By Vibhav Nandagiri

On a street corner east of Durham’s downtown, Cheryl Riley spotted a woman sitting on a ledge outside a grocery store, her upper body bobbing back and forth.

Riley, a Durham County paramedic, pulled over her Ford Expedition with bright blue and yellow markings and asked the woman if she could take her vitals. After getting a go-ahead, Riley checked her blood pressure and oxygen levels.

This was not a stop in response to a 911 call. Riley criss-crosses the city as part of the county’s special Community Paramedics program, and she sometimes focuses on areas where drug users congregate.

“We do not judge,” Riley told the woman after removing the blood pressure cuff and pulse oximeter. “But can you tell me what you took?” 

“Fentanyl,” the woman responded.

“Do you trust your dealer?” Riley probed further.

“I don’t trust nobody,” her patient responded.

Worried about a potential overdose, Riley gave the woman some water and asked if she could call for an ambulance. After initial resistance about being stuck with a big medical bill, the woman acquiesced when Riley comforted her and promised to check on her later.

“That usually doesn’t happen,” Riley told NC Health News. Often, Riley said, the people she encounters in nonemergency situations on her usual routes are wary of being taken to the hospital.

Riley is one of two community paramedics in Durham County. The program began in 2017 to serve people with substance use issues, mental illnesses and chronic medical conditions through home visits, community check-ins and their professional connections with health care centers.

The goal is to cut down on emergency department visits, provide follow-up care after hospital stays and take essential information and medications to patients that some refer to as “frequent flyers” for their numerous ER visits. These specially trained paramedics serve as bridges to clinics, detox centers and other facilities that provide nonurgent care. They also help the elderly, disabled and others make their homes safer, such as pointing out measures they can take to better prevent falls, and help organize transportation to medical appointments.

In recent years, community paramedics have made it a priority to distribute naloxone kits and share recovery resources for people with substance use disorder.

“It’s this many-armed approach that combines both health care with social health and community outreach,” said Riley, who’s been in her current role in Durham for two years and worked in Orange County emergency management before that.

NC Health News joined Riley in early July for part of her rounds and agreed not to disclose identities of the people she stopped to check on.

A statewide effort

Durham County is not the only North Carolina entity with a community paramedic program.

McDowell County touted itself as one of the earlier programs in the country and among the first in rural NC after launching in 2013 with funding from the Kate B. Reynolds Charitable Trust.

Others have launched more recently with some of the $750 million allocated to the state as part of the $26 billion multi-state settlement with pharmaceutical manufacturers and distributors accused of stoking the opioid crisis.

Edgecombe County started a program in 2023. Onslow County, home to Camp Lejeune and Jacksonville, has a large community paramedic team with slots for eight full-time workers. The Johnston County Emergency Medical Services Division has a community paramedic program, as do Davie County, Caldwell County, Orange County, Yancey County.

Nash UNC Health Care realized that it could cut down on some of its repeat emergency department visits by sending community paramedics out for home visits with blood sugar monitors to help people with diabetes, bring medication information and help them navigate medical issues outside a physician’s direct care as vulnerable patients recuperate from a hospitalization. Cape Fear Valley Health did the same thing.

What distinguishes community paramedics from traditional paramedics and emergency medical technicians is their ability to follow up with patients and help them find longer-term treatment options for such problems as substance use disorder, a process they call “bridging.” 

Over the past year, they’ve started using medications for opioid use disorder as part of treatment. These synthetic opioid medications like buprenorphine and methadone help people manage withdrawal symptoms and start on the pathway to recovery, research shows.

Many of the people working in harm reduction and health care, Riley included, believe these medications are a key part of treating addiction as a chronic disease.

A fourth wave

Deaths due to opioid overdoses have been rising in North Carolina, including in Durham County, where opioid-related deaths tripled from 2019 to 2022. NC Health News has reported extensively on the opioid epidemic, its impact on North Carolinians and how counties are responding to the crisis. 

Public health officials have described opioid deaths as happening in three waves, with the third and most recent wave associated with a decade-long increase in overdose deaths from synthetic opioids, most notably fentanyl.

Anjni Joiner, medical director of Durham County Emergency Medical Services and a physician at Duke Health, is part of a growing group of experts observing what they describe as “a fourth wave” from fentanyl being consumed with other drugs — cocaine, methamphetamines and marijuana — often unknowingly.

“People who are not even trying to take opioids … are overdosing,” Joiner said. 

One such case serves as a cautionary tale for Riley. She had just started her job in Durham and encountered a woman who had been smoking marijuana to relieve symptoms from the chemotherapy she was getting while battling breast cancer. Unbeknownst to the woman, the marijuana was laced with fentanyl, and she overdosed. While paramedics were able to revive her, Riley believes it underscores the risks inherent to the drug supply from the streets. 

“We’re seeing a lot more of that — where people think they know what they are taking, but their drugs are contaminated,” Riley said.

Durham data underscores that trend. Joiner said that before the proliferation of fentanyl in recent years, they were seeing, on average, 40 to 60 overdoses per month. Now that monthly average is 80 to 100 overdoses with peaks in the summer months. In July 2023, Durham County emergency medical services responded to a record 102 opioid overdoses — which Joiner and others within county emergency medical services attributed to fentanyl contamination. 

Meeting people where they are

When paramedics respond to a suspected opioid overdose after a 911 call, their first step is to administer naloxone, which is known by its brand name, Narcan. Opioids cause the slowing and shallowing of breathing — which can lead to respiratory failure. Naloxone reverses these effects, but it also produces withdrawal symptoms.

