North Carolina drug overdose deaths appear to be dropping. Why?
By Taylor Knopf
Just as substance use experts celebrated a somewhat mysterious drop in drug overdose deaths across North Carolina, Hurricane Helene blew through the western part of the state, causing death and widespread property damage. In the storm’s aftermath, many residents found themselves without homes and businesses and facing an uncertain future.
For harm reductionists like Hill Brown, the southern director of Faith in Harm Reduction, Helene’s impact raised serious concerns. Brown knew that the disruption to the local drug supply, coupled with the stress of losing housing, could lead to an uptick in overdoses in the coming months.
Over the past month, Brown, who lives in western North Carolina, has been pushing to get the overdose reversal drug, naloxone, into the hands of more people. Brown said she was surprised to find that some rural areas that had previously resisted harm reduction efforts, including naloxone distribution, have begun to embrace these life-saving tools in the wake of Helene.
“Once the [drug] supply comes back online, and people haven’t had good access to their dealers or to whatever supply they were using, there is going to be an uptick in overdoses, because we just don’t know what the supply is going to look like,” Brown said.
“If we’re talking about a crisis where lots of people are losing their housing, or their housing is becoming unlivable because of flooding, then people are going to be stressed out, and they’re going to do things that they know how to do to cope.”
This threat comes when the overdose crisis in North Carolina has shown signs of improvement — at least on paper. The latest data reported by the Centers for Disease Control and Prevention predicts about a 30 percent decrease in overdose deaths in North Carolina from May 2023 to May 2024, a statistic that will be confirmed once death certificates are finalized.
Nationally, the CDC estimates roughly a 13 percent decrease in overdose deaths for the same time period, based on provisional death data.
These numbers will likely shift because the data is incomplete right now, and North Carolina has been particularly slow in reporting its overdose death data to the federal agency, according to a note that initially topped the latest CDC report. Spokesperson Summer Tonizzo, with the N.C. Department of Health and Human Services, told NC Health News that this is an indication that North Carolina has a high number of “pending” deaths.
Provisional data from the North Carolina Office of the Chief Medical Examiner’s Office shows suspected overdose deaths in the state dropping so far in 2024. Credit:North Carolina Office of the Chief Medical Examiner
“These are cases being investigated by NC’s Medical Examiner System which continues to struggle with rising caseloads and staff vacancies — both of which have negatively impacted the system’s ability to timely close pending death records,” Tonizzo wrote in an email.
Even so, North Carolina epidemiologists say, all indicators point to a significant decrease in overdose deaths. But as they dig into the data, a more complex picture emerges — one marked by uneven progress and disparities affecting marginalized communities.
Cautiously optimistic
Those ongoing pressures in the medical examiner system means it takes a long time to certify death reports that go through the state’s medical examiner’s office. North Carolina’s last complete year of finalized overdose death data is 2022.
“We’re almost at the end of 2024. It’s not fast enough,” Mary Beth Cox, an epidemiologist who tracks substance use at the North Carolina Division of Public Health told a NC Opioid and Prescription Drug Abuse Advisory Committee meeting in September.
Because there will always be some lag in the data, researchers like Cox look to some early indicators, such as emergency department visits, to track the state’s progress in addressing the overdose crisis. Since 2018, her department has been putting out monthly reports on overdose trends seen in emergency departments across the state. The latest report shows emergency department visits are down consistently in 2024 over the same period of time last year. For example, 1,055 overdose visits were reported in August 2024 while 1,518 were reported in August 2023.
N.C. Attorney General Josh Stein speaks to the NC Opioid and Prescription Drug Abuse Advisory Committee meeting in September about the decline in overdose deaths, use of opioid settlement spending and presents an award to long-time public health advocate Kay Sanford. Credit: Taylor Knopf
Another early indicator researchers look at is 911 calls seeking help for an overdose. Nationally, first responders report that those calls are down 16 percent in October 2024 from October 2023.
But these systems don’t paint a clear enough picture, Cox said.
“If we’re seeing a decrease in [emergency department] data, does that actually mean a decrease in overdoses? We don’t know. It just means people aren’t going to the [emergency department],” she explained. “If we see an increase in [emergency department] visits, you might say, at face value, that’s a bad thing. But it could mean more people are getting connected to care.”
“Without the death data to supplement, it’s really hard to know what’s going on,” Cox said.
Her team has worked with the chief medical examiner’s office to put out an additional report every month on suspected overdose deaths. Their most recent report shows a 27 percent decrease in suspected overdose deaths in September 2024 from September 2023.
