To understand how overdose death rates and jail incarceration interact at the local level, it is important to examine how state and local policies impact the availability of harm reduction services, substance use disorder treatment, and other supportive services—both in community-based, noncoercive settings, and in jails and other areas of the criminal legal system.

Vera's case studies from two states—New Mexico and North Carolina—highlight programmatic and policy innovations, as well as ongoing challenges for a diverse set of counties in their efforts to respond to the overdose crisis and address the use of incarceration in their local jurisdictions.

Between March and June 2020, Vera researchers conducted phone and video interviews with local experts in Haywood County and Durham County in North Carolina. Vera chose these sites by considering trends in overdose rates and jail incarceration rates, the presence of clear programmatic or policy innovations, diversity in geographic location, demographic composition of the population, and ability to access key stakeholders. You can read more about the methodology and data sources for overdose deaths and jail incarceration rates here.

State Landscape

As in many other parts of the United States, the over-prescription of opioid pain medications has been a major driver of overdose deaths in North Carolina since 2000.^[]North Carolina Department of Justice, “Opioid Crisis,” https://perma.cc/X6XP-UZ2R. Even though North Carolina has had some success in addressing prescription opioid dispensing in recent years, the increased availability of heroin and other synthetic narcotics like fentanyl, as well as stimulant use, has accelerated the overdose crisis across the state.^[]North Carolina Department of Health and Human Services (NCDHHS), “North Carolina's Opioid Action Plan,” https://www.ncdhhs.gov/about/d...; and NCDHHS, “IVP Branch: Poisoning Data” database (Raleigh, NC: NCDHHS), https://www.injuryfreenc.ncdhh.... According to North Carolina’s June 2019 Opioid Action Plan update, opioid dispensing has decreased by 24 percent since 2017. However, over 80 percent of opioid overdose deaths now involve illicit opioids, most deaths involve multiple substances, and there has been a rise statewide in deaths from psychostimulants since 2009. Liora Engel-Smith, “Even as Opioids Ravage WNC, Mountain Folks Say Meth Never Went Away,” North Carolina Health News, December 3, 2019, https://perma.cc/6YBE-KSZS.

In 2017, the state government launched its Opioid Action Plan, with the goals of cutting supply of illicit opioids and inappropriate prescriptions, promoting harm reduction and naloxone use, and addressing the needs of people involved with the criminal legal system.^[]NCDHHS, “North Carolina's Opioid Action Plan.” This last goal is especially crucial. A study of more than 200,000 people released from North Carolina prisons from 2000 to 2015 found that, compared with the general public, formerly incarcerated people were 40 times more likely to die of an opioid overdose during the two weeks after their release from prison and 11 times more likely to die of an overdose over the course of one year post-release.^[]Shabbar I. Ranapurwala, Meghan E. Shanahan, Apostolos A. Alexandridis, et al., “Opioid Overdose Mortality Among Former North Carolina Inmates: 2000–2015,” American Journal of Public Health 108, no. 9 (2018), 1207–13, 1207, https://doi.org/10.2105/AJPH.2018.304514 North Carolina’s average rate of jail incarceration has remained slightly below the national average for many years, and has stayed relatively steady since 2007. In 2015, a total of 16,871 people were incarcerated in North Carolina’s jails, a rate of 256 per 100,000 residents.^[]“Incarceration Trends, North Carolina,” database (New York: Vera Institute of Justice), http://trends.vera.org/rates/n....

