By Taylor Knopf

North Carolina is poised to receive $150 million from a new multi-state legal settlement with pharmaceutical company Purdue Pharma and its owners, the Sackler family, for their alleged role in fueling the opioid epidemic. 

Attorneys general from all 50 states and the United States’ territories finally reached a $7.4 billion agreement with the drug company and the Sacklers in June. This deal — which has taken years to finalize — will move forward once it’s approved in federal bankruptcy court. The company and its owners have faced multiple lawsuits over their marketing of the powerful opioid drug OxyContin. Under the agreement, the Sackler family will pay the majority of the settlement, $6.5 billion, lose control of Purdue Pharma and be barred from selling opioids in the U.S. The family maintains the position that they’ve done nothing wrong.

This settlement is the latest in a series of agreements with drugmakers, distributors and consultants over the manufacture, marketing and sale of opioids that have driven the U.S. overdose crisis for close to three decades. 

North Carolina’s $150 million slice of the deal will be doled out to county governments over the next 15 years, with the largest payments distributed in the first three years, according to N.C. Attorney General Jeff Jackson. His office released an estimated breakdown of the amount each county would receive from the Purdue Pharma settlement.

“The Sackler family owned Purdue Pharma, and Purdue Pharma lied to a bunch of doctors about the opioid they had invented, telling them that it wasn’t addictive,” Jackson said in a video statement, calling this settlement the most important announcement he’s made as attorney general. “This led to the prescription pill crisis, which has now morphed into the fentanyl crisis, which is taking lives every single day.”

More than 41,500 North Carolinians died from drug overdose between 2000 and 2023, according to the state health department. In 2023 — the year with the highest number of overdose deaths on record — the department estimated that an average of 12 people died from an overdose every day in North Carolina. 

North Carolina’s counties will need to sign on to the deal with Purdue Pharma for the state to receive its full portion of the settlement funds, according to Tare Davis, president of the North Carolina Association of County Commissioners and a Warren County Commissioner.

“Local governments, especially counties, are best positioned to help communities prevent, treat, and recover from opioid use disorders,” Davis said in a news release. “We’re grateful to the Department of Justice for holding accountable the companies that fueled this crisis, and proud of county leaders using settlement funds to make real, lasting impact.”

Multiple opioid settlements

This is not the first national opioid settlement agreement. It’s been three years since states received their first payments from a $26 billion national settlement deal with multiple opioid manufacturers and distributors. North Carolina’s portion from that settlement is $1.4 billion, distributed over 18 years.

County and state leaders have signed an agreement that the money from all the opioid settlements is divided so that the majority, 85 percent, goes directly to the counties and a handful of local municipalities. The local governments have agreed to use the money on initiatives that meet certain evidence-based criteria, including addiction treatment and recovery services, as well as harm reduction and addiction prevention efforts. The remaining 15 percent is designated for state lawmakers to spend, which has led to some debate since they are not held to the same criteria and standards as county leaders.

North Carolina has been held up as an example for its transparency around how the state is disbursing and spending the settlement dollars. The records are detailed on a public dashboard and reviewed by the state attorney general’s office. The majority of counties have adopted strategies for combating overdoses and update their spending plans on the dashboard. 

This spring, several county leaders presented what their communities have done with the money at the 2025 NC Summit on Reducing Overdose conference. Some of their plans are tailored to meet the unique needs of their region and complement existing county resources.

Counties combine to maximize impact

Two small counties in eastern North Carolina have agreed to pool their settlement dollars for a bigger impact, rather than duplicating efforts across county lines. Lenoir and Greene counties are setting up an addiction recovery resource center in Kinston across the street from the Lenoir County Health Department in a building donated by a local church. 

“We can bring together education resources, employment resources, peer counselors, LCSWs — that mental health piece — housing, all those things that somebody would need to surround themselves with for recovery,” said Pamela Brown, director of the Lenoir County Health Department.

The goal is to have everything someone struggling with addiction would require in one place rather than scattered around the community. Multiple locations lead to fragmented care: people navigating lots of appointments in different places with various service providers. Brown said the county seats, Snow Hill and Kinston, are only 15 miles apart, and both counties have some transportation resources to bring people to the resource hub in Kinston. Both counties also are carving out space for physician and mental health assessments at their health departments. 

Brown said the center will play a key role for those navigating local family and adult recovery courts, specialized programs for justice-involved people with substance use problems that incorporate treatment instead of just traditional punitive measures. 

Helping with legal problems

Chief District Court Judge Beth Heath presided over the recovery courts in Greene, Lenoir and Wayne counties until she retired last year. She even kept them going by applying for federal grants after the state pulled funding for them in 2011. 

In the process of establishing the recovery court, “we had to develop community relationships with folks that had services that people in recovery needed … like housing and parenting classes,” Heath said.

Now, Heath is helping launch the recovery center. The center will also house a re-entry council to help people who are leaving incarceration establish their lives in the community. She said people using substances often have pending charges, are on probation or are involved with a department of social services. 

