Dramatic headlines on opioids are nearly continuous. The No. 1 cause of death for adults under 45 is fentanyl overdose (not even including other opioids like heroin and prescription pills). The number of drug overdose deaths, in general, has reached over 100,000 a year, including a quadrupling among N.C. teens just since the COVID-19 lockdowns. When drug-overdose deaths first broke 10,000 per year in 1999, it was a shock to the public. But now, reaching that number again would be a major victory.

As families, communities, and addicts themselves across the country call loudly for something to stop the upward momentum of drug-related deaths every year, two basic philosophies have emerged — both of which are present in North Carolina. And as N.C. officials begin distributing the $750 million in settlement money from pharmaceutical companies who had a hand in starting the current crisis, proponents of each approach will be calling for funding to their preferred model. 

The first approach could be called the abstinence-based approach to addiction. It involves a goal of sobriety through abstaining from addictive, intoxicating substances during long-term treatment. The means of achieving this goal vary. The 12-step model — which includes Alcoholics Anonymous and Narcotics Anonymous — is a popular and long-standing path, but there are also behavioral-change models and others. 

Message outside of a 7-11 convenience store in Salem, Oregon (Unsplash)

The second approach is the “harm reduction” model. Rather than insisting on permanent sobriety, harm reduction focused on improving health outcomes regardless of whether the addict chooses to stop using drugs. 

Carolina Journal spoke to Loftin Wilson, program director at North Carolina Harm Reduction Coalition, to get insight into this model. 

“I’m really excited about how the settlement is structured here in North Carolina,” Wilson said. “I like that we’ve laid out specifically, like, ‘Here are the evidence-based categories that the money can be spent on.’”

Wilson frequently uses the term “evidence-based” for preferred harm-reduction programs, like providing stable doses of opioids to addicts — which is commonly called medication-assisted treatment or MAT — and giving clean syringes to those who inject drugs.

Wilson points to studies that show MAT reduces overdoses among opioid users and that “syringe-service programs” prevent Hepatitis C and other communicable diseases. In contrast, Wilson downplayed other approaches as not being evidence-based.

“A lot of times when people in the community who aren’t familiar with substance-use disorder or overdose prevention or harm reduction in general think about spending money, a lot of times money can be directed towards programs that are not evidence based and do not reduce overdose risks and rates of overdose in the community — things like faith-based programs and abstinence-based treatments that don’t have an evidence base that proves that they increase people’s chance of survival,” Wilson said. “It’s really helpful that we have it laid out [in the agreement] like, medication-assisted treatment [MAT], syringe-service program, education in jails, and all of these different categories that our settlement requires.” 

But Keith Artin, president and CEO of Durham-based treatment program TROSA, contends their program, and other similar abstinence-based programs, have a lot of evidence of efficacy too. 

“We’ve had a lot of success over the years with a long-term abstinence-based approach,” Artin, who has been with TROSA for over 20 years, told Carolina Journal in a May 31 phone interview. “We track our graduates for a year after graduation, and over 90% are sober, over 90% employed and have stable housing. And just a handful of folks, less than 5%, have criminal recidivism, which is a pretty strong indicator that they’ve made some significant changes to their lives. Over 90% have some criminal background. And that’s something that we’re trying to help people break that cycle as well.”

Because of his confidence in TROSA’s success rate for those who complete the program, Artin just asks that people with other models be open to a variety of treatment options.

“Recovery is not a one-size-fits-all kind of thing,” Artin said. “It would be great if folks would be open to an array of options, because you’ve got to meet people where they’re at. If people are reaching out for help we should be there for them. And if it’s coming for long-term treatment, we’re here for them. And if it’s for harm reduction… I’m glad there are other programs out there. Because the truth is, that’ll save lives too. I wouldn’t claim otherwise.”

Wilson said that programs like TROSA are not practical, though, because they ask people to leave their daily lives for so long. 

“I think what the research shows is that those are very helpful programs for the very, very small minority of people for whom they are helpful and for whom it is even possible to devote two years of their life to a residential treatment program,” Wilson said of TROSA. “That’s not accessible for everybody. It doesn’t work for everybody.”

Artin agreed it’s a lot to ask, but said addiction is often so ingrained in someone’s life, it takes time to unwind those patterns. And a community-based program away from the life they had been living is a path that works for many. TROSA’s program is also free for participants, avoiding the heavy debt that plagues some who go to long-term recovery programs.  

