European countries use a combination of harm reduction services to prevent overdose deaths, but their techniques are more daring than most Americans are currently willing to try. But opinions could be changing.

By Taylor Knopf

The United States is not the first country to be plagued by heroin and overdose deaths. Western Europe experienced spikes in opioid overdose deaths in the 1980s and 90s. But countries such as France and Switzerland have found ways to support drug users and rein in the problem.

North Carolina Health News has dedicated hundreds of reporting hours to the opioid crisis and its socio-economic side effects in our state. Late last year, we traveled to Europe to see what others have done to address these issues before us.

Read our multi-part series on solutions deployed in Europe: “Lessons from Abroad.”

In Switzerland, we found that the country had to take extreme measures to rein in open drug scenes of the 1980s. People were overdosing and dying in prominent parks and outside the capital buildings in Berne. The Swiss passed a pragmatic, multi-pronged law that resulted in a 64 percent drop in overdose deaths over the last two decades.

The Swiss led Europe with the first safe drug consumption rooms and heroin assisted treatment facilities. Though controversial, the Swiss ran scientific trials and implemented evidence-based programs. The Swiss approach is all about removing barriers to treatment for drug users and getting as many people as possible into treatment. This resulted in trickled-down benefits for law enforcement as the street drug market weakened and crime dropped.

The French have adopted some of the Swiss practices. Their opioid strategy centers around seeing drug users as people first and supporting all of their needs, not just the need for drug treatment. The French have more than 300 harm reduction facilities across a country smaller in size than Texas, those include needle exchanges, places to shower, do laundry, and meet with social workers, psychiatrists and medical doctors. In addition to those centers, there are 480 addiction treatment facilities. The whole network is meshed together to support drug users as they live their best lives.

And it’s all covered through universal health care.

Meanwhile, in the United States, drug overdoses kill more Americans than car crashes. The number of overdose deaths in North Carolina went up from 1,407 in 2016 to 1,884 in 2017.

So what’s next for North Carolina in this opioid fight? Can we expect to see any of the European approaches that have been effective in France and Switzerland?

‘Buy a lot of clean needles’

Right now, North Carolina has 29 needle exchanges, the majority of which are run by a nonprofit organization, the North Carolina Harm Reduction Coalition (NCHRC). Unlike the robust harm reduction centers in Europe with a menu of free services and trained staff, the NCHRC relies on a patchwork of grant funding.

“Imagine how much more could be done if we allocated the resources needed, encouraged partnerships with health departments and provided the funding,” said Virgil Hayes with NCHRC.

“A steady funding stream is the next step towards moving forward.”

While syringe exchanges were legalized in 2016, there has been a ban on any state money going to fund them.

That might change.

Sen. Jim Davis (R-Franklin), who has led the state on opioid legislation the last few years, recently introduced the Opioid Epidemic Response Act, which would lift the ban on state funds going to needle exchanges.

It would also decriminalize drug testing equipment, which Davis said is vital as more controlled substances are laced with fentanyl, a drug that can be 100 times more potent than morphine.

The bill has been parked in the Senate Rules committee since April, but Davis told an audience gathered at the Opioid Misuse & Overdose Prevention Summit on Tuesday that he had a meeting with Senate leadership to move the legislation forward.

UPDATE 7/10/19: State lawmakers passed the Opioid Epidemic Response Act.

He called this piece of opioid legislation his “swan song,” as he will not seek reelection. In a later interview, he said he has confidence the bill will pass, adding that his Senate colleagues look to him for guidance on opioid-related issues.

The NC Harm Reduction Coalition is “overjoyed” at the support for this bill, Hayes said.

“Because of this legislation, vulnerable populations will be able to access HIV, hepatitis C, and overdose prevention services that empower them to reduce the drug-related harms impacting their community,” he said.

Packing naloxone kits in Raleigh. Video credit: Rose Hoban

Davis said he’s changed his position on syringe exchanges over the years as he’s seen data showing the effectiveness of needle exchange programs at reducing the spread of infectious diseases.

“I’m a data-driven guy,” said Davis, who had a career in dentistry.

He said he no longer views needle exchange programs as “enabling” drug use but “empowering” people. He noted the cost of treating one person with hepatitis C can be as high as $60,000.

“You can buy a lot of clean needles with that,” he said.

Davis said he is unfamiliar with the harm reduction strategies in Europe, but again said that he would be interested in the science and data behind their approaches.

“And if they have proven results, evidence-based plans, then I see no reason why we wouldn’t at least try them over here,” Davis said. “We have grant funding available to do different things.”

Harm reduction is one of the three pillars of North Carolina’s revised Opioid Action Plan, rolled out on Tuesday. The others are treatment and prevention. As the nature of the crisis has shifted from prescription pills to illicit drugs, harm reduction has become a larger focus on the plan.

In 2017, there were 1,884 opioid-related deaths in North Carolina, 75 percent involved heroin, fentanyl or a fentanyl analogue, according to the state Department of Health and Human Services data.

DHHS Sec. Mandy Cohen said she sees harm reduction as more than just the needle exchanges.

“I think it’s a matter of not necessarily focusing even on the centers, but how are we embedding all the harm reduction work into all of the things we’re doing across the board.”