“So that means that for us to be really effective in helping people through recovery, we have to help them with their legal problems, so it’s really important for the court to be at the table,” Heath said. “In a small community, we don’t have enough resources to have silos. We need everybody together.”

Wilkes County was poised to launch a recovery court using a federal grant. But the grant was revoked with no explanation in April by President Donald Trump’s Department of Justice. For now, the county’s recovery court is officially on pause, said Fred Wells Brason, president of Project Lazarus, a local nonprofit spearheading the project alongside a local judge, district attorney and some defense attorneys. 

“So we’ll do it in piecemeal if we have to, but it’s currently just on pause. Everybody’s just waiting to see what we can pull through,” Brason said. He’s had to go back to the drawing board, looking at several funding avenues, including the county’s settlement funds. Wilkes County is set to receive nearly $2.5 million from this new Purdue Pharma settlement, but it will be some time before the money actually reaches county coffers. 

In the first two years, local governments in North Carolina spent a little more than $24 million of their initial settlement funds, with about $2 million going toward treatment and services for those involved in the criminal justice system. Several counties have used those settlement funds to start providing addiction medications in jails, including Robeson and New Hanover in the southeastern part of the state.

Just before the first settlement payments began, Robeson had one of the highest overdose death rates in the state at 109 out of 100,000 people in 2021 — nearly three times higher than the statewide rate at the time. The county has invested in many strategies — including naloxone distribution, medication treatment, transportation and housing services — forcing the county’s overdose rate down by 67 percent in just three years. 

Taking medication to people

While Robeson and many other counties have seen fewer overdose deaths since the statewide peak in 2023, the problem has worsened in Edgecombe County. 

The county’s overdose death rate was 86 per 100,000 people in 2024, while the statewide rate was 30 per 100,000 people. The county has few mental health and substance use resources, with only one office-based opioid treatment provider in the county of more than 49,000 people. 

So Edgecombe decided to try something innovative with its settlement dollars.

Two years ago, the county launched a mobile post-overdose response unit. The unit consists of two paramedics who follow up with someone after an overdose wherever they are. They offer harm reduction supplies, including overdose reversal drug naloxone and sterile syringes. The team performs drug testing of illegal drugs to let people know what’s in their substance, which can contain harmful additives like fentanyl or xylazine. They conduct on-site blood tests for hepatitis C, HIV and syphilis, and other health checks. 

And if the person is interested, they can initiate medication treatment for opioid use disorder on the spot.

“So basically, if you overdose in Edgecombe County, we’re gonna track you down somehow or another. We’re gonna bang on your door, and you’ll at least know who we are,” Dalton Barrett, community paramedic program officer with Edgecombe County Emergency Services, said during a presentation in March.

There are some people who don’t answer the door or turn them away, but Barrett said at least half of the time their persistence is met with gratitude.

“A lot of people will embrace you and say, ‘Hey, we appreciate you showing up on our doorstep and saying that you cared,’” Barrett said.

The team also visits the local jail and psychiatric inpatient facility weekly to educate and build connections, allowing for quick referrals into treatment and other services. 

“We see a lot of people get out of there. They’ll call us up, and then we can plug them into treatment pretty quick,” Barrett explained. 

“We saw a lot of combative folks coming out of an overdose… and that complicated their health care interactions down the road,” he said. “So we had to do a lot of work with education, changing the way we were doing things to start off with. Now, the trust, especially within the post-overdose response team, has really been the cornerstone and getting people into treatment, and just doing a good job with some of the harm reduction stuff that we do.” 

Barrett has even managed to initiate treatment in some unlikely places. He gave the example of a man who overdosed three times in one week, but he couldn’t find an address or contact to follow up with him. When Barrett’s team learned that the man worked at a local restaurant as a cook, they tracked him down and met him at work. The man was interested in treatment but resisted going to a clinic because he “didn’t trust those people.” 

“Well, we actually brought the clinic to that person in the parking lot,” Barrett said., “It’s really about trust and relationships and treating people with dignity and respect.” 

Expanding care

Looking ahead, Edgecombe County is planning to launch a mobile medical clinic equipped for testing, ultrasounds, harm reduction and drug checking with the goal of establishing touchpoints before an overdose ever occurs.

The post-overdose response model is spreading. For the past three years, Surry County has been operating a team of EMS personnel and a peer support specialist who follows up with someone after an overdose to offer addiction medication. Jaime Edwards, director of Surry County Office of Substance Abuse Recovery, said the county started the program and is in the process of enhancing the team by adding a mental health clinician using its settlement dollars. 

He said that when the team responds to people who recently overdosed, they discover that many have a co-occuring mental illness in addition to their substance use problem. The team is able to meet someone wherever they are for seven days to administer addiction medication with the goal of connecting them to a treatment provider by the end of the week.

“The system works extremely well if the individual stays involved, because that peer support specialist stays with the person through the transitions,” Edwards said.

The post NC to get $150M from new opioid settlement as counties expand treatment and recovery services appeared first on North Carolina Health News.

Tomar medidas preventivas con antelación puede ser crucial para evitar daños en las personas y en los cultivos.