Across the state, a strong harm reduction movement—with groups like the North Carolina Harm Reduction Coalition (NCHRC), the North Carolina Survivors Union, and the Steady Collective—has contributed to advocacy for and implementation of key policies and initiatives to address the criminalization of substance use. These include increased access to naloxone, Good Samaritan laws, and the legalization of syringe services programs.^[]For information on naloxone access and Good Samaritan laws, see North Carolina Harm Reduction Coalition (NCHRC), “Overdose Prevention Law in NC,” https://perma.cc/7EHH-Z47H. For information on syringe services program legalization, see NCDHHS, “Syringe Exchange FAQs,” https://perma.cc/NKN2-GJMV; and NCHRC, “FAQS On Legal Syringe Exchange Programs In North Carolina,” https://perma.cc/Y47X-ESCV. Increasingly, law enforcement agencies across the state are carrying naloxone, and multiple Law Enforcement Assisted Diversion (LEAD) programs have been established in recent years. ^[]For more information on law enforcement agencies carrying naloxone, see NCHRC, “NC Law Enforcement Overdose Reversals,” https://perma.cc/DD75-75PB; NHCRC, “Law Enforcement FAQ on Naloxone Programs,” https://perma.cc/4FUS-M7C8; NHCRC, NC Harm Reduction Coalition Monthly Updates: December 2019 (Raleigh, NC: NHCRC, 2019), slides 15–18, https://perma.cc/X2WJ-HPUC. For more information on LEAD, see NCHRC, “LEAD,” https://perma.cc/56B7-SBMS. Additionally, a small number of local jails and community partners have been developing programs to provide medication-assisted treatment (MAT) and facilitate overdose prevention and naloxone distribution programs for people with substance use disorders.^[]For more information on MAT in jails, see Taylor Knopf, “For Some Opioid Users in NC, Jail Doesn’t Mean Detox,” North Carolina Health News, February 25, 2020, https://perma.cc/C8GA-PJ9S.

At the same time, however, North Carolina has introduced a new “drug-induced homicide” law, which allows for harsh sentencing of people alleged to have distributed drugs in the event of a fatal overdose.^[]N.C. Gen. Stat. § 14-17(b)(2) (2017), https://perma.cc/B6U6-SBGC. National research suggests that such laws may be racially inequitable.^[]Northeastern University’s Health in Justice Action Lab has compiled a national database of media reports of drug-induced homicide prosecutions. Their database and analysis suggest that these charges are disproportionately brought in cases where the person who fatally overdosed is white and the person who distributed the drugs is a person of color. There is also disparity in sentencing, where the median sentence is close to nine years for defendants of color compared to five years for white defendants. See Health in Justice Action Lab, “Drug-Induced Homicide,” https://www.healthinjustice.or.... .Similarly, the legalization of syringe services programs, though a critical win in 2016, baked inequity into the law by including protections only for possession of syringes and injection supplies, but not safer drug use supplies for smoking, leaving open room for harsher punishment of crack cocaine users.^[]Drug policies have long been shaped by who is associated with using specific drugs, and racial inequities in the enforcement and sentencing of crack cocaine in particular have persisted since the War on Drugs policies of the 1980s. Analysis of the 2009–2012 National Survey on Drug Use and Health confirmed that crack cocaine users were more likely to have ever been arrested in their life and to have been arrested more than once in the past 12 months, compared to powder cocaine users; Joseph J. Palamar, Shelby Davies, Danielle C. Ompad et al., “Powder Cocaine and Crack Use in the United States: An Examination of Risk for Arrest and Socioeconomic Disparities in US,” Drug and Alcohol Dependence 149 (2015), 108–16. A 2006 study of drug enforcement in Seattle also revealed disproportionate rates of drug arrests among Black residents and crack sellers/users, revealing the police department’s focus on enforcement within a downtown, predominantly Black, crack-selling drug market rather than other drug markets in the city where powder cocaine, methamphetamine, ecstasy, and heroin were being sold by primarily white individuals. Katherine Beckett, Kris Nyrop, and Lori Pfingst, “Race, Drugs, and Policing: Understanding Disparities in Drug Delivery Arrests,” Criminology 44, no. 1 (2006), 105–38. For more on historical and legal analyses of racial disparities in drug enforcement and sentencing, see Drug Policy Alliance, “Race and the Drug War,” https://perma.cc/E3YK-D8LF; Equal Justice Initiative, “Racial Double Standard in Drug Laws Persists Today,” December 9, 2019, https://perma.cc/793B-2TF3; Andrew J. Goudsward, “Crack vs. Heroin: 5 Takeaways From Our Investigation Into The Role Of Race In Drug Battle,” Asbury Park Press, June 17, 2020, https://perma.cc/QJ9G-PL67; Jamie Fellner, “Race, Drugs, and Law Enforcement in the United States,” Stanford Law & Policy Review 20, no. 2 (2009), https://perma.cc/7VBE-MR4A. An excise tax on the possession or sale of unauthorized substances has extracted millions of dollars from people for state and local law enforcement agencies and the state’s general fund since it was first imposed in 1990.^[]North Carolina is one of many states that have imposed taxes on illegal drugs. Nikhita Airi and Aravind Boddupalli, “Why Do States Tax Illegal Drugs?” Urban Institute Tax Policy Center, November 18, 2020, https://perma.cc/FJ9Q-938K. Seventy-five percent of the revenue from the taxes goes to the law enforcement agency that conducted the investigation that led to the assessment, and the remaining 25 percent goes to North Carolina’s general fund N.C. Gen. Stat. § 105-113.113, https://perma.cc/7H6E-784E. In 2018–19, more than $8 million in gross tax collections were generated under this law; North Carolina Department of Revenue, Statistical Abstract of North Carolina Taxes 2019 (Raleigh, NC: North Carolina Department of Revenue, 2019), 32, table 15, https://perma.cc/KKD9-GTZ6. Additionally, North Carolina has not expanded Medicaid and suspends Medicaid eligibility for people incarcerated in state prisons.^[]Kelsey Waddill, “NC Starts Medicaid Transformation Program, Sidesteps Expansion,” Healthpayer Intelligence, July 7, 2020, https://perma.cc/2F32-2HTN. For eligibility during incarceration see Catherine McKee, Sarah Somers, Samantha Artiga, and Alexandra Gates, State Medicaid Policies for Individuals Moving Into and Out of Incarceration (Menlo Park, CA: Kaiser Family Foundation, 2015), https://perma.cc/DVB3-38RS.