These symptoms such as sweating, anxiety, diarrhea and vomiting can be serious, according to Riley. Given that, she disputes the narrative that people with opioid dependence can simply quit “cold turkey.”

Medications like buprenorphine help manage withdrawal symptoms and, if administered regularly, have been shown to improve people’s chances of recovery. Durham County paramedics began administering buprenorphine in June 2023. In the ensuing 12 months, 36 people have been started on buprenorphine out of 818 overdose-related calls, according to data shared with NC Health News.

Treatment for ten of those people began in June 2024, the most in a single month. Joiner sees that as a positive sign that Durham emergency service providers are making treatment more available. “It just takes time to really get integrated in the community,” she said.

The slow start is also a reflection of program capacity. When the program began, only community paramedics and paramedics who volunteered to get special training were allowed to administer buprenorphine. As of March, all Durham County paramedics have been trained. Each ambulance is now stocked with the medication, according to Joiner, allowing for administration of buprenorphine whenever emergency services responds to a call.

Joiner said the emergency teams have had the most success with getting people on buprenorphine a few days after an overdose. 

“They’re pretty overwhelmed. It’s a near-death experience, and so we find that when we follow up with them in the next couple of days, [people] are more open to starting on the medication,” she said.

While the goal is to get people into long-term care where they can receive medications regularly, that doesn’t always happen right away. During those lags, community paramedics can provide follow-up care and daily administration of buprenorphine for up to seven days. Often, they call their patients ahead of time and schedule a set meeting point and time to administer buprenorphine.

“I think we’re really innovative in that respect,” Joiner said.

Expanding funding and access

Over the past five years, North Carolina has been investing more in medications for opioid use disorder. Through its Bridge MAT program — MAT being the old acronym for medication-assisted treatment for substance use disorders — the state Department of Health and Human Services funds county emergency medical services to use buprenorphine to treat opioid use disorder.

The first two counties in the Bridge MAT program were Onslow and Stanly, which received grant funding in 2019. In 2023, the funding was expanded to eight more counties, including Durham. Recipients of these grants, crucially, must invest in a community paramedics workforce to administer buprenorphine. 

“People are interested in what we’re doing. They like the idea that there’s something out there that’s supportive, someone that they can call,” said Helen Tripp, program director of the community paramedics program. The Bridge MAT grant has helped sustain Durham County’s community paramedics program and keep it accessible for all residents.

“They don’t have to worry about getting a bill because we don’t charge for what we do,” Tripp said.

The program is about to grow. Tripp said two more community paramedics will be added in Durham County, bringing the total to four. There also are plans to tap into another grant to hire peer support specialists — trained staff who have lived through managing substance use disorder and can dispense their wisdom. 

Riley believes the new personnel will help them keep up with the high demand for their services. Between active dispatches and follow-up visits, her 12-hour shifts tend to be very busy.

“We are health care…but we’re also filling in this home care position. We’re doing a little bit of social work, we’re doing a little bit of case management, we’re working on the opioid overdose problem,” Riley told NC Health News.

But she also appreciates the freedom offered by the community paramedics program. Driving between appointments, Riley checks in on familiar faces — many of them unhoused — as she hands out water, food and naloxone kits. Some of them recognize her from previous visits.

Riley sees this “combination of medicine and helping better your community” as central to community paramedics team missions. 

“Durham has clinics, Durham has resources, Durham has opioid response … but the problem is getting those resources to the people who need them,” Riley said.

The post These paramedics are for more than just emergencies in N.C. communities appeared first on North Carolina Health News.

By Rachel Crumpler

Katherine Farris has been an abortion provider for more than 20 years, and she says that this past year has been the hardest of her career — by a long shot. 

Not her first year of practice when everything was new. Not the year she stepped into the role of chief medical officer at Planned Parenthood South Atlantic to supervise clinic operations across North Carolina, South Carolina, Virginia and West Virginia. Not the years she navigated COVID protocols to keep her staff and patients safe. 

The last year stands out above all the rest, as challenges escalated to a new level.

That’s because a year ago today, North Carolina’s new stricter abortion law took effect, significantly diminishing abortion access in the state. The time frame for seeking most abortions dropped from 20 weeks of pregnancy to 12 weeks, and the law added an in-person requirement for state-mandated counseling at least 72 hours before an abortion.

Farris has had a front-row seat to the upheaval caused by the change in law: Clinic staff frantically reworking operations to comply. Physicians stretching themselves thin to see as many patients as possible — knowing they can never meet the full demand. Patients desperately pulling resources together to book an appointment — often driving hours for care. Clinics turning patients beyond the state’s limits away without knowing whether they will be able to travel elsewhere. 

“These aren’t just numbers to us,” Farris said. “These are real human beings that sit in front of me in my office, and I see the burden this has put on them.”

No longer providing care beyond 12 weeks or practicing to her full capabilities has been a seismic shift that’s been difficult for Farris to adjust to. She gets a glimpse of the more weeks of care she used to be able to provide in North Carolina when she practices in Virginia, which allows abortions up to 26 weeks. 

“Depending on where my feet are planted, that’s what determines the care I can give,” Farris said. “It’s not my skills. It’s not the support staff. It’s not the equipment. And it’s certainly not what the patient needs. It’s just where my feet are planted.”