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HOP está a punto de desaparecer: si la Asamblea General de Carolina del Norte no aprueba una partida especial, dejará de funcionar el 1 de julio.

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Most residential and businesses property losses in North Carolina due to Tropical Storm Helene not covered by flood insurance.

Few Helene victims in NC had flood insurance. Future of federal program unclear. is a story from Carolina Public Press, an award-winning independent newsroom. Our breakthrough journalism shines a light on the critical overlooked and under-reported issues facing North Carolina’s more than 11 million residents. Please consider making a contribution to support our journalism.

Federal cuts have hit NC DHHS funding for local programs, including for HIV, tobacco cessation and well-water testing that face layoffs.

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By Anne Blythe

Many in the food assistance world say they live by the adage “prepare for the worst and hope for the best.”

That’s what Amy Beros, president and chief executive officer of Food Bank of Central and Eastern North Carolina told NC Health News after the federal government first started notifying anti-hunger organizations of pending cuts to the Emergency Food Assistance Program.

It’s also the attitude at Nourish Up, a food pantry network in Mecklenburg County with a core belief that “access to nutritious food is a fundamental human right.”

The news coming out of the federal government these days has been testing the mettle of food program administrators — especially as the U.S. Senate takes up cuts to the Supplemental Nutrition Assistance Program, or SNAP, that were narrowly approved late last month by the U.S. House of Representatives.

“We’re definitely planning for the worst in the sense that we can,” said Melissa Driver Beard, executive director of CORA, a Chatham County food assistance program that calculates it’s facing the loss of $313,788 in federal support. “There’s no amount of fundraising that we can do that’s going to make up for the funds we’ve lost. At some point we can’t accommodate everything.”

The North Carolina congressional delegation — 10 Republicans and three Democrats — broke along party lines on the early-morning May 22 vote for a wide-ranging budget bill that supports much of President Donald Trump’s legislative agenda.

Embedded in the 1,000-page bill are changes to the SNAP program, which provides vital food benefits that help more than 1.4 million North Carolina residents. The reforms require states to contribute more to the food assistance program while the federal government contributes less. States are also instructed to add work requirements for enrollees who are “able-bodied” with no dependents.

Under the existing structure, the federal government shares half the administrative costs for the program and covers the full costs of the food benefits. North Carolina received $2.8 billion in 2024 for the cost of SNAP benefits, according to the governor’s office.

“The things we’re monitoring now is what’s going to happen with SNAP and Medicaid,” Beard said.

‘Perilous budget decisions’

The federal budget, as approved by the U.S. House in the 215-214 vote, would cut nearly $700 billion in Medicaid funding over a decade — a program slash that would affect nearly 30 percent of the state’s population.

Democratic Gov. Josh Stein issued a statement before the vote against the proposed SNAP cuts, saying it would force North Carolina to pay up to $700 million to continue benefits at the existing level “all so that the wealthiest Americans can receive bigger tax cuts.”

“If Congress goes forward with these plans, our state will be forced into perilous budget decisions — should North Carolinians lose access to food, or should we get rid of other essential services,” Stein said.

Critics have described SNAP and other government safety net programs as ones that foster dependency instead of helping people become independent, productive members of society.

But those who work in such programs counter that narrative, pointing out that many recipients are working more than one low-income job, or they are children, seniors or people with disabilities. After paying for the cost of housing, these recipients often have little left over for nutritious food, Eric Aft, the chief executive officer of Second Harvest Food Bank of Northwest NC, wrote in a February post on the organization’s website.

Of the almost 13 percent of the state’s population that relies on SNAP, commonly referred to as food stamps, four in five recipient families have children, seniors or adults with disabilities in them, according to the state Department of Health and Human Services.

For a federal administration whose Secretary of Health and Human Services says it’s his goal to “Make America Healthy Again,” advocates of food assistance programs see that goal as in contrast to the cuts that Congress is considering.

Poor nutrition and food insecurity can lead to heart disease, high blood pressure, type 2 diabetes, obesity, lethargy and struggles with psychological and behavioral health issues, research shows.

The 2023-24 State Action Plan for Nutrition Security points out that the U.S. Department of Agriculture defines “food security” as when all members of a household can access “enough food for an active, healthy life.”

More food-insecure households across the country had children than did not have children, according to the state plan. 

“Research shows that SNAP improves health outcomes, reduces childhood poverty, and decreases health care costs,” according to recent talking points posted by DHHS. “A recent North Carolina study showed that older adults’ participation in SNAP was associated with fewer hospital and long-term care admissions and emergency department visits, and an estimated Medicaid cost-savings of $2,360 per person annually.”

Beyond individual benefits

The SNAP benefits, which average about $5.70 per person per day, help pay for groceries, which can free up money for other household necessities like utility bills, rent, medicine and even transportation. Often, SNAP benefits can help with the purchase of fresh food, which can be more nutritious and healthier than some of the processed foods that don’t cost as much. Many farmers markets across the state also accept SNAP.

