By Jaymie Baxley
Across rural North Carolina, the opioid epidemic has left a devastating mark — overdose deaths have surged, families have been shattered and communities have struggled to find resources to fight the crisis. More than 4,440 overdose-related deaths were reported across the state in 2023, with rural counties accounting for about 41 percent of the toll.
But a wave of funding from the state’s share of a multibillion-dollar national court settlement with the pharmaceutical companies that abetted the epidemic has offered a lifeline by fueling efforts to expand treatment, recovery and harm reduction programs in the hardest-hit areas.
Over the course of 18 years, North Carolina will receive $750 million in opioid settlement funds from the agreement reached with drug companies for their alleged roles in stoking the opioid epidemic. Most of the money will be sent to North Carolina’s county governments to help people and communities affected by the crisis.
In an effort to avoid the mistakes of the 1998 settlement with tobacco companies, when dollars ended up flowing into the state’s general fund instead of being used for tobacco abatement, the office of then-Attorney General Josh Stein created agreements with counties for how North Carolina’s settlement money could be spent.
Counties control 85 percent of the money. When those dollars started flowing almost three years ago, each was able to develop spending strategies that work for their communities.
Several years into the response, county leaders are finding differing routes to success.
Meeting people where they are
Dalton Barrett, a longtime paramedic in Edgecombe County, is on the front lines of the crisis. He manages an experimental post-overdose response team that was created with part of the county’s $5 million share of the settlement.
The team, he explained during a panel at the recent Rural Summit in Raleigh, is unique in that its members care for patients at home or in other settings outside of a hospital under the supervision of a physician or advanced practice provider.
“When we first got started, I knew a lot of the folks that had overdosed or were in active use at the time due to my time on the streets, and I had a good relationship with them,” Barrett said. “My first couple of months was just meeting with them saying, ‘Look, we’re trying to start this thing. What do you think would be beneficial?’”
Based on the feedback he got, the county developed what Barrett considers “one of the most extensive harm reduction programs in the state.” His team connects residents with services ranging from distribution of clean syringes to the ability to check street drugs for potent fentanyl and other additives through a laboratory at UNC Chapel Hill.
“We’re doing a lot of cool stuff that I would have no idea about had it not been for talking with the people that I interacted with,” Barrett said.
Edgecombe had one of the state’s highest rates of death by overdose relative to its population in 2023, the most recent year for which data is available from the N.C. Department of Health and Human Services. The county saw a record 32 fatal overdoses, a nearly threefold increase from the 11 deaths reported a decade earlier.
A total of 182 overdose deaths were linked to the county, which is home to about 48,800 people, from 2013 to 2023. Officials are still tallying deaths from 2024.
The county has historically struggled with unemployment and financial insecurity. Nearly 22 percent of residents live below the poverty line — significantly more than the statewide average of 12.8 percent.
It is also one of only a handful of North Carolina counties with a majority Black population: 56 percent of the county’s residents are Black, according to U.S. Census data.
These factors make Edgecombe particularly susceptible to the epidemic. A national study published in the journal PLOS One found that people with lower incomes were more than twice as likely to die from opioid overdose compared with more affluent groups. Meanwhile the federal Centers for Disease Control and Prevention has reported that Black patients now make up a disproportionately large share of overdose deaths.
Barrett said the post-overdose response team is making progress by tailoring its harm reduction strategies to residents’ individual needs.
He recalled a case involving a 23-year-old man who overdosed three times over the course of one week in December 2023. The man was taken to the hospital after each incident but quickly discharged.
“Basically they’d say, ‘Don’t do drugs, have a nice day,’ and kick him out, which is what we see, unfortunately, around the state,” Barrett said.
Barrett tracked the man down at the restaurant where he worked and offered to administer medication-assisted treatment for opioid withdrawal in the parking lot. The medicine helped, and he agreed to begin regular treatment after Barrett introduced him to a physician’s assistant at a nearby health clinic.
“So far, he has not overdosed again,” Barrett said. “He’s been opioid free, but he’s still got a pretty heavy stimulant use disorder with crack cocaine that we’re working on.”
NCDHHS recorded 94 emergency department visits for suspected opioid overdose in Edgecombe County last year, an improvement over the 104 visits reported in 2023.
Getting the word out
Tiffany Moore, who leads a behavioral health task force within the Beaufort County Health Department, has been working with local stakeholders to craft a comprehensive plan for using her county’s money.
She started by giving as many people as possible a chance to weigh in, inviting residents to suggest potential uses for the county’s $5.7 million share of the settlement during an outdoor event called Community in Action.
“It was one of the biggest community outreach events that Beaufort County has ever seen,” Moore said, adding that Community in Action has since become a “very robust” quarterly gathering. “During these events, we’re introducing the community to the settlement, we’re telling them about the work and we’re inviting them to come out and join us in the strategic planning process.”
The Community in Action event happens in different locations around the county, providing health screenings and clothing and informing residents of the availability of mental health and substance use treatment. The health department also provides the overdose reversal drug naloxone to communities that need it but can’t afford it.
Like Moore, Tia Foula, assistant county manager of Nash County, developed an inclusive process for soliciting input on how to spend the county’s $10.2 million share of the settlement. The goal, she said, was to make sure “people felt their voice would be heard.”
“I think the thing with opioids and substance misuse is that people don’t really like to talk about it, and so we wanted to set up a space where people felt welcome,” she said.
To that end, the county organized a series of public meetings at trusted, non-governmental venues in the area. Each meeting was held at night, making it easier for residents to attend, and extensively promoted with advertisements on radio, television and in the local newspaper.
“We wanted to do it in community locations so that people felt like they were just having a conversation in a place that they were comfortable,” Foula said, adding that the county offered virtual options for residents who couldn’t attend the meetings or felt uncomfortable sharing their feedback in public because of the “stigma” surrounding opioid abuse.
As part of its outreach, the county made a concerted effort to involve community members who had been affected by the epidemic. Foula said some of these people were decades removed from their struggle with substance use disorder, while others had only recently begun their road to recovery.
“One of my favorite parts about the process was that we made sure we lifted the voices of people with lived experience,” she said. “At each meeting we had a lived experience panel with people from the community, and the storytelling that happened in that space was so powerful. I think it helped kind of break down some of the stigma and helped people to understand that these are real challenges that our community members are dealing with.”
Nash County is now putting the finishing touches on a strategic action plan that Foula hopes will reflect the priorities and concerns of the community.
“Really, the benefit of this whole process has just been the connection,” she said. “Being able to identify the resources, identify the partners and just let the community know that we care — I think that is really the value of this process.”
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