North Carolina Attorney General (now governor-elect) Josh Stein attended the meeting and applauded the group for their tireless work to address the opioid crisis. His office played a key role leading the multi-state legal challenges that resulted in $1.5 billion in opioid settlement money for North Carolina.
“We are starting to see some hopeful developments on the horizon,” Stein said in September. “Obviously, we are not naive. We know the work is not done. There is so much more to do. But it’s appropriate to see and appreciate that something is better today than it was yesterday because folks have been working really hard for that to happen.”
Cox cautioned that these decreases don’t appear to be uniform across all demographics. “This is still very provisional data, very subject to change. But we’re seeing it across multiple indicators that historically marginalized populations, particularly our Black communities, are still experiencing a slight increase.”
Source: KFF analysis of CDC WONDER Multiple Cause of Death Cause of Death File, Final 2022 and Provisional 2023 Credit:KFF
While the overall trend offers glimmers of hope, Cox acknowledged the sobering reality behind the numbers — nine people are dying by overdose every day in North Carolina.
“That’s a lot of people still,” Cox said. “Certainly we’re headed in the right direction, but it’s a whole lot of death.
“Every one of those deaths is preventable.”
Not the full picture
Those who work in harm reduction, like Michelle Mathis, executive director of Olive Branch Ministry, say the state’s surveillance data fails to capture the reality they see on the ground. Mathis’ ministry serves people who use drugs in the foothills/Western Piedmont area of North Carolina. Olive Branch offers multiple fixed syringe exchange sites and mobile programs.
“The trends that we see — and when I talk to other agencies as well — they’re not seeing this big downward reporting in overdoses,” she said.
She said that harm reduction workers always ask participants: Are you aware of any overdoses or have you personally experienced an overdose since the last time we saw you? Their answers are consistently recorded, but Mathis said the state health department only takes up that data once a year to include in an annual report.
“I have argued for this for as long as syringe services have been legal in the state. … We have to have some kind of monthly reporting mechanism,” she said.
Mathis said the majority of people that participate in Olive Branch’s exchange do not call 911 or go to the hospital when someone overdoses.
“Perhaps overdoses are not necessarily down, but people have access to more Narcan — because of harm reduction agencies — and so they are not as prone to being involved with EMS and the hospitals,” she said.
She added that a big reason her participants say they hesitate to call 911 during an overdose is fear of the state’s “death by distribution” law, which has been strengthened by the state legislature since it was enacted in 2019. The law allows prosecutors to charge someone with second degree murder if they sell drugs to someone who then dies of an overdose. Advocates say that the line between drug dealer and drug user is blurry, as people often buy and sell drugs from their friends and people they use with, who might not be what most would consider a “dealer,” per se.
Advocates say this law deters people from seeking help.
Brown, who has worked on advancing harm reduction efforts in Mitchell, Yancey and Buncombe counties, also said it’s hard to make sense of a reported drop in overdoses after witnessing the ever-changing illegal drug supply and people’s fear of potential death by distribution charges.
Why are overdose deaths declining?
These huge drops in overdose deaths being reported in North Carolina and around the country are puzzling to many. Substance use experts at the Street Drug Analysis Lab at the University of North Carolina say that a 15 percent to 20 percent decrease in drug overdoses would be “unprecedented.”
“To our knowledge, no public health intervention in the United States has ever achieved this benchmark,” members of the lab wrote in a recent blog post. “Something has changed. And that this is happening without central coordination is a big deal. It has major implications for the way we think about overdose prevention interventions.”
Adams Sibley, social behavioral scientist with UNC lab, co-authored the lengthy blog post, which digs into the many leading hypotheses for the mysterious drop — from increased naloxone distribution to law enforcement operations at the border to removal of barriers to addiction treatment.
Sibley also presented to the NC Opioid and Prescription Drug Abuse Advisory Committee in September and said the decrease is likely a combination of many things, including the presence of xylazine in the street drug supply and a shift from injecting substances to snorting or smoking.
Xylazine, a veterinary tranquilizer, is an additive that has been increasingly found in the illegal drug supply added to fentanyl or heroin. It can cause nasty wounds and potentially deadly skin infections at the site of injection.
“There’s a hypothesis that xylazine is one contributor to the drop in overdose deaths in a positive way,” Sibley explained. “Xylazine gives fentanyl legs, which means people may be using fentanyl less throughout the day because it’s prolonging the perceived effect of fentanyl. Xylazine also causes these skin injuries, and so it might be encouraging people to switch to smoking.”