Below are case studies of two counties in North Carolina: Haywood County, a small, rural county in western North Carolina, and Durham County, a larger county located in North Carolina’s Research Triangle region.^[]North Carolina’s Research Triangle is a nine-county region anchored by the cities of Raleigh, Durham, and Chapel Hill and three major research universities—North Carolina State University, Duke University, and University of North Carolina. Despite their very different geographies and economies, these two counties have been positive outliers for a variety of their practices and policies to address substance use and overdose prevention, particularly for people entangled in the criminal legal system. At the same time, the experiences of both Haywood and Durham Counties raise questions about the effectiveness of interventions implemented in criminal legal system settings, and the sustainability of current reforms due to uncertain funding streams and impending budget cuts. For more on the methods used to select these counties click here.

Haywood County

Haywood (population 62,317) is a rural county in the Appalachian region of western North Carolina, bordering the state of Tennessee, with a majority white population (95.9 percent).^[]United States Census Bureau, “QuickFacts, Haywood County, North Carolina,” https://perma.cc/XE6Y-EAAY. Some community members described Haywood as poorly resourced compared to neighboring counties, such as Buncombe County, but also noted that a number of other counties bordering Haywood are even more cash-strapped.^[]For the median household income in Haywood County compared to the national average and neighboring counties, see DATAUSA, “Haywood County, NC,” https://datausa.io/profile/geo/haywood-county-nc?compare=united-states; DATAUSA, “Buncombe County, NC,” https://datausa.io/profile/geo/buncombe-county-nc; and DATAUSA, “Transylvania County, NC,” https://datausa.io/profile/geo/transylvania-county-nc

Since 2003, Haywood’s overdose death rate has been steadily increasing, reaching a high of 30.9 deaths per 100,000 county residents in 2018, relative to a statewide rate of 22.4 deaths per 100,000 North Carolinians in the same year. The local jail population rate increased sharply from 2000, levelling off in 2013 as the local jail reached full capacity.^[]Jessi Stone, “Haywood Jail Reaches Capacity,” Smoky Mountain News, November 27, 2019, https://perma.cc/5338-UX2T. To better understand how stakeholders at the county level interpret and address these trends, Vera researchers spoke with staff members of the Haywood County Sheriff’s Office and staff and participants from the NCHRC.