Those benefits go a long way in rural North Carolina and the state’s small towns, where one in six residents have benefited from SNAP, compared with the one in nine residents in metro areas. The benefits also help support some 46,000 people in the state’s large veteran population.

The benefits of SNAP extend beyond the individuals and families to help stimulate the economy, too, advocates say. People’s purchases ripple out to farms, producers, local grocery stores and other retailers.

Stein outlined some of those concerns in a May 8 letter to North Carolina’s congressional delegation and to members of the House and Senate committees on agriculture.

Not only are SNAP benefits used at 9,200 retailers across the state, there were 169,000 new applications to the program in October after the remnants of Hurricane Helene caused unprecedented flooding in late September 2024, wreaking destruction in 25 western counties. By March of this year, 239,000 people there relied on SNAP, the governor wrote.

“Cuts to SNAP would undermine rural economies in particular and threaten the viability of local grocers in places where food access is already limited,” Stein said in the letter.

“SNAP is one of the most effective, efficient, and essential tools we have to fight poverty and hunger. It supports working families and bolsters rural economies,” Stein added.

New layer or unpredictability

Beros, head of the Food Bank of Eastern North Carolina, told NC Health News this week that her organization is used to some adjustments to federal funding, but the cuts under discussion will significantly affect people in need of nourishment.

Additionally, she’s worried about cuts that could shrink Medicaid in this state and about the news of the pending loss of the Healthy Opportunities Pilot — a fledgling program that received national acclaim after its 2022 launch. 

“We know there’s changes with every administration,” Beros said this week. “Hunger shouldn’t be political. But unfortunately the decisions that lawmakers are making has made it political.”

Tina Postel is chief executive officer of Nourish Up, the food pantry network in Mecklenburg County that strives to provide help to the more than 200,000 people with food insecurity in their immediate area.

After proposed cuts to food assistance programs were revealed several months ago, Postel and others said, the uncertainty about available funds has added a layer of unpredictability to planning for nonprofits and other safety net organizations that often operate on lean budgets.

“I definitely feel like we are reeling and feeling whiplash,” Postel said. “I understand as a nonprofit executive trimming fat from a budget. We’re not serving lobster in our pantry.”

Nourish Up provides fresh foods and other nutritious groceries in the state’s second most populous county and offers groceries for people struggling with food insecurity. 

“We’ve weathered recessions, we’ve weathered pandemics,” Postel said.

Now the organizations are dealing with the chaos created by uncertainty about government funding and cuts that are just one Congressional chamber away from becoming reality. 

“Fortunately, I am surrounded by people every single day who believe food is a basic human right,” Postel said.

One of those people is Danielle Moore, chief operations officer at Nourish Up. In an interview with NC Health News, Moore explained the far-reaching impact of a 50 percent cut to the Second Harvest Food Bank of Northwest North Carolina in the Emergency Food Assistance Program, commonly referred to as TEFAP.

“A 50 percent reduction in TEFAP is about a million-dollar gap for us,” Moore said, which means fewer fruits, vegetables and frozen meats for the people who get sustenance from the network of food pantries. “Planning is difficult any time. We have been planning for the worst, being optimistic while also being realists.”

Fund drives can’t fill gap

In addition to the SNAP cuts, the House budget also proposes cuts and changes to Medicaid that will apply to many of the same populations that Nourish Up serves. 

The cuts come at a time when many food banks and pantries are seeing an influx of people. 

“Overall, our numbers are still at record highs,” Postel said.

Administrators at Nourish Up and at other food banks and pantries across the state have been urging people to get in touch with lawmakers to advocate for continued assistance.

Although many of the organizations are turning to philanthropists and private funders to help close the gap, Postel said, the hole might be too large to fully fill.

“We have asked our donors once again to dig deep,” Postel said. “But there’s not a fund drive in the world that can make up the gap that our government is creating.”

The post Proposed SNAP cuts trouble NC food assistance programs appeared first on North Carolina Health News.

Leaders in federal, state and local governments often have different ideas about how to mitigate future floods in NC.

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By Jaymie Baxley, Rose Hoban and Grace Vitaglione

The Healthy Opportunities Pilot, a Medicaid program that addressed the nonmedical health needs of low-income North Carolinians, will cease operations July 1, according to an announcement obtained by NC Health News.

The first-in-the-nation effort that has drawn national attention and praise was launched in 2022 and has provided assistance to nearly 30,000 people across three largely rural regions of the state. Beneficiaries received deliveries of food, rides to doctor’s appointments and other services designed to combat the social, economic and geographic factors that keep people on Medicaid from getting and staying healthy. 

An independent evaluation delivered to lawmakers this past winter also showed that the program was starting to save money on some of the more expensive beneficiaries in Medicaid.

But spending plans proposed by the North Carolina House of Representatives and the Senate effectively cut funding for the program.

While the two chambers still have to hash out a final budget due by June 30, the state Medicaid head, Jay Ludlam, told program partners in a letter Monday that it would be fiscally irresponsible to continue the program without secured funding — risking “unpaid costs and broader system instability.”

Ludlam shared additional details with the program’s stakeholders in a conference call on Monday afternoon. In an interview with NC Health News, he said they expressed “disappointment” with the decision.