Switching mode of drug consumption from injecting to smoking or snorting is a harm reduction measure because people use smaller amounts of drugs at a time. And smoking has surpassed injecting as the most common way people use drugs, according to the CDC. There are several reasons someone might switch to smoking, Sibley said.
“One is that if you’ve been injecting for a long time, you may not have a lot of places left to inject,” he said. “You might have scarred tissue, collapsed veins, abscesses, etc., and so smoking is a feasible option. The second reason is dose titration. It’s easier to pace yourself when you’re smoking as compared to when you’re injecting. So this is a rational choice.”
Mathis said she has witnessed a shift toward smoking in participants of Olive Branch Ministry’s syringe exchange programs. She noted that the law that legalized syringe services programs does not allow for the distribution of smoking and snorting supplies.
“So we see — and we want to acknowledge — that change in mode of consumption is contributing greatly to this massive positive trend,” she said. “Yet state statute does not allow us to distribute the supplies which could really help boost this trend if we could legally do it.”
Sibley reminded the audience gathered in September that it’s important to stay humble, examine the data closely and listen to people who use drugs.
“We are not always in control of the numbers and the trends,” he said. “We know treatments are working. We know naloxone is working. But there may be reasons that overdose deaths are dropping that are out of our control.”
In rural Avery County, Helene washed away one of the only dental clinics
By Jaymie Baxley
When your house is flooded and all your soggy belongings are piled on the street in front of your home, having a cavity or a toothache might seem like a small problem.
But it could become a bigger problem for residents of Avery County, where one of the primary dental clinics was inundated with floodwaters generated by the remnants of Hurricane Helene in late September.
More than a month after the storm, most stores and restaurants in Newland, the county seat, are still closed. Piles of ruined belongings sit waiting for collection in the yards of battered homes throughout the little town, which lies in a bowl surrounded by mountains and is bisected by the North Toe River.
On a recent afternoon in the lobby of Avery Medical, a clinic near the center of Newland, two women shared stories about the devastation they’d witnessed. One told the other she would have been “assed out” if the floodwaters that surged through her home had risen just a few inches higher.
“I’m just blessed that we made it out alive,” she said.
A total of 102 Helene-related deaths have been confirmed in North Carolina as of Nov. 8. At least five people from Avery County perished in the storm.
Avery Medical is run by High Country Community Health, a nonprofit that provides affordable care to low-income patients who lack health insurance. Many people in this rural county, which has a population of about 17,500, depend on the organization.
Nearly 15 percent of Avery County’s residents live below the federal poverty line, and 14.6 percent are uninsured, according to data from the N.C. Rural Center. The median household income for the county is only $53,500, well below the statewide average of $70,800.
Debris piled in front of a waterlogged home in Newland. Credit: Jaymie Baxley/NC Health News
Alice Salthouse, CEO of High Country, said seeing the storm’s toll on the struggling community has been “gut-wrenching.”
“Every day on my way to work, I drive past people’s homes — and everything they’ve owned is outside waiting for somebody to come take it all to the dump,” she said. “We’ve got older adults who have lived in their homes for years and years, and now their homes are gone. People’s lives have changed and will never be the same again.”
Care during a crisis
High Country moved quickly to help residents in the immediate aftermath of the storm.
Providers for the organization, which has nine locations in western North Carolina, deployed southeast of Avery to Hickory Regional Airport in Catawba County to care for patients who had been evacuated there from nursing homes and rehabilitation centers in Helene’s path.
Staff members traveled hazard-strewn roads to deliver food, medicine and other essential items to people in the federally declared disaster area. Avery Medical became a distribution hub for supplies donated by local charities and churches.
Before-and-after images of a plaza parking lot in Newland. (Photographs by Google Street View and Jaymie Baxley/NC Health News)
But the organization did not emerge unscathed from what The Avery Journal-Times described as the “one of the greatest natural disasters” in the county’s 117-year history.
Avery Dental, a High Country-run clinic in Newland, suffered heavy flooding, with waters rising as high as four feet inside the facility. Salthouse said everything in the seven-chair clinic, from dental equipment to the insulation packed behind its sheetrock walls, was either destroyed or contaminated.
“We’ll have to put up new walls, put down new flooring and redo the electrical,” she said. “It’s almost like building a whole new place, only more complicated.”
High Country experienced an estimated $3.6 million in lost revenue and property damage in connection with Helene, with most of that tally tied to the ruination at Avery Dental.