Public health and community responses

Since the mid-2010s, Haywood has been a hub of activity for stakeholders in harm reduction, public health, and the criminal legal system as they have responded to substance use and rising overdose death rates. NCHRC staff described how, thanks to groundwork and relationship building over the years, many community members and government officials—including law enforcement leaders—are supportive of the work they do. NCHRC operates syringe services programming throughout the county, provides overdose prevention education and services in the community and in the jail, and more recently, operates the county’s LEAD program. Steady Collective, in neighboring Asheville, has also been a regular collaborator with NCHRC in the region, sharing harm reduction resources and strategies.

Haywood County currently has three fixed-site syringe services programs. These programs operate a few days each week out of the county health department and two community organizations. Harm reduction staff and volunteers also provide mobile, peer-based services and supplies for safer drug use and overdose prevention throughout the county.^[]NCDHHS, “Syringe Services Program in North Carolina,” https://perma.cc/P2NQ-AEG6. NCHRC staff explained that “they’ll go anywhere” throughout the county to meet people, but also explained that, in this rural Appalachian region, there are still pockets of people who use drugs who are very difficult to reach, particularly those who are geographically isolated, experience extreme poverty, and/or are distrustful of service providers—even staff of a community-based harm reduction organization. NCHRC has relied on several strategies; for example, the organization equips syringe services program participants who are closer to the social networks of hard-to-reach people who use drugs with harm reduction supplies to distribute to their peers. NCHRC also engages with people who sell drugs, providing them with harm reduction supplies and information.

Although MAT for people who use opioids is available in Haywood County, residents pointed to a lack of transportation, high out-of-pocket costs, and insurance issues as key barriers that impede access to treatment for many people. MAT providers in Haywood County accept Medicaid, but only for in-clinic/office treatment, not take-home doses. In addition to the lack of Medicaid expansion for North Carolina, NCHRC staff lamented that having a felony conviction can mean disqualification or new barriers to federal assistance, including Medicaid.^[]See The U.S. Commission on Civil Rights, Collateral Consequences: The Crossroads of Punishment, Redemption, and the Effects on Communities (Washington, DC: U.S. Commission on Civil Rights, 2019), 22-88, https://perma.cc/ZB7R-W4MH.

“We know [MAT] is the most effective treatment, [but] here you have this extra barrier for the group that needs it the most.”

Another Haywood resident explained that they were often frustrated by the costs, travel time, and long waits in line to access MAT at local providers in Haywood. As a result, they sometimes left the clinic empty-handed and resorted to seeking drugs instead.

Criminal legal system responses

LEAD—the pre-arrest or pre-booking diversion program model that originated in Seattle—has been implemented in a number of jurisdictions across North Carolina. NCHRC launched Haywood County’s LEAD program in the summer of 2018 with the Waynesville Police Department, and enlisted a second local law enforcement agency, the Canton Police Department, at the beginning of 2020.^[] NCHRC, “LEAD,” https://perma.cc/56B7-SBMS. NCHRC staff reported that, although there are notable champions for the diversion initiative, the use of diversion as an alternative to arrest has not been widespread among officers; referrals to the LEAD case manager from law enforcement have been slow or nonexistent at times. Even though officers now carry naloxone, stigma toward people who use drugs persists. NCHRC staff explained that some officers view people struggling with substance use disorder in this way: “They don’t want help, they can’t change, they’re not changing fast enough.”

However, NCHRC staff noted the issue is often not that people do not want help, but that they do not want help when it comes from the police. Another interviewee expressed their frustration with the local police, who continue to favor arrest and incarceration over diversion: “What type of person would rather see you go to jail, instead of treatment?” NCHRC staff and participants explained that police tasked with drug enforcement in Haywood County regularly harass and target certain groups of people who use drugs, particularly those experiencing poverty and homelessness.