“I think they’re disappointed, in part, because they understand and see every day the impact that this program is having on the people that they serve,” he said. “They know what we’ve built together, and what we risk losing if we’re unable to find funding.”

Rep. Donny Lambeth (R-Winston Salem) said the budget was too tight this year to continue funding the pilot program. In a text to NC Health News, he also said lawmakers haven’t seen enough “valid justification” to show the benefits outweigh the $175 million cost of the program for the next two years.

Initial results showed savings

Thirty-three of the state’s 100 counties were included in the pilot.

The program was created through a waiver, approved by the Centers for Medicare and Medicaid Services during the first Trump administration, that allowed the N.C. Department of Health and Human Services to use federal Medicaid funds — usually earmarked for medical expenses — to address needs such as food, transportation and housing.

The N.C. General Assembly had to agree to match federal funding for the program.

Lambeth said the concept of Healthy Opportunities is “really good,” but that he hasn’t seen compelling evidence of the cost savings the program promises to create.

An independent evaluation showed the pilots have driven down the cost of health care by as much as $1,020 each year for each Medicaid beneficiary who’s participating in the pilot — largely by helping people stay healthy. That’s because program participants were prevented from becoming sicker or from using more expensive kinds of care. 

The researchers wrote in JAMA in February that “results of this study suggest that the HOP program was associated with increased spending at enrollment, followed by a subsequently lower spending trend.”

The most-utilized services were for beneficiaries to receive a food box, a “prescription” for fruits and vegetables, or help with finding or maintaining housing.

Participation in the program has also been “associated with decreased emergency department utilization,” according to the report, which was completed by researchers from the Cecil G. Sheps Center for Health Services Research at the University of North Carolina.

Information showing the positive impact of HOP was being shared with state officials as recently as last Friday, when the program was highlighted as part of a symposium in Raleigh. 

During the event, Seth Berkowitz, an associate professor at the UNC School of Medicine, said emergency department visits and adult hospitalizations have been “significantly reduced” across the three pilot regions. He said the program has also led to decreased health care expenditures, with the state saving about $85 a month per participant. 

“We know that non-medical factors frequently undermine what would be otherwise successful health care,” Berkowitz said. “For example, when someone doesn’t have healthy food to eat, the diabetes medicines that would control blood sugar can’t really do their job, and an asthma inhaler isn’t going to be as effective if a child with asthma is living in moldy, dilapidated housing.”

Reactions 

Three agencies facilitated services for program participants in the pilot regions. These organizations — Access East, Community Care of the Lower Cape Fear and Impact Health — acted as intermediaries, coordinating the distribution of goods and services through a network of more than 140 nonprofits and community partners.

The state will continue to pay the agencies through September to “wind down” the program, Ludlam said.

“We hope that we’re able to continue to work with the General Assembly to help them understand maybe more clearly the impact of this program on health and the positive budget impact it has on North Carolina,” he said. “Hopefully, we can convince them to get this program back in the budget, but we’ll continue to work with the network leads through at least the next couple of months, and then reassess where we’re at then and how much funding is needed to just continue.”

Laurie Stradley, CEO of Impact Health, said the program’s demise would negatively affect the more than 60 community organizations that partnered with her agency to provide services across 18 counties in western North Carolina.

“It’s really important to us, and I know my colleagues in the other parts of the states feel this way too, that being a part of this pilot doesn’t cause harm to those organizations and make it harder for them to meet their missions,” she said. “This sort of turn on a dime is going to be really hard on them in terms of making their budgets and supporting their staff and delivering food or housing or home repairs — whatever it is that’s really core to their mission that drew them into the Healthy Opportunities Pilot.”

The agency, she added, is “committed to leveraging every dime we have available and to seeking other funding to ease that transition” for the organizations. 

Participation in Healthy Opportunities in the western part of the state grew in the aftermath of Hurricane Helene, which displaced many families in the region. 

Rep. Eric Ager (D-Fairview), who represents part of western North Carolina, said Healthy Opportunities made a huge impact during and right after the storm. The program already had lists of those who had been receiving food deliveries and might need help. 

He’s heard from constituents worried about the loss of the program, as it allowed them  access to food and services they otherwise couldn’t afford. The pilot project helped local farmers sell wholesale food that was provided to people who might have had to instead get their groceries at a convenience store, where the food wouldn’t be as healthy, he said.

“Instead we’re going to pay more for worse [health] outcomes,” Ager said.

Rep. Rodney Pierce (D-Roanoke Rapids) said that in his district, the pilot gave people access to fresh fruits and vegetables. (One out of four children is food insecure in northeastern N.C.)

“This is something that literally saves lives and extends lives,” Pierce said.

He and other Democratic lawmakers asked DHHS to provide them with evidence of the program’s benefits so they can make the case for continuing funding to their Republican colleagues. Pierce said it was disappointing that the program was cut after only three years of operating.

“You haven’t really given it a chance to show what it can do. I think you have to give it at least five years to see if it’s fruitful,” he said.

