From 2017 to 2019, about 50 people died of opioid overdoses in Durham County each year. During the pandemic and its aftermath, that number spiked as high as 137 a year, matching a statewide increase.
As a harm reduction programs manager at the North Carolina Harm Reduction Coalition (NCHRC), Loftin Wilson saw this all play out on the ground. NCHRC founded the first statewide community-based naloxone distribution program in the South. Since 2013, they have reported distributing over 224,000 naloxone kits and received over 27,000 reports of successful overdose reversals using their naloxone kit.
Wilson grew up in Alamance County and started working with NCHRC as a volunteer in 2010. His areas of focus include making harm reduction accessible for people who are transgender, living in rural communities, or incarcerated.
This year, he was appointed to the Durham County Opioid Settlement Advisory Committee, which will guide the Board of County Commissioners as they figure out how to spend the county’s share of billions of dollars that giant pharmaceutical manufacturers and distributors are paying to state governments, mandated as part of a settlement for the companies’ role in exacerbating the opioid epidemic (especially by marketing prescription painkillers as “nonaddictive”).
The companies have generally not admitted fault in the crisis, but advocates and officials both hope that the money helps turn the recent decline in deaths into a real turning point for the crisis.
North Carolina is receiving $1.4 billion in the initial settlement, which will be distributed to municipalities until 2038. The City of Durham is in line for $4.5 million; so far it has planned to give money to organizations that serve people who use opioids, like Lincoln Community Health Center, Durham Technical Community College’s Mobile Addiction Treatment & Primary Care Services, and the often-lauded HEART program. Durham County is set to receive $21.7 million. So far the county has authorized spending about $1.8 million in funding, largely on personnel—opioid program manager, peer support and harm reduction specialists, paramedics—and safer syringe program supplies.
We interviewed Wilson about Durham’s response to the ongoing crisis, the ongoing racial disparities in overdose deaths, and how the opioid epidemic has changed since the first of those pivotal lawsuits went to trial in 2019.
INDY: Could you tell me about NCHRC and your work there?
Loftin Wilson: We started as kind of a grassroots organization doing HIV advocacy and harm reduction before anything was legal in North Carolina, and then we’ve grown a lot over the years.
And now our work is a combination of direct services, working directly with people who use drugs in the community, and then doing a variety of technical assistance for other organizations on different harm reduction strategies and how to implement them, advocacy at the state and local levels around policy issues that affect people who use drugs, and we provide a lot of training to a whole bunch of different stakeholders who affect the lives and health of people who use drugs: stakeholders in the healthcare system, the criminal justice system, treatment, social services.
For direct services, we have seven syringe service programs (SSPs) that we directly operate at NCHRC … all the way from Wilmington on the coast to Haywood County in the mountains. And one of our programs is [in] Durham, which is the one that I work at and provide direct services at. The Durham program has been operating officially since 2016, which is when syringe programs were legalized in North Carolina.
You mentioned 2016 as when syringe service programs [which allow people to exchange their used needles for new ones], were legalized. Could you say more about how the work has changed over the years?
Like a lot of SSPs in North Carolina, we kind of had our roots in peer-led underground stuff that was happening prior to legalization. So for a few years, two, three years before legalization, just on my own, I did some peer-based exchanges, very bare bones, just like needles and naloxone, mostly with people that I knew and places that I knew.
And then when SSPs were legalized in North Carolina, we registered the program and it became a part of NCHRC. Now we operate three days a week. Mondays we do delivery, so we can come to folks anywhere in Durham County if they can’t come to us, prioritizing people who are disabled or elderly or have other reasons that they have trouble getting to us. And then Wednesdays we have a street outreach route, where we post up at different spots, the same spots every week around town, and some of those locations we’ve been going to every single Wednesday since 2016, so we’re part of a community of people who know us and recognize us. And then Fridays we have drop-in hours that are hosted by the Recovery Community of Durham in their office at the Elizabeth Street Church, and folks can come by and get services there.
Our program has grown a lot, because every year we’ve increased the number of people that we see and the amount of services that we offer, and we’ve started offering a lot of different wraparound services.
And the drug use landscape has changed a lot since 2016, because 2016 was in the middle of the wave of heroin being replaced with fentanyl and fentanyl analogs. We think about the opioid overdose crisis in waves. There was the wave of overprescribing of prescription opioids, and then the tightening of restrictions on that supply, and a lot of people who are using prescription opioids switching to using heroin. And then the wave of the heroin supply being increasingly replaced by fentanyl. And then the wave that started around 2020: an increasing dilution of the fentanyl supply with a variety of other substances, including nonopioid sedatives like xylazine and medetomidine and various other cuts and fillers.
Durham is special for a lot of reasons, but one of the reasons that it’s special is that it is a historical dope town. So there’s a lot of people who’ve been using heroin regularly their whole adult lives, who were affected by the fentanyl crisis differently, because they, a lot of times, didn’t have that sort of classic opioid-crisis trajectory of somebody starting with pills and switching to heroin and then to fentanyl. So they were affected by the fentanyl crisis deeply, but not in exactly the same way.
And that mirrors what we’re seeing now, that while overdose rates and overdoses are dropping nationally and in North Carolina, we’re still seeing the rates too high in communities of color, particularly among Black and Indigenous drug users, and that’s the majority of who our program sees here in Durham is drug users who are Black.