These tactics may partially explain why there are such high rates of repeat bookings in the Haywood County Jail. One NCHRC participant described how, once a person has been identified by law enforcement and/or found with drugs one time, local police will continue to target them, “constantly trying to find something…they're going to pull you over every time.” NCHRC staff and participants also reported that law enforcement officers have ignored policies and laws put in place to encourage access to life-saving health and harm reduction resources for people who use drugs. For example, NCHRC gives an identification card to everyone who accesses their services to ensure that they are not harassed or arrested for possession of syringes and other injecting supplies that reduce their risk of infectious disease; one NCHRC participant shared that police are known to rip up syringe-service program identification cards during their stops.^[]According to the North Carolina Department of Health and Human Safety, “The law legalizing syringe exchanges includes limited immunity for possession of syringes and injection supplies…. Exchange staff, volunteers and participants must have documentation of participation (in the form of a participant card or other written documentation) in order to claim limited immunity.” NCDHHS, “Syringe Exchange FAQs,” https://perma.cc/NKN2-GJMV. Through their outreach with people in the county jail, NCHRC staff have also learned of people being arrested after calling 911 in response to an overdose, or having naloxone confiscated after a search.

Previous research from nearby Western Carolina University on incarceration at the Haywood County Jail identified concerning rates of repeat arrests and jail stays, particularly among people struggling with substance use disorders.^[]A 2016 study found that close to eight out of every 10 people in the Haywood County Jail either met DSM-5 criteria for at least one severe substance use disorder, reported substance use in the past week, and/or reported recent injection drug use. Overall, 43 percent of people in the jail had been booked in at least twice in the past year, and those who reported recent substance use and/or met the diagnostic criteria for a severe substance use disorder were overrepresented in this group. Albert M. Kopak, Alyssa L. Raggio, and Norman G. Hoffmann, “Substance Use Risk Indicators and Offending Patterns Among Local Jail Inmates,” Journal of Correctional Health Care 25, no. 2 (2019). https://pubmed.ncbi.nlm.nih.go... NCHRC staff who facilitate overdose prevention education and outreach in the jail also confirmed that they often see the same people cycling in and out of the jail. Since assuming the role in 2013, the current sheriff, Sheriff Greg Christopher, has supported investments in transitional housing for people when they are released and efforts to improve access to substance use disorder treatment.^[]Haywood Pathways Center, “Flip This Prison,” January 2, 2015, https://perma.cc/7BWP-PRH5; Cory Vaillancourt, “Haywood Sheriff All about Customer Service,” Smoky Mountain News, February 28, 2018, https://perma.cc/RC9U-DNF7.

Interviewees also reported that the sheriff has facilitated access to the jail for NCHRC staff and other recovery-oriented peer support services. With a grant through a managed care organization, Haywood is currently in the early stages of developing and implementing a jail-based MAT program.^[] Haywood is one of only a handful of county jails in North Carolina that are operating or developing MAT programs; Taylor Knopf, “For Some Opioid Users in NC, Jail Doesn’t Mean Detox,” North Carolina Health News, February 25, 2020, https://perma.cc/C8GA-PJ9S. In November 2019, the sheriff was “in the process of reviewing best practices and talking with other detention centers that are already working a MAT program”; Jessi Stone, “Haywood Jail Reaches Capacity,” Smoky Mountain News, November 27, 2019, https://perma.cc/5338-UX2T. According to staff from the sheriff’s office, as of early 2020 (prior to the COVID-19 crisis), people who were already receiving MAT in the community had been able to continue receiving their medication when they were detained at the Haywood County jail.

There is a new initiative through the local health department to connect people to buprenorphine treatment when they are released from jail; it currently serves women only, though the jail plans to expand the program.^[]Becky Johnson, “A Fighting Chance: Program Offers Hope For Addicts Getting Out Of Jail,” The Mountaineer, January 10, 2020, https://perma.cc/6T98-9JA9. The sheriff is also working to secure funding to hire a licensed clinical social worker to support people in the jail with mental health needs, as well as co-occurring substance use disorders. Staff from the sheriff’s office said that they hope their efforts can contribute to addressing the overdose crisis in Haywood County as “not just a criminal justice issue, but a holistic issue for the entire community.”

