Rural Harm Reduction: Spotlight on Edgecombe County, North Carolina

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Background

In eastern North Carolina, between Raleigh and the Atlantic Coast, lies Edgecombe County, a largely rural county with a population of about 48,000. Compared to the state and country as a whole, Edgecombe County has a high percentage of Black residents (56 percent), as well as high rates of poverty, incarceration, and unemployment. All of these factors increase the likelihood that people will be affected by the potential harms of drug use and the war on drugs.

Indeed, Edgecombe County has been hit hard by the nation’s ongoing overdose crisis: from 2017 to 2022, the county’s drug overdose death rate was 33 per 100,000 residents (compared to a statewide rate of 27.6). The county is also among the hardest-hit areas in North Carolina when it comes to HIV, with 10 new diagnoses in the first six months of 2023, compared to six the year before. And hepatitis C – a virus that spreads primarily through injection drug use – was among Edgecombe County’s top health issues and priorities in a 2022 needs assessment.

All of these issues provided fertile ground for harm reduction, a pragmatic approach that repeatedly saves lives and supports health at the population level, where abstinence-oriented interventions often fail.

The program

Launched in May 2023, the Edgecombe County Community Paramedic Program (ECCPP) is an innovative, tailored harm reduction program funded primarily by opioid payment dollars, although it also utilizes funding from the state’s local management entities. The ECCPP is a partnership between the province’s emergency medical services and the department of public health. Two paramedics provide a variety of mobile overdose response and harm reduction services (and even some primary care services) five to six days a week from 7:30 AM to 6:00 PM.

ECCPP harm reduction services

This comprehensive range of harm reduction services addresses a spectrum of problems associated with drug use and exacerbated by socio-economic inequalities. In addition to reducing the risks of infectious diseases and overdoses, the distribution of syringes and naloxone helps build trusting relationships and facilitate access to treatment. Thanks to its mobile nature, the program is already reaching harder-to-reach populations – such as young Black men – who have been historically underrepresented in harm reduction care and have recently experienced some of the highest overdose rates in the state and nation. The ECCPP also fills gaps in Edgecombe County’s primary care infrastructure by meeting residents in need wherever they are, both literally and figuratively. And the paramedics who staff the ECCPP provide education and outreach to the community, including naloxone training.

Recent successes

So far, 2024 has been a successful year for the ECCPP. According to Community Paramedic Program Manager and Logistics Officer Dalton Barrett, the program has:

• Distributed 277 boxes of Narcan And 600 syringes to participants in the spraying service program between July 1, 2024 and October 7, 2024.
• Made 34 referrals to care from January 2024 to October 2024 (10 referrals in September alone).
• Seen 26 individuals at least once a month, others less often.

Policy lessons

In North Carolina, smart policies are laying the foundation for trusting relationships between first responders and people who use drugs, making it possible to provide more comprehensive care like that offered by the ECCPP. For example:

• Robust Good Samaritan laws allow people who witness an overdose to respond by administering naloxone and calling emergency medical services without fear of criminal consequences.
• By authorizing evidence-based spraying services – including needs-based equipment distribution and allowing mobile operations – rural harm reduction programs can tailor themselves to the needs of the local community.

Nevertheless, there is still work to be done to reduce the risks associated with illicit drug use. Although the ECCPP provides referrals (and some warm transfers) for medication treatment for opioid use disorders, North Carolina’s restrictions on the gold standard medication methadone limit their ability to truly meet patients’ needs. Relaxing state regulations on methadone – for example, reducing requirements for patients to receive home doses, allowing individualized counseling, reducing the number of annual drug tests to comply with federal guidelines, discouraging discontinuing care when patients have a positive drug test, and more – would improve access to this life-saving medicine.