Despite the new restrictions, abortion volume in North Carolina has not dropped significantly since Senate Bill 20 took effect a year ago on July 1. In large part, that’s due to the efforts of abortion clinics, providers, abortion funds and other support networks that have worked to keep abortion accessible. Patients themselves have also gone to great lengths to overcome the increased obstacles to access care.

“Patients are incredibly resilient and resourceful,” Farris said. “But every day, I am angered that they have to be. They should not have to be so resilient. They should not have to be so resourceful. They should be allowed to get this care from a provider they already know and trust in their own community.”

Frantically adjusting

Calla Hales, executive director at A Preferred Women’s Health Center, which operates two abortion clinics in North Carolina, tries not to think about the day a year ago when abortion access in the state changed. 

Newly gained Republican supermajorities in the state General Assembly — a result of one Democrat’s abrupt party defection — swiftly passed the state’s stricter abortion law, Senate Bill 20, over the objections of medical professionals and Gov. Roy Cooper’s veto.

Hales said the first weeks were particularly tough and frantic.

“I really remember most like not sleeping for days on end,” she said. “To be quite honest, there is a stretch of time that last week of June and the first couple weeks of July where I was probably sleeping like five hours a week.”

She knew the stakes were high. The clinic needed to quickly change its operations to comply with the law and serve as many patients as possible.

Physicians and abortion clinic staff reworked processes, patient flow and schedules. They trained staff. They learned the new state-mandated counseling script and reporting requirements. 

“You’re having to figure it out on the fly,” Hales explained. “Patients don’t stop needing care to provide you with the time to stop and figure out how to address practices to better change to the scope of these new rules.”

Amber Gavin, vice president of advocacy and operations at A Woman’s Choice, an abortion provider with three clinic locations in the state, said clinics grappled with how to accommodate twice as many appointments to provide abortion care for the same number of patients. Patients coming in for two in-person appointments strains the physical space within the clinic and the staff’s time. 

Even now, with processes worked out, it continues to be an intricate balance of accommodating the increased volume of people in and out of the clinic, especially given the ramped-up pressure of the reduced time frame that abortion procedures can take place in North Carolina, Gavin said. 

As a result of the new requirements, abortion volume in the state dropped substantially during the months immediately after the implementation of Senate Bill 20, according to data from the Guttmacher Institute, a national organization that tracks trends in reproductive health. However, the number of abortions provided each month has since ticked back up, returning to volumes in line with pre-Senate Bill 20 numbers. In March, North Carolina provided about 4,030 abortions — the highest monthly volume since the law took effect last July — according to the latest data available from Guttmacher.

All three abortion clinic providers in the state that NC Health News spoke with said they’ve added days of abortion care to their schedules. They’ve also gotten creative with some of the appointment offerings, adding some later in the day, as they recognize that some patients can’t make it to morning appointments with the travel distances they are facing. Planned Parenthood has even expanded the locations where it provides medication abortion; the Durham health center started the service last month, and the Greensboro location is scheduled to start in mid-July.

A year later, some days can still be just as frantic as those early days, Gavin said. Phones ring off the hook. Patients’ emotions boil over — and staff’s can too. Clinic staff increasingly have to expand beyond providing medical care, doing more coordination to help patients navigate to other states to receive care past the 12-week North Carolina limit.

The abortion law also remains in flux, with two lawsuits challenging certain requirements that lawmakers implemented. That keeps abortion providers on their toes awaiting any decisions that further affect how they can provide care.

For instance, last month, U.S. District Judge Catherine Eagles in Greensboro issued a judgment that struck down several of North Carolina’s rules on dispensing medication abortion pills. Lawyers for Republican legislative leaders promptly appealed the judge’s decision.

Increased patient hurdles

Abortion providers say the most burdensome part of the law is the requirement that a patient go to an in-person appointment for state-mandated counseling at least 72 hours before an abortion. Previously, this pre-procedure counseling could occur over the phone or online.

The new requirements mean that patients must visit clinics at least twice — and many need to travel long distances to reach one of the state’s 14 abortion clinics spread over nine counties. The additional appointment means extra time off work and more travel, hotel stays and child care costs.

“People don't have extra money lying around that they can just stay in a hotel for three days,” Farris said. “They don't have someone to watch their kids for three days. They can't get time off of their job for three days. It's really incredibly cruel, especially because it is so medically unnecessary.”

One of the biggest barriers to abortion access is cost, said Justine, a Carolina Abortion Fund staff member who requested that NC Health News only use her first name for security reasons. Garnering the resources for a two-visit process under Senate Bill 20 can be even more of a challenge as nonmedical costs for gas, flights, hotels, child care and lost wages accumulate. That’s reflected in the sizable uptick in the number of callers seeking financial assistance to cover these practical support costs to get to their appointments, Justine said.

Justine said Carolina Abortion Fund, which helps patients pay for part of their procedure, is distributing more funding per month than before Senate Bill 20, but it is only able to meet about 40 percent of caller demand. In March, the latest data Carolina Abortion Fund could share with NC Health News, the organization distributed more than $70,000. In comparison, in March 2023, the organization distributed about $45,000.

Every month — typically after around 10 business days, depending on call volume — Carolina Abortion Fund exhausts its monthly funding, Justine said. When that happens, volunteers and staff members work with callers to help figure out funding, referring them to other funds and resources.

Farris says the financial and logistical challenges caused by the increased restrictions are pushing abortion care later in pregnancy. For example, Farris said she recently saw a North Carolina patient who came in for her initial appointment at 11 weeks pregnant. But by the time the patient could obtain her abortion procedure, she was 15 weeks pregnant — past the 12-week limit. Ultimately, she took a bus to Virginia, where Farris provided her abortion care.

