Vance County — with its open, rural spaces just north of the Triangle — might not seem like one of North Carolina's hotspots for heroin. But it's one of four counties where heroin overdoses spiked the most from 2010 to 2016, according to a Duke University study published in this month’s North Carolina Medical Journal.
The death rate per 100,000 people grew 1,300 percent in Vance during that six-year period.
The rates also jumped 13-fold in Brunswick and New Hanover counties along the coast and in Gaston County near Charlotte.
“We’ve known for a while that Vance had a much higher rate of overdose compared to other counties,” said Loftin Wilson of the N.C. Harm Reduction Coalition. “It’s crazy to look at the map and see one near Charlotte and two on the coast, and this little county up near Virginia have the highest rates.”
Across North Carolina, the heroin death rate multiplied by 10 over the same six years.
The study divided North Carolina's 100 counties into five groups based on the amount of change in the heroin death rate. Wake County was in the second-highest cluster of 27 counties. Twenty-nine counties were in the bottom cluster with little or no growth.
Duke professor Nicole Schramm-Sapyta, one of the leaders of the study, said Vance, Brunswick, New Hanover and Gaston counties “need the most reactive response in terms of looking at treatment resources for their citizens and looking at why opiate deaths are so high.”
From 1999 to 2016, opioid-related deaths in North Carolina increased 800 percent, according to the study. A national epidemic began in the 1990s with overdoses of prescription drugs.
In 2010, heroin overdoses started rising, and in 2013, a new wave of overdoses rose as fentanyl and other synthetic opioids became more available, according to the Centers for Disease Control and Prevention in Atlanta. Since 2013, illicit drugs like heroin and abuse of fentanyl have overtaken prescription drug abuse as causes of overdose deaths.
“With fentanyl, there’s two things going on,” said Alan Dellapenna of the N.C. Department of Health and Human Services. “One, it has massively increased availability. Two, it has extremely high potency, so you’re having lots of people die.”
Fentanyl is a synthetic prescription opioid that is cheaper and easier to produce than heroin, Schramm-Sapyta said. The study examined death certificates and recorded and compared heroin overdoses by county. It measured illicit drug abuse instead of prescription drug abuse, so it did not count deaths from prescription drug abuse without the presence of heroin.
“Probably one of the reasons that heroin deaths are escalating in some places is that dealers are mixing in fentanyl more aggressively or more unpredictably,” Schramm-Sapyta said. “So heroin users don’t know what they’re getting and are overdosing, as fentanyl is so much stronger than heroin."
Lessons from Wilkes
The study's authors were inspired by Wilkes County, which in 2007 had an extremely high overdose death rate and made a community-based initiative to fight the crisis using education for doctors and patients, support groups and other local projects. In the study, Wilkes, which is in northwestern North Carolina, dropped to the rung of counties with the slowest rate of increase in heroin deaths.
“We learned from Wilkes County,” Schramm-Sapyta said. “Someone from the local hospice was seeing families come in; everybody knew who was dying. That led to conversations with medical providers, who were used to prescribing to people who worked manual labor jobs and needed pain medication. The community came together and really dug into the problem.”
County-by-county data may encourage local governments to adapt their approaches to the opioid crisis. While larger, urban counties such as Wake have more deaths in total than the four more rural counties, they also have more people, resources and hospitals, and their rates of death per 100,000 people are lower.
“Urban counties have the benefit of more people to do the talking,” Schramm-Sapyta said. “We want to have a deep conversation of what’s going on, which is easier to do in a small rural county where everyone knows everybody. We want to ask the county leaders and health officials: Who’s coming into the emergency room, who are the users, what is the network, and how are people interconnected?”
In 2015, the NCHRC worked with Granville Vance Public Health and local law enforcement to form a coalition to give out educational materials, fentanyl test kits and naloxone, a life-saving drug that can reverse overdoses. Since then, they’ve given out more than 2,000 naloxone kits and successfully reversed over 270 overdoses, according to an article this month in the same journal, written by Lisa Macon Harrison, health director of the GVPH.
“Local solutions can be unique and creative, and having volunteers who know the community can really help,” Harrison wrote in the article. “It’s important to find the best way to reach the populations in need and build trusting relationships. That’s the expertise NCHRC brings to a community.”
In 2016, syringe exchanges became legal in North Carolina, and since then, the NCHRC has run a mobile program to bring supplies to people’s homes in Vance and nearby counties. Other locales have fixed needle exchanges, but the NCHRC catered its Vance program to the local culture.
“Not a lot of people have access to transportation, and there’s no public transportation, so for folks in a trailer 45 minutes from town, it’s not likely they’ll get in to a regular visit to a needle exchange,” Wilson said. “Plus you don’t have an opportunity for anonymity — people know if you drive a particular road at a particular time of day, what that means. So people might not want to go to a fixed site. We give people more privacy by meeting them where they’re comfortable.”
Opioid Action Plan
In 2017, the DHHS created the Opioid Action Plan and releases data each month for local governments and organizations to analyze and adapt into their tactics.
“Our strategy is one of active surveillance,” Dellapenna said. “We try to provide the data and resources to folks so they can address the epidemic locally. We know there isn’t one solution; there’s many solutions. Everyone’s working on trying things out.”
The study fits into a larger picture of university researchers working with the DHHS, law enforcement and local communities to chip away at the opioid epidemic.
“Not one thing got us into this situation and not one thing is going to get us out, but we do know things that work,” Wilson said. “We know expanding access to medication and treatment works; we know that syringe exchange works. We know heavily criminalizing drug use does not work; we know that forcing people into treatment does not work.”
While the study focused on heroin-related deaths in 2010-16, according to DHHS data and U.S. Census estimates, the rate of heroin deaths actually dropped statewide in 2017, from 5.6 deaths in 2016 to 4.7 in 2017. In comparison, death rates from fentanyl and similar drugs have more than doubled each year: from 2.4 in 2015 and 5.3 in 2016 to 10.9 in 2017.
“Twenty percent of high school students in North Carolina have used opioids recreationally by 12th grade,” Dellapenna said. “You used to know where your parents’ liquor cabinet was, and now you know where the medicine cabinet is.”
To get help
If you or someone you know is at risk of opioid overdose and you want more information, the NCHRC also runs an office in Raleigh. Visit its website at www.nchrc.org.