Durham, in my understanding, has taken some real steps to prioritize this kind of work—and correct me if that’s not the case—but is it different working with county governments across North Carolina?
It’s so different! And that brings us to one of the both strengths and challenges of the way that our opioid settlement is structured in North Carolina. And I think this is the best way to do it, I can’t think of a way that would work better.
The way that our attorney general structured it is that the majority, I think 85 percent, of the money goes directly to the local counties and municipalities.
And so each county or municipality can decide how it wants to spend the money, as long as it stays within the guidance of the opioid settlement MOA [memorandum of agreement], which lays out which strategies you can use.
They’re all great evidence-based strategies, things like syringe service programs, naloxone distribution, housing for people in recovery, diversion from criminal justice systems—all kinds of wraparound services like that are allowable. So each municipality gets to decide which strategies it wants to support, so there’s a lot of local autonomy, which I think makes a lot of sense, because counties have different needs and they should get to decide how they want to spend the money.
But then it does also mean that if you live in a county—and this is not Durham, we’re very fortunate in Durham—but if you live in a county with commissioners who don’t believe in harm reduction or are very punitive in their approach, then that can affect how the settlement is enacted in that particular county or municipality.
Is there anything you wish Durham, Orange, and Wake Counties were doing differently?
more opioids coverage
Sometimes I wish we could be moving faster than we are, but I recognize that, especially compared to other counties, there has been a good sense of urgency and there’s also a good literacy on the part of decision makers about the strategies that are allowable and that they are the most impactful, the most evidence based, and that they are things that our community really needs and, in many cases, was already doing. [Durham is] unusual in North Carolina. We have two syringe service programs. We have our community-based one, and then the Durham County Health Department has one as well. There’s many counties that still don’t have any at all.
We already had a number of really strong access points for medications for opioid use disorder. Again, that’s something that some counties don’t have. We have a lot of the strategies already in place; they just need to be scaled up to meet the need.
You just had your first meeting of the county advisory committee for the settlement fund. What is the purpose of that committee?
My understanding is that its purpose is to guide and advise the county commissioners’ decisions. So in Durham we have two pots of funding, the city has its own funding and the county [has its own] …. In the future, we’re going to be involved in advising, developing RFPs [requests for proposals] for organizations in the community to apply for funding, and then potentially advising the county commissioners on which strategies Durham should focus on, but I’m not sure exactly the time frame.
There’ve been some community meetings so far that the county has held to solicit general community input on which strategies people feel like are most important to focus on. There was a survey at some point that the county did. It was an online survey, and I asked them to make a printable copy, so I could take it on outreach and have people fill it out there, because an online survey is not accessible to everybody, so there have been a lot of good efforts in getting community input, and I’m hopeful that there will be continued mechanisms for that.
We previously wrote about some of the settlement funds going out, and one of the city council members we interviewed said something like “It’s rare to see that these people who caused this crisis are actually now having to contribute money to start to fix it.” Does that ring true to you? Do you feel like there is some justice coming through this money?
This is money that we have because many, many people died, so we have an obligation to the people that we’ve lost and the people that have experienced so much suffering over these past 20 years of the opioid overdose crisis.
The money needs to be invested in a way that honors that loss and supports the people who are currently struggling. And I think we have a really good example to learn from with how the tobacco settlements went awry, and how, to my understanding, those settlements weren’t structured very well. There weren’t adequate guidelines, so a lot of that money got spent on things that were probably helpful but weren’t necessarily directly related to mitigating the suffering caused by tobacco. So I think it’s just up to us on the local level to take that structure and to follow through, remembering that it is money that comes from death and suffering.
Is there anything you think people are missing from the conversation, or from their understanding of harm reduction or the opioid crisis or the settlement money, or anything that you find yourself often trying to work to correct?
We’re very fortunate that people in Durham have a very strong understanding of what harm reduction is. There’s one understanding that can sometimes be embraced, which is that harm reduction is a way to funnel people into detox, it’s a way to sort of lure people into treatment.
And that is not my understanding of harm reduction. That is not the historical basis of it.
The idea is it supports people’s autonomy, and recognizes that people have all kinds of relationships with drug use, and that when people have substance use disorders or problematic relationships with drug use, that’s not just a relationship between me and the drug I’m using.
That’s the relationship between me and the social context that I’m in and the resources that I have access to, and all of these big structural drivers like poverty and racism and all of that that’s way beyond an individual person’s decisions.
So I do feel like we’re lucky that a lot of our leaders do seem to have that structural analysis. They understand how things like race and class play into people’s vulnerability to drug-related harms. I feel like we have a very strong foundation.
Is there anything that I didn’t ask about that you think is important?
I think it’s important to recognize that we’re in an extremely new and terrifying chapter in the ongoing war on drugs in the United States and that it’s hard to predict how things are going to unfold. There’s a lot of funding that’s already been cut for a variety of public programs, including ones that are focused on harm reduction and particularly HIV prevention.
And so at the local level, the state level, the county level, the municipal level, and the community level, [it’s important] that we can create resilient and well-supported ways of supporting each other.
Reach Reporter Chase Pellegrini de Paur at [email protected]. Comment on this story at [email protected].