Salthouse said it will be months before the clinic reopens.
Dearth of dentists
Avery Dental shares a plaza with a half-dozen other businesses, including the Times-Journal, in Newland’s commercial center near the North Toe River. Those businesses also flooded, but the loss of the clinic dealt an especially harsh blow to an area where access to dental services was already limited.
Furniture and equipment stacked near the entrance of Carolina Barbeque, a storm-damaged restaurant next to Avery Dental on Pineola Street in Newland. Credit: Jaymie Baxley/NC Health News
According to data from the University of Wisconsin Population Health Institute, the average ratio of dentists to residents in North Carolina is 1-to-1,630. But in Avery County, there is just one dentist for every 2,200 residents.
Salthouse said the disparity was much worse before Avery Dental opened its doors in 2015. That year, there was only one dentist per 5,860 people.
While there are other dental offices in the community, the clinic is the only option for many residents because of its sliding-scale fee system. Patients are charged what they can afford to pay based on their income.
“They can come in and see the dentist for far, far less,” Salthouse said. “I mean, when was the last time you went to the dentist and got your teeth cleaned for $45?”
Avery Dental is also one of the only local providers that accepts Medicaid. Data from the N.C. Department of Health and Human Services show that more than 4,300 Avery County residents are currently enrolled in the program, with children accounting for about 43 percent of the county’s enrollees.
“You have a huge population of children that are on Medicaid,” Salthouse said. “Having a dentist in this county is crucial, but recruiting them to this county is difficult.”
One barrier to recruitment, she said, is the area’s topography. The roads to Avery County cut through snow-prone mountains, making travel hazardous in the winter.
The mountainous terrain also amplified Helene’s impact on the county. Steep slopes and ravines funneled water from the swollen North Toe River and its tributaries into low-lying areas.
Serving the underserved
Ashton Johanson joined the staff of Avery Dental less than two months before the clinic was flooded.
A disc golf enthusiast from Colorado, Johanson earned his degree in dental surgery from the Utah School of Dentistry and went on to work with low-income patients at public health clinics in the Salt Lake Valley. He had been thinking about moving to North Carolina when he learned about a job opening for a dentist in Newland.
“I had a few opportunities around the state, but this seemed like the best fit for me and my family,” he said. “We wanted to try something different, and this was an area with a population that really needed dentists. It seemed like a chance to serve the underserved, which is something I’m passionate about.”
Johanson, who began seeing patients at Avery Dental in August, was still adjusting to his new environment when the environment was upended by Helene.
Since early October, he has been working out of a van parked in front of High Country’s medical clinic about half a mile from the waterlogged dentist’s office. The vehicle was previously used as a mobile clinic for cleaning children’s teeth at local schools.
While it can’t accommodate all the same services as the dental clinic, the mobile unit has enough space and equipment for Johanson to provide emergency exams, tooth extractions and fillings.
Before-and-after images of a business in Newland. (Photographs by Google Street View and Jaymie Baxley/NC Health News)
“The first week we were open, we had a hard time getting patients in here,” he said. “Even if people had tooth pain or some other dental emergency, their houses were underwater and the roads weren’t drivable. They had bigger problems than coming in to see us.”
Business began to pick up once the waters receded. Johanson said more than 100 patients have visited the mobile unit over the past month, with about eight people stopping by each day.
In the meantime, High Country has contracted with a demolition crew to gut the flood-damaged interior of Avery Dental. After the facility has been stripped to its frame, air quality studies will be conducted to ensure that it is free of mold spores and disease-spreading bacteria.
High Country is soliciting bids to rebuild the clinic at the same location and restock it with dental equipment. Salthouse estimates the project will cost between $500,000 and $750,000.
“This is a very big deal for this county, for us to get this dental clinic back up and running,” she said.
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Post-Helene, mental health providers help kids cope
By Emily Vespa
Weeks after the remnants of Hurricane Helene ravaged western North Carolina, tens of thousands of kids across the region still don’t know when they’ll be able to return to a sense of normalcy.
At a Chapel Hill park on a recent sunny afternoon, displaced families, many from the Asheville area, found a place to connect over the unknown.
“Life around here goes on as normal, but we are people who just experienced an extremely traumatic event that we weren’t necessarily prepared for,” said Joe Ainsworth, a school counselor for Buncombe County Schools and the organizer of the picnic for displaced families.
