBRANT is a collaborative partnership with stakeholders throughout the county working together to prevent overdoses and save lives by distributing free overdose rescue kits with a counter-acting, non-addictive drug called Narcan (generic: naloxone). Naloxone rapidly reverses overdoses from heroin and prescription painkillers, though observation is necessary after administration to be sure additional doses are not needed [7].
A key leader in this work is the NCHRC, which has worked with GVPH and a number of other partners to successfully distribute over 2,294 naloxone kits and achieve 276 reported reversals across both Granville and Vance Counties. The successful work of Project VIBRANT also led to the addition of both a fixed and a mobile syringe exchange program for Vance County in 2017. Syringe exchange programs became legal in North Carolina on July 11, 2016, the day Governor McCrory signed House Bill 972 into law [8, 9]. Local solutions can be unique and creative and having volunteers who know the community can really help. For example, NCHRC volunteers in Vance County are distributing naloxone kits and education about treatment and referral options through pawn shops. It's important to find the best way to reach the populations in need and build trusting relationships. That's the expertise NCHRC brings to a community.
In October 2017, GVPH hosted a local 2-county opioid leadership forum with the help of the standardized materials sent to all counties from NCACC, with the express purposes of heightening awareness and understanding about opioids and substance use addictions; discussing the causes and effects of addiction and its impact on the county; learning about successful prevention and treatment programs; and identifying education, prevention, and treatment strategies. The half-day forum included physician experts, local providers, a peer counselor sharing his own story of recovery, the local mental health managed care organization sharing information about treatment options, public health leaders facilitating discussion, and North Carolina Attorney General Josh Stein as the keynote speaker. More than 200 individuals in the communities across Granville and Vance counties attended and provided evaluation feedback that the information shared was informative and necessary to address the problem of opioid use disorder locally. The forum initiated community engagement in new ways. It seemed to make it okay for leaders across different agencies to ask questions, and it started more widespread understanding about opioid use disorder and options for treatment that extended from the forum to schools, Sunday school classes, and health care providers.
Finally, GVPH is involved in a statewide movement called the Stepping Up Initiative that aims to address mental health and substance use disorder among the jailed population. This unique approach in underserved rural areas of North Carolina is a collaboration across 5 counties: Franklin, Granville, Halifax, Vance, and Warren. The group is entering the 3rd year of the collaboration, which includes local providers, county leaders, jail administrators, social service leaders, public health leaders, magistrates, and other judicial system leaders. There is general recognition that rural under-resourced areas struggle with not enough providers for substance use disorder treatment and not enough systems to address social determinants of health for people who need more appropriate mental health and substance use disorder care than local jails can provide. The regional coalition is divided into work groups in 2018 to address standardization across the intake process in the 5 local jails and data collection about mental health and substance use disorder, as well as funding and grant writing. Progress may be slow, but it is marked. The lack of resources is stark and yet the collective will to do something productive and helpful is, too.
Conclusion
Communities have many challenges in dealing with the opioid crisis. So far, it has taken creativity and compassion to make inroads to address the effects of opioids locally. Resources to address the crisis are incredibily limited, especially in poor and rural areas of our state. Compassionate action is the best choice we have as we build the evidence for what works.
Acknowledgments
Potential conflicts of interest. L.M.H. and F.M. have no relevant conflicts of interest.
- ©2018 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.
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