Guttmacher data shows that in 2023, a total of 1,720 North Carolinians obtained abortions in Virginia — the most popular out-of-state choice.

“When they write this law, they just assume everyone will magically know they're pregnant sooner and come in right away,” Farris said. “But the human body doesn't work that way, and people's life circumstances don't work that way. So instead, what happens is while some people are coming in much sooner, we also, on the other end of the spectrum, see people push later and later in pregnancy by the time they can get the resources.” 

Others may be unable to pull the needed resources together. Clinics say a number of people don’t make it back for another appointment after the in-person counseling. 

The additional logistical hurdles can also create a more trauma-filled experience, said Simran Singh Jain, an abortion doula in Durham. Over the past year, she’s worked with about 30 people seeking abortions. The time crunch is forcing people to move more swiftly to access care, potentially neglecting their own emotions as they stay hyperfocused on navigating the logistics.

“We're having much more of those logistical conversations, and so people don't really have the opportunity to actually process what is a very vulnerable moment in their lives,” Jain said. “Because of that, I'm finding a lot of people are reaching out to me months later for the support that they were not able to take at the time because they were so focused on that logistical piece — just how challenging it is to get an abortion fundamentally — versus being able to actually take the time to navigate their own emotions about it.”

And a handful of patients continue to show up to clinics thinking they are getting an abortion that day, and they are devastated to learn they can’t — caught off guard by the two-appointment requirement.

Hales said these people often assume it’s a clinic policy rather than state law. She’s seen people plead to have the abortion on the same day — saying that they’ve already put much thought into the decision and don’t need another waiting period — but her hands are legally tied.

In other cases, said Rachel Jensen, an abortion provider in the Triangle, she’s cared for patients with nonviable pregnancies who have questioned why they have to wait 72 hours — the longest waiting period in the country. 

“I don't have a good answer,” she said. “It's because of the state law. And it's a really sad thing to say that your medical practice is dictated not by medical best practices, but by essentially arbitrary policies.”

The post One year into new abortion limits, N.C. patients and providers struggle to shoulder the load restrictions bring appeared first on North Carolina Health News.

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It’s 6:30 p.m. on a Friday night in Boone, North Carolina, and a hush falls over the East Boone Listening Room.

“We spent many years trying to find a space like this in town,” says artist and songwriter Sarah DeShields. 

Boone, which is home to Appalachian State University, has plenty of small to mid-sized venues, but they tend to cater to the college crowd or tourists. Because these hot spots are designed more for drinking and socializing, the performers often end up getting drowned out by the noise. 

What DeShields says Boone was missing was a space for singer-songwriters to showcase their songs to an audience intent to listen. 

“So, we decided to just make it ourselves!” DeShields laughs.

All the chairs in the East Boone Listening Room are taken, and I’m not surprised. Every time I come to these listening events, the place is packed wall to wall. So, I find a little spot on the floor and settle in to listen to the other songwriters before it’s time to play my own set of three songs.

The listening room hosts concerts on the second Friday of each month and is housed in the Boone Studio Collective – a space typically used by photographers and other artistic professionals. On listening nights, the studio is transformed into a small, cozy venue. The events are free, but attendees are encouraged to donate directly to the artists via Venmo or PayPal.

“I think it’s actually a need. People need connection,” says Meris Gantt, another songwriter and creative consultant who helps curate the evenings along with DeShields and fellow artists Will Willis and Simon and Sydney Everett. 

After the pandemic, Gantt felt people were hungry for that human connection they couldn’t get online. In a way, the Listening Room has become a place where people can heal from both the vitriol and the isolation of the pandemic. It’s a space for an artist to share their deepest emotions free of judgment and free of noise.

When I think about the greatest challenge to my own artistic work, it is indeed noise, and I don’t just mean singing over the racket of a crowded bar – though I’ve done that more times than I care to count. Artists are increasingly competing with the noise of a global music marketplace. 

Online streaming platforms, while they have their advantages, have saturated the market with endless content. It’s hard for a songwriter to cut through the noise, much less get paid a fair wage for their creative labor.

But that’s another beautiful thing about the Listening Room. Songwriters from all over have played here, but for the most part, “we try to make it hyper-local,” Gantt says, thereby instilling the value of not only an in-person, embodied musical experience but also a local one.

Becoming “hyperlocal” is a concept that’s increasingly appealing to me, especially in a world that every day becomes more and more oriented towards the compelling but somewhat artificial connections and consumption that the internet provides. These days, I – and I believe many others – are less interested in what’s cutting edge globally and more interested in what my own community has to offer me.

This is what I’ve found at the East Boone Listening Room. I’ve found Appalachian folks singing songs about what it means to live and love and work and grow here in Boone, in Appalachia. 

I’ve heard songs about what it means for your religious beliefs to change when you live in a highly religious context. 

I’ve heard songs that wrestle with being a descendant of settlers on a land that once belonged to the Cherokee. 

I’ve heard songs about watching people die of addiction and about the experience of incarceration. 

I’ve heard songs about local floods and mountaineer ghosts who haunt the hills.

These are deeply Appalachian songs about deeply Appalachian struggles. But the genre is not limited to what people typically think of when they imagine Appalachian music. Certainly, some artists incorporate traditional Old Time musical instruments like a banjo or mandolin. But the diversity of sound is something the curators of the East Boone Listening Room take great pride in. If a tourist from “off the mountain” were to wander into the East Boone Listening Room in hopes of simply experiencing a stereotypical “down home” sound, they’d have to go elsewhere to get their hillbilly trope fix.