The post Healthy Opportunities Pilot told to prepare for program to shutter July 1 appeared first on North Carolina Health News.

Elimination of maternity unit in Harnett continues pattern of lost women’s services in rural NC hospitals, including several nearby counties.

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By Taylor Knopf

A new report by Disability Rights North Carolina found that a legal tool used to hold patients against their will for psychiatric treatment is frequently misused — violating patients’ rights and causing them long-term harm.

When a person is having a mental health crisis — such as if they’re thinking about suicide, acting erratically or experiencing hallucinations — they often end up in a hospital emergency department. They’re commonly brought in by a concerned family member or by police who have responded to a 911 call.

If a medical provider determines that the patient is a danger to themselves or to those around them, they will file a petition with the courts for an involuntary commitment custody order. These committed patients temporarily lose the right to make their own decisions while being treated for psychiatric problems or substance use. The process also usurps the rights of a parent or guardian to make health decisions for a child — a reality that surprises many family members and patients. 

In this process, a patient doesn’t receive legal representation until they are admitted to an inpatient psychiatric facility. But that process can stretch out for days, weeks or, in some cases, months while waiting for an inpatient bed to become available, all at a cost of thousands — or tens of thousands of dollars — to individuals, private insurers or government-funded programs like Medicaid. 

In the meantime, patients are held — unable to leave — in often chaotic hospital emergency departments without mental health treatment and without an attorney.

Requests for involuntary commitments have been on the rise in North Carolina for over a decade, increasing by at least 96 percent, according to data collected and reported by NC Health News, rising from about 54,000 in 2011 to more than 106,000 in 2021.

“It is this giant sledgehammer of a tool that is used for all manner of crises inappropriately, and it should be reserved for those very few, very limited number of cases where someone doesn’t have another option, really is posing risk of serious harm to self or others,” said Corye Dunn, who leads policy efforts at Disability Rights NC. The group is North Carolina’s federally mandated protection and advocacy organization charged with looking after the legal rights of people with disabilities.

The Disability Rights team conducted a yearlong investigation into the use of involuntary commitments in North Carolina. They monitored 10 emergency departments across the state and interviewed those involved in the commitment process, including hospital staff, legal experts and mental health advocates, as well as patients and their family members. 

The organization found that the involuntary commitment process is frequently overused and misused to address behavioral health crises, and the state is not keeping track of how often or where that is happening. 

“Shifts in policy and culture have advanced convenience over due process to the point that one psychiatrist describes IVC [involuntary commitment] as ‘the easy button,’” Disability Rights staff wrote in a comprehensive report released Tuesday. “This description bears out as evidenced by the ease with which IVCs are initiated as well as the sheer volume of petitions represented in the data.”

Disability Rights chronicled what the report called an “expensive, wasteful and abusive” process that leaves countless children and adults stuck in emergency departments — legally unable to leave — with no access to their phones, jobs, education, family or friends as they wait for a psychiatric bed to open, all while receiving little mental health treatment beyond medication. 

The report makes more than 30 recommendations to improve North Carolina’s involuntary commitment process, including policy changes, procedural changes, data collection and calls for specialized professional education. 

Violation of rights

North Carolina involuntary commitment laws allow adults and children to remain locked in an emergency department anywhere from days to months without any due process. Many are physically tied down, locked in rooms or chemically restrained, meaning they’re placed on drugs to subdue them.

The Disability Rights team went into emergency departments across the state and saw this problem up close. 

“At one small, rural hospital, two men under IVC custody orders languished in the open on medical gurneys beside a nurse’s station because there wasn’t a private room available to them. The men used their sheets to cover their heads, perhaps to shield them from the bright lights and busy activity around them, and perhaps to provide some measure of dignity,” the report reads.

At another emergency department, Disability Rights staff saw a mental health patient in a four-point restraint, meaning his hands and feet were strapped down to his bed. 

“This is almost like science fiction to me,” one hospital staff member told Disability Rights. “I am watching what is happening to human beings and wondering, are we actually helping people?”

The dense, 45-page report gives the example of one young man who was committed where the “facts” section of his petition was left blank, meaning it gave no reason for why he should be detained and treated involuntarily. The magistrate signed it anyway. He was held in the emergency room, handcuffed and transported by law enforcement — which is common practice. 

Once he was admitted to a psychiatric hospital, his appointed attorney noticed the petition was blank and submitted a motion to a judge and had the commitment dismissed. Disability Rights asserts that he was illegally detained for five days. 

“Even really savvy health care consumers, parents and advocates find it difficult to push back against the tide once this process starts,” Dunn said. “They’re just stuck.”

Parents hamstrung

Parents often find themselves blindsided by the involuntary commitment process, where they lose decision-making power over what happens to their children. Many are left in the dark about where their child is going or what treatment they’re being provided. 

The Disability Rights report, which frequently cites reporting by NC Health News, includes an interview with Dan and Megan, parents of a child who was committed and taken to a facility against her parents’ wishes where she was mistreated and allegedly sexually assaulted by another patient. NC Health News reported the family’s experience and dug into additional complaints against the psychiatric hospital.