Cohen says there’s been a huge push to get naloxone, an overdose reversal drug, into the hands of the public. In 2017, there were 4,176 reported community naloxone reversals, and the number of law enforcement agencies carrying naloxone increased from 136 in 2016 to 252 in 2018, according to DHHS data.

Wanted: Medicaid expansion



North Carolina Democrats believe the next step is to get thousands of North Carolinians access to addiction treatment by expanding Medicaid. Expansion has become the theme for almost every health care related advocacy group that has walked through the legislative building in Raleigh this session.

“To fully turn the tide of this opioid crisis, we have to expand Medicaid,” said Cohen at a press event in April.

“We need to get thousands and thousands of folks suffering from opioid addiction into treatment, and I can’t do it with just those federal grants,” she said after announcing that the state received an additional $12 million federal grant for treatment on top of the $45 million already spent.

“We could bring $4 billion to North Carolina with one word, and that’s ‘yes.’ Yes to expanding Medicaid,” Cohen said. “That will help us to have the tools we need.”

With the grant money spent so far, 12,000 more people entered addiction treatment, according to DHHS.

“However, there are about 120,000 people who need access to treatment, and expanding Medicaid is the single biggest lever we could pull — that we are not right now — to get more folks into that treatment,” Cohen said.

She pointed to an example in Ohio. After the state expanded Medicaid, Cohen said the overdose deaths in Dayton, Ohio dropped by 50 percent. That’s what the secretary said she would like to see happen in North Carolina.

Cohen and Gov. Roy Cooper have been promoting Medicaid expansion at every opportunity.

However, the legislature seems unlikely to budge on the issue. A few House Republicans introduced a bill that would help close the coverage gap for some working North Carolinians, although they are not calling it Medicaid expansion. That bill has not moved since introduction.

Meanwhile, the House and Senate are in budget negotiations, and neither chamber included a provision for expanding Medicaid in its version of the budget. When asked about it, Senate leader Phil Berger (R-Eden) doubled down on his stance against it.

Public education campaign

Attorney General Josh Stein echoed the call for Medicaid expansion while announcing a new public education campaign called More Powerful NC. Prevention and education are other key components of the state’s Opioid Action Plan.

“The campaign is to empower people all across North Carolina so they know what to do to fight this crisis,” Stein said at a press announcement to launch the campaign in April.

The campaign will consist of TV, radio, billboard advertising about drop boxes for unused opioid pills and lock boxes for the medication people keep in their houses that they might need.

“You should not leave a loaded gun in your medicine cabinet, you should not leave these pills unprotected either,” Stein said.

He continued by telling North Carolinians to talk with their doctors about alternative ways to treat pain. Stein encouraged everyone to visit the website to learn about tools, resources and ways to get involved in prevention and treatment in their communities.

Taking policies a step further



While the focus in North Carolina centers around public education and expanding treatment options and needle exchanges, there have been some efforts around the nation to take harm reduction a step further with supervised drug consumption rooms.

How do drug consumption rooms work? Video credit: Taylor Knopf

However, U.S. officials have pushed back hard. Earlier this year, the U.S. Department of Justice sued Philadelphia when locals tried to open a safe injection room.

At the annual State Health Directors meeting in Raleigh in January, U.S. Surgeon General Jerome Adams urged public health officials to improve upon the harm reduction methods they have available instead.

He pointed to the example in Philadelphia.

“They had one [syringe exchange] that operates by mobile vehicle a few days a week. Instead of focusing on that, they want to start a fight over something much more controversial,” Adams said.

When asked about the approaches in Europe and how far he would be willing to go with harm reduction in the U.S., Adams said what works for one community, might not be the best solution for another.

“We still haven’t optimized syringe service programs in most of our country, even though now we have federal funding in some ways available for syringe service programs. Before, pragmatically, I’m going to push for these other interventions, I want to make sure we’ve optimized the interventions we’ve already fought to make available,” Adams said at the January event.

“I’m not discouraging folks from studying the issue,” he added, “but I think we in public health really need to lean into getting people into treatment, increasing access to naloxone, increasing the availability of syringe service programs — the things that are already out there that we haven’t optimized.”

Policy evolving



Officials at the U.S. State Department communicate with European drug policy experts on a regular basis, according to James Walsh, deputy assistant secretary of state for the Bureau of International Narcotics and Law Enforcement Affairs.

Walsh said people in his department have been tracking what works and doesn’t work in Europe for years.

“The main thing that we agree with them — and this is our policy that has evolved over the years — is that it has to be a balanced approach,” Walsh said in an interview with NC Health News. “The majority recognize that the health portion is a critical solution. So we are taking a similar approach from a U.S. drug policy perspective: that opioid addiction, in particular, is a disease, and we are recognizing that it is a disease that’s treatable.”

He cautioned that the definition of harm reduction in Europe is not the same in the U.S., particularly when talking about drug consumption rooms.

“We have some disagreements,” he said.

Walsh has turned a lot of his attention to fentanyl and its analogues being shipped into the U.S. from other countries, including China.

Progress was made earlier this year, he said, when the president of China agreed to make all forms of fentanyl a controlled substance.

“That commitment is a very big deal for us,” Walsh said.

Additionally, he said there’s been a big push toward creating a network to look at the toxicology of drugs coming in from overseas.

“We can start having an early warning system of what’s being mixed, the adulterants in these various drugs coming in,” Walsh said. “The mixing creates a lethal cocktail, and we are discovering that more and more happening overseas.”