“It’s a lot to ask for someone to come to a program like TROSA,” Artin said. “It’s a big step. It’s a commitment. But then there are people who come here and look at it like, if you’ve spent several years or dozens of years in addiction, then to commit two years of your life to turning it around maybe is not such a bad deal.”

Proponents of this model say that for those who want a life completely free of opioid addiction, after two years in an abstinence-based program, they can often start fresh, free of dependence on the drug. But after years of MAT and clean-syringe programs, even if they’ve avoided overdose and Hepatitis C, they remain dependent on opioids. 

With the $750 million in opioid settlement funds now starting to arrive in N.C., groups like TROSA and N.C. Harm Reduction Coalition are closely watching how the money will be spent.

Wilson said NCHR hasn’t applied for any grants, but that they will likely be working with different counties and municipalities that receive money and implement harm-reduction services. 

“Our main goal isn’t necessarily whether we get any amount of money,” Wilson said. “Our main goal is just hoping it gets to the programs that are proven to work.”

The main focus for NCHR seems to be funding the MAT opioids like Methadone and Buprenorphine.

A common criticism on MAT is that the same pharmaceutical industry that profited off of over-marketing of opioids is now profiting off of selling more opioids to those same addicts. And now pharmaceutical companies are being taken to court and made to pay settlements on how they marketed these MAT opioids too.

For example, Indivior, the maker of what was the most popular MAT drug, the Buprenorphine-based Suboxone, was forced to pay the largest opioid settlement in U.S. history in 2019 for illegally marketing the drug as less addictive than other opioids. Indivior agreed to pay $1.4 billion to end the U.S. Department of Justice probe. There are also widespread reports of MAT drugs being abused rather than taken as prescribed. But harm-reduction proponents see the benefits as outweighing these concerns.

“Methadone and Buprenorphine help people get stabilized so that they’re not using drugs that are illicitly manufactured and that have analogs that vary wildly and are what are killing people in overdoses,” Wilson said. “And they help people maintain stability so that they can address other aspects of their life that they need, like housing and employment and personal relationships, things like that. The longer that you’re able to stay stable on the medication, the greater your chance of recovery.” 

Wilson added that “It’s about what works for people in terms of their own health and getting their lives back into a place where they want it to be. It’s not about holding out for this perfect ideal of if somebody was perfect they’d do this or that.”

But many on the West Coast in cities that went all-in on harm-reduction policies (like safe-injection sites, needle exchanges, “housing-first” programs, MAT, and decriminalizing drugs) say it has enabled a growing open-air drug scene to emerge. Michael Shellenberger, a one-time harm-reduction activist, wrote “San Fransicko” and ran for governor of California based on the idea that these policies had made the problem much worse. 

A growing chorus, even in these highly progressive cities, are saying that many of those free, clean needles end up on public sidewalks; the free housing and resources simply enable a deadly lifestyle; and the legal leniency has meant turning a blind eye to increasingly dangerous and inhumane conditions. San Francisco District Attorney Chesa Boudin, who ran on leniency on drug offenses, was just recalled on June 7 over the issue, among others. 

According to Wilson though, “The goal of harm reduction is to increase people’s health and wellbeing. That includes abstinence [from drugs], absolutely, if that’s the person’s goal and what they want and what’s achievable for them. That’s increasing their health and wellbeing. If someone’s goal is to be on MAT for whatever period of time, that’s also that. If somebody is not ready for that or not interested in that, the goal is to help them use drugs more safely so that they’re less likely to die of an overdose or a communicable disease.”

The demand for both approaches in N.C. and across the country is spiking as the opioid crisis continues. TROSA is consolidating their Durham operations onto one large campus and also creating a new Winston-Salem campus. The new campus will eventually have 200 beds and will open later this summer. The Durham location has around 500 slots. 

Artin said they want to focus on getting the two locations they have where they need to be before doing too much with new grants. But he’s hopeful about the impact the money can have and open-minded to potential new projects down the road. 

“Sure, we’re absolutely looking into it,” Artin said about the opioid grant money. “We’re absolutely looking at various grant opportunities that might be out there from that settlement fund. I do know we’ve been really fortunate to have strong support from the state legislature the past couple years that allowed us to do a lot of the things we’ve done the last couple years, including reinforcing our infrastructure and expanding to Winston-Salem. If we have an opportunity that makes sense, we’ll certainly pursue it.”

Artin added, “If the folks who are distributing those funds can continue to make sure that a variety of options are available to people, then we’re going to support it — whether that’s through TROSA or other programs.”