Although these are promising initiatives, they do not yet come close to meeting the needs of everyone struggling with a substance use disorder who comes through the doors of the Haywood County Jail. The sheriff and his staff continue to partner with the researchers from Western Carolina University to share more recent data, which should inform future planning about the needs for substance use-related services and supports within and beyond the local jail. The experiences of one Haywood County resident who was arrested and detained at the county jail earlier this year exemplify concerns about relying on jails as a setting for intervention. The resident reported that they did not receive any withdrawal management supports and, during their short stay, did not have the chance to meet with anybody offering treatment or harm reduction services: “They put you in detox in jail and then just release you straight out, which seems odd to me.”

Conclusion

In recent years, harm reduction, public health, and criminal legal system stakeholders in Haywood have been building capacity to respond to rising overdose death rates and support people who use drugs with key interventions. Prominent among these are naloxone distribution, overdose prevention education, syringe services programs, MAT, and LEAD. Many of these are impressive and unique for a rural county with limited resources, although more work must be done to achieve buy-in and support from law enforcement and some government leaders.^[]In August 2020, the Haywood County Board of Commissioners renewed its partnership with NCHRC to link people with substance use disorders to care, in spite of opposition from two of the five members of the Board of Commissioners. Jessi Stone, “Resistance to Harm Reduction Grows in Haywood,” Smoky Mountain News, August 12, 2020, https://perma.cc/BBP8-X2HL; and Luke Weir, “Harm Reduction Grant Extended by Split Vote,” The Mountaineer, August 19, 2020, https://perma.cc/S8YY-4UZG.

Now, like many places across the country that have been impacted by the COVID-19 pandemic, Haywood has tough decisions ahead for how to invest in public health and public safety. During the pandemic, a considerable number of people were released to reduce the jail’s population and lower the risk of spreading the virus.^[]The Haywood County Jail has maintained a lower population since the COVID-19 pandemic; in August 2020 the jail population was 90 people, compared to 125 people around the same time the year before. Kyle Perrotti, “Detention Center Maintains Low Population amid Pandemic,” The Mountaineer, August 6, 2020, https://perma.cc/G437-LTMU. However, as the local jail has been close to or at capacity since 2013, the sheriff has continued to advocate for the county to expand the jail.^[]Jessi Stone, “Haywood Jail Reaches Capacity,” Smoky Mountain News, November 27, 2019, https://perma.cc/5338-UX2T; Rex Hodge, “High Occupancy at Haywood County Jail Drives Plans for Expansion,” WLOS, November 6, 2020, https://wlos.com/news/local/haywood-county-prepares-to-expand-jail; and Cory Vaillancourt, “Haywood County Sheriff Proposes $16 Million Jail Expansion,” Smoky Mountain News, November 3, 2020, https://perma.cc/7CZN-Z993.

When asked to comment on Haywood’s jail incarceration trends over the last 15 years, one interviewee summed it up as emblematic of a “judicial system that’s draconian and refuses to grow or to learn from the rest of the fucking world.” Haywood County leaders and community members who are committed to addressing rising overdose death rates and jail incarceration rates face the challenge shared by many rural jurisdictions across the country: how to better support people through community-based services rather than continuing to churn people through the cycle of arrest and incarceration.

Durham County

As part of North Carolina’s nine-county Research Triangle region, Durham County (population 321,488) is the sixth most populous county in the state and its county seat, the city of Durham, is the fourth most populous city in North Carolina. Durham County’s population is 43 percent non-Hispanic or non-Latinx white, 36.9 percent Black, and 13.7 percent Hispanic or Latinx.^[]United States Census Bureau, “QuickFacts, Durham County, North Carolina,” https://perma.cc/25RV-G3WX.