A sign at the picnic in Chapel Hill for western North Carolina families displaced by Hurricane Helene on Oct. 13, 2024. Credit: Emily Vespa / NC Health News
At the park, kids of all ages doted on therapy dogs and picked at pizza. With the muffled sound of basketballs thudding on nearby courts in the background, mental health providers talked with families about ways to cope with the devastation that has upended their lives.
It’s an early but important step in the long-term healing process, Ainsworth said.
“The broad implications of what displacement looks like is huge,” he said. “I think we’re still trying to figure out what that even looks like — and how we can help.”
Helping kids cope
In the aftermath of a disaster, it’s normal for kids to feel anxious or overwhelmed, said Nivee Roy, a licensed professional counselor who specializes in trauma.
“Kids are people. They’re little people, but they’re people nevertheless,” said Roy, who drove from Charlotte for the picnic. “They have feelings and emotions, and because this disaster was so monumental in its dimensions, it’s sometimes so hard to comprehend.”
Parents and guardians might see some of these behaviors in children after a disaster:
Trouble sleeping
Forgetfulness
Difficulty following directions
More meltdowns
In the first one to three months after a traumatic event, people experience short-term stress, Roy said. After that, stress becomes chronic. For Helene survivors, the early months are an important “window of intervention” to provide mental health support and help children recover long-term, she said.
“Our brain has the full capacity to heal itself,” Roy said. “We want to foster that.
“We want to introduce healthy coping skills, a safe place to connect and share those feelings, and then pick up a routine that is the new normal.”
An attendee at a picnic for displaced western North Carolina families holds a handout on coping with traumatic events as she pets a therapy dog on Oct. 13, 2024. Credit: Emily Vespa / NC Health News
It doesn’t take a mental health professional to support kids after a disaster, Robin Gurwitch, a professor in the Duke University Department of Psychiatry and Behavioral Sciences and at the Center for Child and Family Health, told NC Health News in an interview.
“Sometimes, particularly as parents and caregivers, we worry: ‘Oh my gosh, what if I don’t get my child the help they need immediately?’” Gurwitch said. “You’re the help they need immediately.”
Roy joined other mental health professionals in teaching families at the picnic about ways to help each other heal. Most important, she said, is simply for parents to talk to their kids about what they’re feeling. Creating a routine can also help children grapple with the disruption in their ordinary habits.
If children have changes in behavior that worsen or persist for more than six weeks after the disaster, then it’s important to seek help from a mental health provider, experts say.
Returning to a new normal
It’s college application season for high school seniors like Jayden Thomas, who attends A.C. Reynolds High School in Asheville. Though many state schools have extended deadlines and will waive application fees for western North Carolina students, she said it’s been hard to navigate the process without having access to her guidance counselor. She also misses marching band, which she’s been in for four years.
“It’s kind of apocalyptic, almost,” said Thomas, 17, at the picnic. “I want to go home, but it’s not really the same anymore.”
Jayden Thomas, a senior at A.C. Reynolds High School, stands at a picnic in Chapel Hill for displaced western North Carolina families on Oct. 13, 2024. Credit: Emily Vespa / NC Health News
Thomas had been displaced with her family for nearly two weeks in Raleigh.
“I felt a little guilty leaving, honestly, leaving all my friends behind and wanting to help with the relief efforts, wanting to volunteer,” Thomas said. “But it just wasn’t safe for us.”
Buncombe County Schools Superintendent Rob Jackson said Thursday that the system plans to have a reopening date soon and is “working very hard for the emotional well-being of our staff and students when we return to the buildings after the challenges of the past few weeks.”
School counselors and social workers from across the state will assist Buncombe County’s staff when schools return, Jackson said.
In the meantime, communities are organizing to provide support for students. One Asheville elementary school’s staff visited students at their homes to pass out goody bags.
“When our students can’t come to us, we go to them!” the school’s Facebook post read.
Staff from another Asheville school created a “Bookmobile” to hand out books in local neighborhoods and keep kids reading, the district posted in a different Facebook group.
Ainsworth, the school counselor, said he was overwhelmed by the generosity of volunteers as he was organizing the picnic. But the need is still extremely great, he said, especially for smaller school districts with less resources than Asheville’s.
“I think forever moving forward, western North Carolina will be pre-Helene and post-Helene, and we just have to work on defining what that post-Helene looks like,” Ainsworth said. “And hopefully, when it comes to how it’s affected our students, we can get the help that we need to help them kind of work through this and become resilient and strong moving forward.”
The National Child Traumatic Stress Network offers an app called “Help Kids Cope” with guidance for how to support children after various disasters. The app is free to download on the Google and Apple app stores.