“That’s one of the hardest things — the helplessness. It was very hard to learn we were not in control of what was going to happen to her,” Dan told Disability Rights. 

North Carolina law encourages voluntary treatment over involuntary, but that is not what happens in reality, the report found.

The report recommends amending state law to require that involuntary commitment petitions of adults under guardianship and children include information about the legal guardian’s and/or parents’ involvement in the patient’s care and why voluntary treatment could not meet the respondent’s needs.

“If the checkbox is on the form, then more magistrates ask questions about it,” Dunn said. “I think of them as speed bumps. They’re not barriers, but they slow you down enough to ask the questions, like ‘Does he want to go voluntarily?’” 

Not enough data

Once a patient is under an involuntary commitment custody order, they must wait until hospital staff can find an inpatient bed in one of North Carolina’s psychiatric facilities. A patient can be held under a custody order for seven days, and if a bed is not found by then, the petition can be renewed. 

According to state law, this can go on indefinitely. 

Disability Rights found that these successive commitment petitions create a loophole where the patient continues to be held against their will without legal representation, because that only are assigned attorneys once they have been admitted to an inpatient bed — not while they wait in an emergency department. People detained in jails are arraigned within 72 hours of arrival — more due process rights than people who have been involuntarily committed.

The report recommends amending state law to eliminate successive petitions and to appoint legal representation to the patient at the time a magistrate issues the custody order so respondents can have timely representation. 

The report also reveals that data on successive seven-day petitions is not kept, so there is no way to know how often or where this is happening. 

The report found that roughly 37 percent of the total number of involuntary commitment petitions from the past six years were people who went on to receive forced psychiatric hospitalizations. That means 63 percent of petitions didn’t meet criteria for commitment or could be successive petitions on some of the same individuals. 

There is no way of knowing what’s truly happening with the majority of petitions for involuntary commitment in this state because the data is not collected. 

“So it is impossible to analyze where adjustments to law or policy should be made to prevent its wrongful, wasteful, or inefficient use,” the report reads. 

The report recommends additional reporting and interpretation of data, including the outcomes of each petition for involuntary commitment and the number of people discharged from the emergency department after a custody order because they didn’t meet the criteria — danger to self or others — for an involuntary commitment.  

It suggests making all data readily available to the public on an electronic dashboard, similar to one in Florida. Even the current limited amount of data is not easy to find.

‘Dumping’ patients

Nearly all of the emergency department leaders included in the report described instances where businesses and organizations would use the involuntary commitment process inappropriately to drop off patients — particularly children in the foster care system or older adults with dementia living in nursing homes.

Hospital administrators complained to Disability Rights NC that county Department of Social Services agencies from all over the state had dropped off kids that have been removed from their homes when they are unable to find foster family or other placement for them. 

“I can appreciate it is hard for the DSS agencies, but it is not a receptacle for kids,” an attorney who represents children under involuntary commitment told Disability Rights staff. “I would be interested to see what can be done about DSS using hospitals as dumping grounds.”

The report mentions a hospital administrator in eastern N.C. who threatened to sue different social service agencies three times for room and board, which resulted in the agencies picking up their kids within days. Children in the foster care system are often the ones who end up living in emergency departments the longest, the report found.

“From the hospital perspective, it feels like these people who have a responsibility to these folks with disabilities have dumped them here and not given us any tools to deal with it,” Dunn said.

Rusty Miles, emergency department director at Carteret Health Care in Morehead City, told Disability Rights that housing foster children in the emergency department is a challenge.

“These kids don’t get the services they need — they miss school, socialization and outside play,” Miles said. “We do the best we can, but it’s a real disservice to keep these kids here.”

The report recommends an expansion of community-based care options to prevent overuse for patients who really shouldn’t be committed and who do not meet the criteria for an involuntary commitment. It also recommends looking into shifting costs for “frivolous” or repeated commitments to those agencies inappropriately seeking a commitment to leave patients at the emergency department. 

Lawmakers chip away at the issues

When asked about some of these issues last week, Sen. Jim Burgin (R- Harnett) told NC Health News that if patients are inappropriately left at the emergency room by a county DSS or a nursing facility, that the hospitals “ought to be able to charge back to their facility for that.” He’s introduced legislation in the past that’s addressed a similar accountability issue. 

Burgin had not seen a preview of the report, but he’s been a leader in the state Senate on mental health issues. He has requested — and accompanied Disability Rights staff — to visit psychiatric facilities in the past. He said he’s been keeping tabs on a few patients to see how they fare over time. 

There is a 7-year-old child in his district who stayed in a local emergency department for 119 days, he recounted. And it wasn’t this child’s first involuntary commitment. Burgin said the 7-year-old has autism, and his behaviors sometimes become more than his single mother can handle. She takes him to the emergency room looking for help.  

“I think involuntary commitment into an emergency room is a failure for us,” Burgin said. “Unless they are injured, that is not the place we need involuntary commitments to go. They’re not set up to handle them properly. They don’t have anything to take them to the next level of care. So basically, they get them in and check them, and then sedate them, do a telepsychiatry, or have somebody look at them, and then it’s a holding pen. 

