It was a comment made almost in passing that struck me the hardest as I wrapped up a 30-minute conversation with Cat Glenn, co-founder of Band Against Heroin, volunteer with the North Carolina Harm Reduction Coalition and employee at Choices for Recovery, a holistic rehab facility in Charlotte.
After spending a half-hour discussing stats, practices and theories surrounding opioid addiction and ways to treat it, I turned off my recorder and continued to chat with Glenn, whom I had met a year ago while working on a story about a rash of overdoses that had struck her circle of friends and other folks in the Plaza Midwood neighborhood. As we left Common Market together, she mentioned how she was concerned about a young woman she knew who had been clean for months and was living in a sober-living home in Charlotte but had relapsed and overdosed the night before.
The woman was in the intensive care unit, and Glenn had no way of knowing how much damage had been done.
"It's just shocking. You think that someone's doing good, you think they got it. You have no idea. And then, all it takes...," Glenn trailed off.
It's easy to feel disconnected from the terrifying statistics that describe how an opioid epidemic has been sweeping through the United States over the last decade, but it's impossible not to grasp it once people you know have fallen in the fight. I myself have lost longtime friends to heroin and opiate addiction in the year since writing the above-mentioned story. For folks like Glenn who work in the field every day, it's an all-too-common occurrence.
In our state, the problem seems to constantly be peaking. A report released by Castlight Health earlier this year listed four North Carolina towns as among the 20 with the worst opioid abuse problems in the United States, with Wilmington listed as the worst in America. The other three were Hickory (5), Jacksonville (12) and Fayetteville (18). Prescription opioid abuse often eventually leads to heroin abuse, and a recent rise in painkiller prescriptions has matched up succinctly with a similar rise in heroin use and overdoses.
"Above all, we can never forget that the faces of substance use disorders are real people. They are a beloved family member, a friend, a colleague, and ourselves," U.S. Surgeon General Dr. Vivek Murthy wrote in a report released in late November titled, "Facing Addiction in America: Surgeon General's Report on Alcohol, Drugs and Health." The report is shocking in its scope, calling problematic drug use "the country's most pressing public health concern," while pointing out that nearly 21 million Americans — more than the number of people who have all types cancers combined — suffer from alcohol and other drug dependence.
Perhaps most unprecedented is the surgeon general's office's endorsement of harm reduction practices, a theory that has long been rejected as harmful and enabling in many traditional drug treatment programs.
Harm reduction is defined as a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. In the fight against opiate addiction — which took the lives of more than 55,400 people in 2015 — harm reduction tactics include the supply and use of overdose-reversal drugs like naloxone and the implementation of syringe exchange programs to help prevent the spread of disease by injection-drug users.
According to Tessie Castillo, advocacy and community coordinator with the North Carolina Harm Reduction Coalition (NCHRC), the surgeon general's report, which recognized the value of both the above-mentioned practices, was mostly a symbolic victory for the harm reduction community.
"We didn't really pay attention to that honestly," Castillo says. "I mean, we're happy about it, but I don't know how helpful it is. I don't have a whole bunch of new people calling me because of that report."
The work Castillo and the NCHRC has been doing on the ground for years, however, has had a measurable effect on attitudes toward harm reduction throughout North Carolina, as can be seen by new laws recently passed by state legislators and acceptance in a treatment community where harm reduction advocates were once shunned.
Part of Castillo's job is to work as a lobbyist on behalf of NCHRC, and the organization has helped pass two laws in the past three years alone that have been crucial in adding legitimacy to the harm reduction movement.
The first was the Good Samaritan Law, passed in April 2013. It was written to help allay the fear that would discourage people from calling 911 when a friend or acquaintance overdoses on drugs by not charging that person with a crime for possession, even if they were on probation.
"That was a huge issue with people dying," Glenn said of the importance of the Good Samaritan Law. "Nobody was calling the cops. They would dump [overdose victims] and leave because they were afraid of getting in trouble."