DeShields, who sometimes plays ambient electric guitar and sometimes plays a folksier acoustic guitar, writes music that is indeed genre-bending. She was born in Scotland and her songs are often inspired by her connection to the land, both in Scotland and her new home in North Carolina. These songs of Scottish migration evoke the rich and decidedly Appalachian tradition of mourning and celebrating the exchange of one unique topography for other. 

About her performance at the East Boone Listening Room, DeShields says, “People are still talking to me about what happened in them when they were listening to me sing. It felt very sacred to me. I felt known and seen in my community in a new way.”

When my time to play arrives, I approach the microphone feeling a bit intimidated. The room is absolutely quiet. All heads are up, no one is looking down at their phones. While you may see a few folks take quick photos of the performers, for the most part, devices are put away and people are fully present.

But as much as I feel unnerved, I feel emboldened, buoyed by the earnest attentiveness and eager reception of the listeners. Like DeShields, I too feel seen. There are my people. This is my community. It is a place where I can express my most complex thoughts and feelings and be understood. I can present myself rather than a perfect performance without having to shout over the noise or cut through the excesses of our modern-day world.

“We just want people to be humans here,” says Gantt. 

And be human is exactly what I am able to do at the East Boone Listening Room.

Amanda Held Opelt is a singer-songwriter and the author of A Hole in the World: Finding Hope in Rituals of Grief and Healing and the forthcoming Holy Unhappiness: God, Goodness, and the Myth of the Blessed Life. She writes about faith, grief, rituals and life in Southern Appalachia. She lives with her husband and two daughters in Boone, North Carolina.

The post In North Carolina, A Sanctuary for Local Songwriters Emerges: The East Boone Listening Room appeared first on 100 Days in Appalachia.

By Taylor Knopf

North Carolinians in need of mental health support now have more places to call — and soon will have more places to go — for help. The state health department is investing more money in a greater array of mental health crisis services, including those run by peer support specialists. 

In addition to 988 — the rebranded nationwide suicide prevention help line — North Carolina recently added a statewide Peer Warmline. 

A Warmline is a noncrisis mental health support line staffed by peer support specialists — people living in recovery from mental health problems who may have also experienced substance use, psychiatric hospitalization, homelessness, incarceration or a combination of these. 

People with a history of mental illness sometimes prefer talking with people they feel they can relate to, who may have had similar experiences. And unlike 988, the North Carolina Warmline will not call for law enforcement or EMS unless the caller requests it. Though emergency responders are rarely dispatched after calls to 988, it occasionally happens — and the possibility does deter some people from calling.

Callers can reach the 24/7 Peer Warmline at 1-855-PEERS-NC (1-855-733-7762). The 988 call center also connects callers to the Warmline by request.

The state Department of Health and Human Services recently partnered with Promise Resource Network, a Charlotte-based peer-run mental health organization, to launch the statewide Peer Warmline. Promise Resource Network has been operating a Warmline for several years for Mecklenburg County residents, and it briefly scaled up to answer statewide calls during the early months of the pandemic. Then funding constraints led them to cut back to local calls.  

Historically, North Carolina has not always invited peers to crucial mental health service meetings or invested much in the types of peer-led services that some advocates have requested. Now, there seems to be a shift in this trend.

In addition to the Warmline, the state health department is investing $22 million in community crisis centers, including a new peer-run center that will open in Wake County. The facility will be in Raleigh, operated by Promise Resource Network and mirror the services at its peer respite center in Charlotte. 

A peer-run respite is designed to be a voluntary alternative to hospitalization for people in mental health distress, allowing them space and time to de-escalate their emotional crises without the hospital. Completely staffed by peer support specialists, respites are peaceful, home-like settings where people can stay and receive help from trained peers who are on their own recovery journeys. 

In response to the droves of people showing up at emergency rooms and psychiatric hospitals for help during their mental health crises, North Carolina is investing more in crisis alternatives such as the Warmline and peer respite, as well as new community crisis centers. DHHS recently announced financial support for five new centers for adults in Alamance, Forsyth, New Hanover, Pitt and Vance counties and three new centers for children in Gaston, Pitt and Vance counties. 

The funding for many of these new initiatives comes from state lawmakers’ $835 million investment in mental health services last year. The money comes as a result of a federal bonus that came to North Carolina when the state expanded the Medicaid program.

“We got money to invest in the crisis system,” said Kelly Crosbie, director of the NCDHHS Division of Mental Health, Developmental Disabilities, and Substance Use Services. ”We’re going to invest in some of the more traditional things that make up a good crisis continuum — everything from 988 to crisis teams to crisis receiving facilities, which are a much better and appropriate alternative to the emergency room for a lot of people that need that level of care instead.”

Peer support in demand

With the launch of the national crisis line 988, state-level data showed that 45 percent of more than 90,000 calls a month were from repeat callers, according to the 988 data dashboard.

“They are calling for someone to talk to, so we wanted to offer them an opportunity to talk to somebody with lived experience — someone who can share their experience of recovery and their experience of the system in North Carolina,” Crosbie said of the Warmline. “We just know it’s a valuable resource.”

Warmlines have been shown to reduce loneliness and participants’ use of mental health crisis services. Additionally, a review of several studies found that digital forms of peer support improve the lives of people with serious mental illness by “enhancing participants’ functioning, reducing symptoms and improving program utilization.”