“We’re basically warehousing them until we find another place to put them,” he said.

Burgin called the entire process inappropriate and unnecessarily expensive. He emphasized the need to get ahead of the problem and provide adequate services up front so people don’t end up in emergency rooms and psychiatric hospitals with mental health issues. 

“I want to fix this end of it, too, but we’ve got to get to the front of it. It’s the old adage about saving the kids coming down the river, but let’s also go up and stop the kids from ever getting in the river,” Burgin said. “We’ve got to deal with the other end of how these kids ever got in the situation that they end up being involuntarily committed.” 

State lawmakers have put significant funding toward alternatives to the emergency department for patients in mental distress. In the 2023 budget, they allocated $835 million for behavioral health needs, with $80 million to increase crisis services and $20 million to start a non-law-enforcement transportation pilot program for mental health patients under involuntary commitment. 

‘Your mortgage might not get paid’ 

The involuntary commitment process comes with a lot of trauma for patients being held against their will, even when they agree to treatment. 

They are often strip-searched for items they could use to hurt themselves. They languish in emergency departments with no access to fresh air, sunlight, family or even their phones. Some experience being restrained, locked up or drugged into submission. Once a bed is available, they are then handcuffed and placed into the back of a law enforcement vehicle to be transported to the next facility. 

Many find they are more harmed than helped through this experience. And then, when they’re discharged, they have to deal with the consequences of having been locked away. Forced hospitalizations have caused some to lose their jobs or housing, and they end up with medical debt from care they didn’t want, Disability Rights found. 

“Your mortgage might not get paid. Your job doesn’t get done. Your kids need care,” Dunn said. “We have to stop pretending that people experiencing emotional distress are a different group of people. They are not sitting to the side with no responsibilities and no relationships.” 

Research shows that people who have been involuntarily committed tend to subsequently distrust the medical system, and they can be reluctant to seek care in the future — sometimes with tragic consequences. 

Mounting costs

Inpatient psychiatric hospitalization is expensive; costs can be more than $2,000 per day, depending on the facility. Disability Rights reports that even in the smoothest possible scenario — where a person goes to the emergency department and is quickly transferred to a psychiatric hospital and is released after a few days — the cost will be at least $10,000. A 30-day commitment order could easily equate to a $60,000 bill, according to the report. 

“Unfortunately, the law says the patient is responsible for the cost even if they didn’t want the treatment,” the report states.

Involuntary commitments stay on an individual’s record and can prevent them from pursuing certain types of careers, as was the case for a 34-year-old man in western North Carolina, an example included in the report. He served in the National Guard and had been working as an EMT and volunteer firefighter for a decade when he was recruited for a law enforcement position. But he failed the firearms background check and was told he couldn’t move forward in his training at the law enforcement academy. The reason: He was involuntarily committed during a rough period of his life while a teenager. 

The report recommends additional training for magistrates, who sign off on the initial custody order, on the impact of involuntary commitments and the alternative mental health crisis options available in the community. Magistrates in North Carolina do not have to be lawyers, and their training only includes four hours on the involuntary commitment process. Their annual continued education also doesn’t include information on involuntary commitments.

“If you want to prevent basically a carceral mental health system, you’ve got to provide something that’s less restrictive in the array of services,” Dunn said. “That’s peer respites. Respite for caregivers. Peer living rooms and resource hubs, and all the ways that we know we can provide support to people without locking them up. 

“If we’re not doing that, we aren’t really serious as a state about our commitment to the well being of our residents.”

Bright spots of progress  

The report highlights two hospitals that have recognized the harm and unnecessary burden of excessive involuntary commitments and launched initiatives to reduce their use.

WakeMed Health in Raleigh reduced its involuntary commitments by 60 percent, with most patients receiving care on a voluntary basis, hospital leaders reported to Disability Rights. To further reduce unnecessary distress and law enforcement involvement, WakeMed covers the cost of transportation for both voluntary and involuntary commitments.

In Avery and Watauga counties, similar progress is unfolding. Involuntary commitment rates there have also dropped by 60 percent. Before this initiative, “IVCs were passed out liberally, and there was a lack of understanding of the long-term impact,” said Stephanie Greer, president of the Avery Healthcare Market over Cannon Memorial Hospital and Appalachian Behavioral Health Hospital. “Magistrates were begging for guidance.”

In 2010, leaders from across the two counties formed a small, focused team to address the issue. They held each other accountable, even when discussions got uncomfortable, Greer said. One breakthrough came when a district court judge suggested requiring mental health assessments before magistrates issued custody orders. That led to the creation of crisis units at local hospitals and mobile crisis teams to evaluate patients before commitment petitions moved forward.

The impact has been substantial. Magistrates now issue custody orders only 40 percent of the time. Law enforcement involvement has also plummeted — from an average of 2,800 hours per month in 2010 to just 120 by 2015, according to Greer.

“Their work shows that when communities come together to solve an issue, they can design systems that work for them,” the report reads.

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