Perhaps the most important addition to the Good Samaritan Law was that it opened up access to naloxone, a drug that can be used by first responders and civilians alike to reverse overdoses.
Before the law was passed, civilians were not allowed to have naloxone in the home and organizations weren't allowed to pass it out. Since the law passed, the NCHRC alone has passed out more than 35,000 naloxone kits across the state and know of at least 5,000 incidents in which those kits were used to successfully reverse an overdose.
While the Good Samaritan Law was just a four-month effort from Castillo and fellow lobbyists, their most recent success took much longer. For five years, the NCHRC has been fighting to legalize syringe exchange programs — in which addicts can safely trade in their used needles for clean ones — in North Carolina as a way to curb the spread of diseases like HIV and Hepatitis C, among other benefits.
"It was very difficult to convince the legislature that it was a good idea to pass out needles to people who are actively using drugs," Castillo says. "We took many years educating them on the benefits; the fiscal benefits, the disease-prevention benefits, the benefits of connecting with people and helping them get into treatment, the law enforcement benefits."
In the end, it was that last one that helped the NCHRC gain the legitimacy it needed. Once the NC Sheriff's Association and the North Carolina Association of Chiefs of Police were on board, lawmakers felt more comfortable with passing the law, which was written into the controversial House Bill 972.
Since the law was passed in July, 15 syringe exchange programs have popped up throughout the state. In towns like Chapel Hill and Hillsborough, the county health department runs the exchanges. Some underground exchanges have now become legitimate, and have run into an overwhelming response. The Needle Exchange Program of Asheville reportedly went from passing out 30,000 syringes a month to 60,000.
In Charlotte, the opposite has happened, as a lack of funding has made things difficult for Kat Nelson, founder of the Queen City Needle Exchange. Glenn and Castillo have attempted to help Nelson with the resources she needs, and the grassroots exchange is still moving along, but a lack of knowledge about it has made it hard for growth.
Attempts to reach Nelson for this story were unsuccessful.
The new laws have given harm reduction advocates like Castillo a legitimacy that can be measured in the reactions of those involved with more mainstream recovery programs such as methadone clinics or 12-step programs.
"When I started six years ago, I would regularly get hung up on and doors slammed in my face," she says. "Nobody wanted to talk to us. Everybody thought we were crazy. 'This is a radical little organization that wants to enable drug use,' that's what everybody said. But over the years that has changed in so many ways."
Before the Good Samaritan Law was passed in 2013, Castillo and the NCHRC had a hard time getting any treatment centers to offer access to naloxone to be used in the case that a client relapses.
Despite the fact that NCHRC's research has shown that folks just leaving treatment are at highest risk of suffering a fatal overdose if they use again, treatment centers couldn't justify it.
"We just got door after door after door slammed on us," Castillo says. "No one in the whole state would take that medicine. They said, 'It's against our philosophy. We keep telling them they'll never relapse and if you give them naloxone you're admitting that it might happen. We don't want them to think that way.'"
NCHRC workers especially focused on methadone clinics — where addicts receive the opiate as a way to curb withdrawal symptoms without experiencing the same intense high — as there are often high rates of active drug use amongst methadone users. They hit the same obstacles in most cases, until the Good Samaritan Law passed.
After years of rejection, since 2013, the NCHRC has helped supply every methadone clinic in the state with naloxone, save for one. According to Castillo, the McLeod Center in Charlotte is the last remaining hold-out in the state. It's believed there's one official there that doesn't approve of harm reduction practices being mixed with treatment options.
Calls to McLeod Center in Charlotte for insight into harm reduction went unreturned.
Glenn has seen interest in harm reduction grow in the organizations she works with, such as the Center for Prevention Services (CPS), an organization that works with youth in the greater Charlotte area to prevent drug addiction before it happens. CPS has begun working harm reduction into its presentations since it's become more accepted by lawmakers and police.
"It's because it's legal. It wasn't happening before," Glenn says. "NCHRC has been doing work for years and years and nobody was really grasping it until you get the validation of the law. And then people love that. If it's legal now that must mean it's good to go, and we're not going to get in trouble. It's definitely up and coming."