According to local residents and service providers, Durham County has been a “heroin town” since the 1970s. They say there are different generations of people who use drugs in Durham, from people in their 50s or 60s who have used heroin or crack cocaine for decades, to people who started using prescription opioids and then transitioned to using heroin and fentanyl in more recent years. Although Durham County’s overdose death rate has remained slightly lower than North Carolina’s and the country’s averages, there have been steady increases since 2003, reaching a peak of 15.6 per 100,000 residents in 2018. Like many other places across the East Coast, Durham County has experienced spikes in fatal overdoses since 2015 due to increases in the adulteration of heroin and cocaine with fentanyl.^[]NCDHHS, “IVP Branch: Poisoning Data,” database (Raleigh, NC: NCDHHS), https://www.injuryfreenc.ncdhh...; Thomasi McDonald, " A New Synthetic Opioid Contributes to Spike in Triangle Drug Overdoses,” News & Observer, March 24, 2017, https://www.newsobserver.com/news/local/crime/article140590408.html; and Bryce Pardo, Jirka Taylor, Jonathan P. Caulkins et al., The Future of Fentanyl and Other Synthetic Opioids (Santa Monica, CA: RAND Corporation, 2019), https://www.rand.org/pubs/research_reports/RR3117.html.

Durham County is one of the few small/mid-sized counties to have decreased its jail incarceration rates in recent years—from a peak of 341 per 100,000 residents in 2008 to 226 per 100,000 residents in 2018. And, importantly, even though racial disparities persist, jail incarceration rates in Durham have decreased considerably for Black and Latinx residents during this same time frame. To better understand how stakeholders at the county level are interpreting and addressing these trends, Vera researchers spoke with members of the Durham County Sheriff’s Office, staff with the NCHRC, and the founder of the North Carolina Formerly Incarcerated Transition program.

Public health and community responses

Grassroots efforts to decrease overdose death rates have sometimes outpaced government action in Durham and have motivated public-health responses into action. For example, unsanctioned syringe-service programs were operating in Durham for years before they were legalized in North Carolina in 2016. Durham is also notable for its unique access to capital and other resources due to its proximity to many of North Carolina’s top universities. This was a factor in the inception of one of the county and state’s unique reentry programs, the North Carolina Formerly Incarcerated Transition (FIT) program, according to the program’s founder, Dr. Evan Ashkin of the University of North Carolina at Chapel Hill.

Launched in 2017, the FIT program operates in Durham and several other areas across North Carolina. The program helps people living with chronic diseases—including substance use disorder—who are released from prisons and jails by connecting them with health care services and supports in the community. Reflecting on the need for the FIT program, Dr. Ashkin explained that, in his community practice, he regularly saw patients who had been diagnosed with a chronic disease while incarcerated and were released with no transition plan and no sense of how to continue care for their condition. Due to the elevated risk of overdose death among people who are formerly incarcerated, there was an imperative for FIT to focus on substance use disorder.

Dr. Ashkin explained that the FIT program was modeled after the Transitions Clinic Network model, and relied heavily on support from community-based organizations and coalitions in Durham to get off the ground. A critical component of the FIT program is that it employs community health workers—who themselves have histories of incarceration and can offer peer navigation and support—to establish and maintain connections to care for people when they are released from prison or jail. Although these supports and connections are critical, Dr. Ashkin also noted that FIT patients often face barriers with basic needs—including access to transportation and stable housing—which impede their ability to manage their health and transition back to the community.

Another key resource recently made available in Durham is a low-cost buprenorphine medication-assisted treatment (MAT) program, which has been operating out of a local federally qualified health center (FQHC) for about two years. Prior to this program, Durham advocates said it was almost impossible for low-income people to access buprenorphine. One advocate also explained that the fact that buprenorphine is available at the FQHC, integrated with other health resources, is helping to destigmatize MAT as a treatment option for people with a substance use disorder: “There’s a long way to go, but there has definitely been increased understanding of, and acceptance of, and investment in MAT.”

Criminal legal system responses

Durham has experienced downward shifts in its jail incarceration rates since 2008. There has been renewed energy among local stakeholders with the 2018 elections of a progressive, reform-minded sheriff and a new district attorney, both of whom have established new policies to reduce pretrial incarceration.^[]Dana Terry and Frank Stasio, “Durham’s First Black Sheriff Fights For Retraining And Rebuilding,” WUNC, June 4, 2019, https://www.wunc.org/post/durh...; and Daniel Nichanian, “The Prosecutorial Chronicles, May 2019: Durham DA Rolls Out New Policies To Reduce Pretrial Detention,” The Appeal, May 31, 2019, https://perma.cc/9YAE-EN6T.