Even before the Warmline expanded statewide, Cherene Caraco, chief executive officer of Promise Resource Network, said that the 988 call center was transferring people to her organization’s Warmline, especially during the pandemic when the Mecklenburg Warmline tried to scale up and answer statewide calls. She believes that when the 988 call center started referring callers to the Warmline, a nontraditional mental health resource, that gave it “a level of validation within the system that didn’t otherwise exist.”

“[The 988 call center] saw the value of it before we were funded statewide. Their endorsement is a big deal,” Caraco said. 

The statewide Warmline continues to gain traction. Noah Swabe, chief operations officer at Promise Resource Network, said the state’s financial support allowed the Warmline to double its number of full-time peers who answer the phones, which he said is necessary as call volume continues to increase. The Warmline recently received more than 4,000 calls in a one-month period, he said. 

In addition to the Warmline, Promise Resource Network’s peer respite has been in high demand. The Charlotte respite, which opened in 2021, is always full. Swabe said there is about a monthlong waitlist to get in. People with mental illness appreciate the nonjudgmental environment where they can stay in an unlocked facility for up to seven days while receiving support from peer support specialists. Promise Resource Network also has what the organization calls a “recovery hub” nearby, which has classes, groups and programs to support people.

Swabe said the plan for Wake County is to open a recovery hub and respite care to provide wrap-around services for those looking for alternative mental health support. Funding will come from DHHS, Wake County and Alliance Behavioral Health.

Buy-in from state and national leaders

During the Warmline ribbon-cutting ceremony, Crosbie visited the peer respite in Charlotte for the first time and said it was beautiful. 

“It is a peaceful setting. It offers dignity and offers a safe space. It offers harm reduction for folks who are using [drugs]. It’s very comprehensive,” she said. “We want to build more of those. Those are the kinds of places we need.”

In addition to the respite DHHS is helping to fund in Raleigh, Crosbie said she wants to see more peer-run spaces, like peer living rooms or day programs, and supportive places for those with mental health issues who are stepping down from hospitalizations, like the one operated by GreenTree in Winston-Salem. 

“We think peer services are wonderful evidence-based, great outcomes, resources for people. So we just know that, and so we’ve been looking at really refreshing our peer portfolio because it’s effective,” Crosbie said. “And we also are in the midst of a [health care] workforce crisis, and we’ve got lots of peers, and peer supports are effective treatment resources.”

Historically, peer-run organizations have struggled to scrape together funding to keep their programs going. The new outspoken support from Crosbie and the new waves of funding could be huge for the peer movement in North Carolina. 

Caraco, who has been a leader in the peer-led recovery movement for nearly two decades, said the support from the federal government and other national groups has also helped those in the more traditional mental health system recognize peer support as essential.

“The Biden administration has created a unity agenda and is naming peer support as a necessary component of a healthy array to prevent suicide, to support people, to create access, to [help with] workforce shortages,” she said. “They have been […] endorsing peer support for a variety of different reasons where our system is either struggling, has gaps or just not well equipped to do.”

“So we have not only more recognition at the federal and national level, but more push into states and to communities to make it a sustainable, healthy part of their community,” Caraco said.

Crosbie said she couldn’t speak to culture at the North Carolina division of mental health before she took the position, but said for her, peer services are “non-negotiable.” She has seen the power of peer support in her own family.

“For my father in particular, who had a serious mental illness, for so many reasons did not get traditional treatments,” she said. “But he was always helped significantly by peers. That was the only type of help really that made any difference to him, and therefore to me and my family.”

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Innovative Construction Group pointed to community college and workforce training programs as factors in the decision to pick Siler City.

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By Jaymie Baxley

Small purple boxes have become a promising tool in Wilson County’s fight to lessen the deadly toll of the opioid epidemic. 

ONEbox is a first aid-like kit that contains doses of naloxone, a nasal spray that can rapidly reverse the effects of opioid overdose. When the kit is opened, a screen embedded in the lid plays a video of a paramedic giving step-by-step instructions for administering the drug.

“Let’s take a deep breath,” says the woman in the video, speaking in either English or Spanish, depending on the language selected. “Step No. 1 is to check to see if somebody really is unresponsive. You can do that by gently shaking them or shouting, or you can use your knuckles against the sternum to see if you get a reaction.”

Dozens of the kits have been placed in strategic locations throughout Wilson County in recent weeks. Jeff Hill, executive director of the Wilson County Substance Prevention Coalition, said he wants the boxes to become so ubiquitous that “any layman will know what it is, know how to identify it and know how to use it.”

“At the end of the day, we understand that anybody in the right place, right time and right scenario can become, or needs to become, a first responder,” he said. “Wherever I can’t be, a ONEbox can — and that could be the difference between life and death.”

‘Community of first responders’

Hill first encountered ONEbox at a conference last year in Washington, D.C. Impressed with the kit’s lifesaving potential, he brought back a sample to show county officials.

“My initial reaction was, ‘Wow, it is so compact and it gives you everything that you need — all the tools that you need — to help save a life,’” said Lori Winstead, deputy manager for Wilson County. “With this system, you kind of avoid that fear of not knowing what step comes next. It puts you at ease, and that’s important in an emergency situation.”

At the time, Winstead was working on a spending plan for Wilson County’s first tranche of funding from a landmark settlement with the pharmaceutical companies that stoked the national opioid epidemic. Money from the settlement, which brings $7.5 million to the county over the next 18 years, can only be spent on services and strategies that address the crisis. 