Harm reduction has also been historically met with skepticism in 12-step programs, where complete abstinence is seen as the only escape from addiction.
Edgar Lobeira, a Mooresville resident who has been attending Narcotics Anonymous meetings in the Lake Norman area and Charlotte for more than 18 months, said he used to believe any discussion of harm reduction was wrong, although his views have changed as he's learned more about it.
It's clear that he still struggles with its full acceptance, but he sees its value.
"Personally, my view is that it is enabling to an extent, but if I know somebody who I care about who's in the middle of it, I'd rather them have that and not die than the opposite," Lobeira says.
"Most [recovery] communities would say that's enabling — I still feel that way to an extent — I do think it is enabling and it's not OK to use once you've been introduced to a program and you've been shown by people that there's another way out, rather than just carrying this thing around just in case you O.D. so you don't die, or getting clean needles because they're handed out to you. It's kind of a double-edged sword."
For advocates like Castillo and Glenn, introduction to a program is an ideal situation for someone participating in harm reduction. Each naloxone kit includes pamphlets with information on how to seek help, while syringe exchanges are often used to educate users and encourage them to get treatment.
But for the most part, harm reduction is all about keeping people alive and safe, no matter a victim's history.
Castillo has recently seen a new aspect of the debate come to the forefront, as some people argue that a person shouldn't be allowed access to naloxone after overdosing multiple times. She emphasizes that, while it's ideal that surviving an overdose just once will serve as a wake-up call and inspire a person to seek treatment immediately, it doesn't always work that way.
Arguing that repeat overdose victims should be punished or have help withheld is sending a dangerous message, she says.
"We really can't be the judge of that. We can't draw some arbitrary 'three strikes and you're out' line," Castillo says. "It's important to let people recover at their own pace. We value everybody's life, and the value of a life doesn't decrease the more times that they're saved, which is kind of what people seem to be saying."
A nonjudgmental look at heroin addiction is something even Glenn has been struggling with as she rebrands an organization she formed with friend Adam Griffith called Band Against Heroin, which hosts concerts in an effort to pass out naloxone and educate folks on harm reduction and treatment options.
In the lead-up to the first two "Heroin Kills" shows held in Charlotte over the last year, her team created stickers and t-shirts reading "Fuck Heroin" and "Junk Ain't Punk." They quickly realized that, while the clever slogans were a hit among users in recovery and friends and family members of active users, they were perpetuating a stigma that pushed active users further into the shadows, feeling further ostracized.
Band Against Heroin organizers always set up a large table with naloxone kits and a plethora of educational materials on treatment options, but if heroin users are too intimidated to come to the shows, the bands are simply playing to the choir.
"What we want to do is be able to open up the conversation around people who do use heroin, to give them the resources that they need," Glenn says. "But the heroin users aren't stepping foot through the door because they see 'Fuck Heroin' and they see this show that's anti-heroin, and they feel stigmatized. But that was not our original intention. We wanted to bring the community including heroin users together."
For the next show, planned for Greensboro on Jan. 28, Glenn will be shifting gears a bit, implementing an approach more friendly to active users.
In the meantime, she'll continue her daily work with the multiple organizations she is involved with. When I caught up with her four days after our original conversation, she told me the young lady who had overdosed the previous week was still in the hospital, although it appeared she would recover fully with no brain damage.
The woman was saved with CPR, but Glenn believes naloxone would have made her recovery a quicker process. She pointed to the incident as a reason harm reduction can't be overlooked.
"The fact of the matter is that people will struggle with this all their lives. If you are a heroin addict or opiate addict, I say you should carry naloxone on you for the rest of your life; when you've been 20 years sober, when you have kids and a husband and a job, you never know," she said. "There is no cure to addiction. That means you will forever have the disease and the struggle with drugs and alcohol can get you at any time."
It's safe to say that in the world of drug treatment and recovery, working for the best while planning for the worst is sometimes the only option.