Public health and criminal legal system stakeholders have also been building cross-disciplinary and interagency partnerships to advance overdose prevention and substance use disorder treatment for people involved with the criminal legal system. They have driven key initiatives like the county’s new jail-based MAT program, one of the few programs in North Carolina.^[]“Durham County Department of Public Health Receives State Funding to Combat Opioid Crisis,” press release (Durham, NC: Durham County Department of Public Health, December 13, 2019), https://perma.cc/7WAH-8MFK; and Knopf, “For Some Opioid Users in NC, Jail Doesn’t Mean Detox,” North Carolina Health News, February 25, 2020, https://perma.cc/C8GA-PJ9S.

Durham’s jail-based MAT program is being implemented in two phases, which started in March 2019. The first phase focuses on continuing methadone, buprenorphine, or naltrexone treatment for incarcerated people who had already started treatment in the community. In the second phase, originally planned for March 2020 (though delayed due to COVID-19), people who are screened for an opioid use disorder will be able to start treatment in jail with either buprenorphine or naltrexone.^[]NCDHHS, Using Medication-Assisted Treatment in Jails: A North Carolina Focus (Raleigh, NC: NCDHHS, 2019), https://perma.cc/7JGE-SCU9. In developing and implementing this program, Durham County’s sheriff explained one of the key lessons they have learned—the importance of having community-based resources with which to connect people when they leave jail:

"We want to make sure these individuals, when they leave our facility, have every opportunity to continue the success that they’ve had while they were incarcerated. And the only way to do that is through the peer support and appropriate case management [to] make sure they have the resources that they need."

Plans are in place to recruit peers and substance use counselors to support the MAT program. And staff from the North Carolina Harm Reduction Coalition (NCHRC) already conduct outreach and overdose prevention education three to four times a week in the jail. NCHRC staff provide naloxone kits to people upon release and aim to connect people with services and information in the community. One staff member explained the value of building relationships inside and outside of the jail:

"Almost every time I come into the pod I see somebody I knew from the outside, and a lot of times, I meet people in the pods and then they would come up to me on the streets, like 'Hey! I met you in the county!'”

In the background of these ongoing efforts is the constant tension that many of these initiatives are grant-funded and may not be available in the next few years. More sustainable funding from county and state sources is needed to maintain them, as well as to push for more progressive and transformative approaches.

And despite important reforms and positive trends in recent years, racial disparities remain in Durham County’s criminal legal system. In 2018, Black residents and Latinx residents, respectively, were still 6.1 times more likely and 2.58 times more likely to be incarcerated in Durham County’s jail than white residents.^[]See Vera Institute of Justice, “Incarceration Trends, Durham County, North Carolina," http://trends.vera.org/rates/d.... Local advocates also report that people are still being arrested for minor drug possession and sex work, suggesting that, despite the progressive wave of leadership, the “machinery" of policing and prosecution may be slow to change.

Conclusion

Many local stakeholders in Durham County acknowledge that they are uniquely positioned to implement meaningful public health and criminal legal system responses to prevent overdose deaths and reduce jail incarceration. They credit this in part to their access to resources and networks, their proximity to North Carolina’s key research universities, and the recent wave of progressive criminal legal system leaders being elected into office. As with initiatives like the county’s jail-based MAT program, there are valuable opportunities for Durham to pilot new approaches that other jurisdictions across North Carolina, and the country, may be able to learn from and adapt to their local settings.

Key gaps and challenges still exist for Durham, as racial disparities persist in jail incarceration rates and other areas of the criminal legal system. The election of two new progressive leaders in Durham does not guarantee a reversal of the criminalization of people of color, poor people, and people who use drugs. Deliberate and focused action is needed.

It is too early to detect whether recent initiatives can reduce the rising rate of fatal overdoses or nudge longer-term incarceration trends further downward. However, stakeholders in Durham appear committed to building on their efforts, evaluating their impacts, and continuing to drive change.