ONEbox fit the bill. In April 2023, the Wilson County Board of Commissioners agreed to buy 200 kits for $40,000. Hill’s coalition received the kits in February and began distributing them to local nonprofits, government agencies and businesses such as Casita Brewing Co. and Thomas Drug Store. 

He said the demand was “greater than we expected.” The coalition ran through its initial supply within three weeks, prompting the county to order another shipment of 200 kits.

“I think it caught on so fast because the community bought into being a resource,” said Hill, adding that Wilson is the first county to deploy the kits in North Carolina. “Our quote here in Wilson County is ‘we’re a community of first responders, not a community dependent on them.’” 

Unlike many of the state’s rural counties, Wilson has seen a decrease in fatal overdoses. The latest available data from the N.C. Department of Health and Human Services shows that Wilson County had 30 overdose deaths in 2022, down from 37 deaths a year earlier. 

The use of naloxone rose over the same period. The Wilson Times reported that local paramedics administered naloxone to 105 patients in 2022, a 34 percent increase from the previous year. That number does not include doses administered by other public safety agencies and civilians. 

Hill said the kits are part of a larger effort to improve community access to lifesaving interventions. He noted that Wilson County’s Board of Education approved a policy last May requiring every school in the district to keep a supply of naloxone. 

“That’s very rare because most people would view that as, ‘Oh, no, we have a drug problem,’” he said. “That’s not what our school system is saying. What they’re saying is the same way we have an AED and a first aid kit on site, God forbid, in case of emergency, we want to make sure that we have naloxone to protect the sanctity […] and the livelihood of our students.”

Another example, he said, is Wilson Professional Services, a local medication-assisted addiction treatment center that offers free naloxone to anyone who requests it. The facility also provides training so people know how to properly administer the drug. 

Naloxone has been readily available for years at community hubs like the Wilson County Public Library, where a staff member used it to save the life of a man who overdosed in 2022. 

Creating a model  

The county’s swift adoption of ONEbox has not gone unnoticed by the kits’ distributor, the West Virginia Drug Intervention Institute. 

“Wilson has certainly been one of the more comprehensive approaches that we’ve seen,” said Susan Bissett, president of the institute. “They’re using the libraries. They have them in bars and restaurants. They’re working with the schools and the local higher education facilities.”

Bissett traveled to Wilson County with a film crew last month to record testimonials from local leaders. The recordings, she said, are meant to show other communities how to successfully implement the kits.

“To see another Appalachian community embrace this has been incredible,” she said. “The fact that it is a more rural community — and how they’re making sure that boxes are in locations strategically placed throughout the community so that bystanders can respond — is incredible.”

Her comments were echoed by Joe Murphy, creator of ONEbox. Murphy said he came up with the idea after seeing his small West Virginia hometown “ravaged by drugs.”

“The way that every single organization we’ve talked to in this community has embraced it, from law enforcement to the public sector, is unbelievable,” he said. “You just don’t see this anywhere in the country.”

Hill believes Wilson County could be a bellwether for other communities in North Carolina. He said officials from neighboring counties have already expressed interest in deploying ONEbox kits based on the successful rollout in Wilson.

“The goal is to create a model that can be replicated,” he said.

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By Jennifer Fernandez

BURLINGTON — Omira Thompson sat on the floor Wednesday feeding lunch to two of the boys in her infant classroom at First Presbyterian Child Development Center.

One made a face, then tried to wipe out his mouth with his bib, which made Thompson laugh. “Guess he doesn’t like pear,” she said.

Thompson, the lead teacher for the infant classroom, is one of 32 teachers at the five-star rated child care facility, which serves about 90 children — from infants through age 6.

Across North Carolina, child care centers such as First Presbyterian’s will be faced with some difficult decisions in the coming months as the last of federal pandemic aid dries up at the end of June. The money, which Congress first allocated in 2020 during the early, confusing days of the pandemic, helped centers pay teachers more through raises or bonuses; some were even able to provide benefits — often for the first time. The grants were renewed in 2021 and again last year. 

If centers can’t maintain that level of pay, teachers may leave to make more money at places like Target or Starbucks, child care advocates say.

A survey of child care centers released last week shows that without that extra government funding, centers expect to lose teachers, close classrooms, raise tuition and fees or a combination of those measures. More than 1,500 child care facilities in North Carolina could close, according to the survey commissioned by the North Carolina Child Care Resource & Referral Council.

“The work that we do is significant. We deserve the respect. We deserve a salary that is commensurate with what we do,” said Davina Boldin-Woods, director of First Presbyterian Child Development Center. “But more importantly, our children deserve it.”

The ‘cliff’

Pandemic aid from the 2021 American Rescue Plan Act has helped child care providers boost pay and benefits, and it has subsidized the cost of child care for many families. 

Last year, legislators approved using $150 million in discretionary funding from federal pandemic aid to continue the stabilization grants. 

The so-called funding cliff, first expected in December 2023, is now expected to happen in June when that funding ends.

Child care providers, along with legislators from both parties, state officials and the state Chamber of Commerce, unsuccessfully petitioned the General Assembly to include $300 million in the state budget last year to cover the loss of the federal pandemic aid to help providers maintain raises or bonuses for staff for another year. 

“As long as I’ve been in the business, early education professionals have wrestled with the shortage of child care workers and a marketplace competing for teachers with better pay and benefits,” Andrew H. “Sandy” Weathersbee, owner of Providence Preparatory School in Charlotte, told the N.C. General Assembly’s Joint Legislative Oversight committee on Health and Human Services on Tuesday. 

“However, we’ve not been able to find a solution for the problem because it’s bigger than we are,” he said, “and we need help.”

Effects on workforce

Child care plays a crucial role in the economy. Parents can’t work if they have nowhere to send their children.

A different survey last year of registered North Carolina voters showed that 26 percent of parents with children younger than 5 left the workforce because they couldn’t find affordable child care. 

Six in 10 of those same workers reported missing work because of a problem with child care, according to results of the phone and online survey of 500 people commissioned by the NC Chamber Foundation. 

Three in 10 did not pursue job training or continuing education due to a lack of affordable child care, and 37 percent refused a job opportunity, promotion or job change because it would increase child care expenses.

“Affordable, quality child care supports working parents on the job, allows businesses to recruit and retain talent, and helps North Carolina children develop skills for success in school and life,” Meredith Archie, president of the NC Chamber Foundation, said in a statement when their survey results were released. “The health of North Carolina’s economy is directly tied to the strength of its workforce. This survey shows that North Carolinians understand the critical role of child care and want it to be a top priority for the state.”

The chamber found that across the political spectrum, majorities of people wanted the state to increase funding to make affordable child care more accessible to workers.

A long-term study of children in Michigan who received quality early childhood care found they were more likely as adults to make a living wage and own a home compared with peers who did not receive that care.

“It’s not a child care issue. It’s not a parent issue. It’s an economic issue,” Boldin-Woods said. “So the economy, it literally doesn’t work unless early education and child care work.”

Educators, not babysitters

The first few years are a crucial time for children, whose brains are growing at nearly a million neural connections per second, according to Harvard University’s Center on the Developing Child. 

“The environment of every child’s first three years provides the foundation for the rest of their life,” Weathersbee said. “In other words, the cake is baked by the time a child turns 3 years old.”

Boldin-Woods said children spend anywhere from eight to 10 hours a day in an early education program “discovering and learning the things that are going to set them on the path to success.”

“I don’t think people see the significance of the work that is done, or understand the long-standing impact and the wide-ranging impact that early education … can have,” she said.

Researchers from across the globe have studied the effects of high-quality child care and education, according to the Buffett Early Childhood Institute at the University of Nebraska. Information from more than 150 scientific studies shows that good care can have major impacts, short term and long term, on everything from cognition and social-emotional development to school progress and earnings. It can also reduce antisocial behavior, lower welfare participation and even reduce trouble with the law.

Research also shows how important brain development is to health outcomes later in life. 
A landmark North Carolina study, the Abecedarian Project, followed for decades children from low-income families who received high-quality child care. It found that children who received better care ended up healthier as adults, with lower rates of heart disease and diabetes and better mental health.

Finding solutions

“There is creative strategy going on,” said Janet Singerman, president and chief executive officer of Child Care Resources Inc. and co-leader of the Child Care Resources & Referral Council.

Kentucky legislators passed a bill in 2022 that set aside $15 million to create a public/private partnership between employers and the state to help families pay for high-quality child care.

States from Montana to Maine are increasing eligibility for child care subsidy funding through the federal Child Care and Development Block Grant program, according to a Feb. 21 article by the Center for American Progress.

Several states are pouring money into stabilizing the child care system: California is investing $600 million and Minnesota $316 million to increase pay for child care workers.

In the North Carolina budget passed last year, legislators addressed child care in several ways, such as $525,000 to increase the capacity of family child care homes and supporting a $900,000 pilot program that shares costs among families, the state and the provider. 

The budget also included an increase in child care subsidies, mostly federal money used to help offset the cost to parents, although the increase was based on older market data. 

The reimbursement covers 30 percent to 50 percent of the cost of a classroom slot, said Ariel Ford, who runs the Division of Child Development and Early Education for the state Department of Health and Human Services. But you can’t operate a business at 50 percent of the cost, she told lawmakers.

Ford said legislators should again look at increasing subsidies when the General Assembly reconvenes later this month.

“What we know is that the child care subsidy as we have it now is based on what our local families can afford to pay. But that’s not really what it costs,” Ford told the committee during her testimony Tuesday. “What that means … is that those wages just keep getting pushed down for child care because they can’t raise the cost anymore for families to afford it, which means they can’t pay any more for teachers to be in the classroom.”

Weathersbee suggested several ways local governments and businesses could work together to fix the problem, from employer tuition sharing and tuition discounts for early educators to a tax credit for tenured staff and tax incentives for employees offering certain benefits to child care employees.

Closures already happening

Based on response to the Child Care Resource & Referral Council survey, the expected closures would leave about 92,000 children without a child care home. That’s on top of the thousands of children who have already lost a slot as hundreds of facilities closed in the past year alone.

According to state data, the number of licensed facilities dropped from 5,500 in February 2023 to 5,166 in February this year. Enrollment during that period fell from 220,303 to 214,088. There are also 386 fewer teachers.

Many of the providers that plan to stay open said they’ll have to increase tuition and fees and expect to lose staff, forcing them to combine or close classrooms, reduce the number of children they serve or close entirely.

“There is no question we need to increase investment in child care across this nation. It is an underfinanced system,” Singerman said.

She called the survey responses “sobering.”

“If we care about what’s happening to our children, and our parents in the workforce … then child care is an issue that we should all have a stake in,” Singerman said.

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