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How did North Carolina legislators increase access to evidence-based treatment?

August 17, 2022

Roxanne Saucier is a consultant with Open Society Foundations. She works to advance harm reduction and drug policies grounded in human rights and public health, and has been an advocate for good drug policy in North Carolina since 2010. We talked to her to understand what happened in North Carolina this past legislative session. 

One of the Principles calls for states to invest in evidence-based programming. What was the challenge with how North Carolina had traditionally been investing in treatment?

North Carolina legislators are keenly aware of the rising number of overdose deaths in North Carolina and, during the 2021 budget cycle, we saw a lot of earmarks for treatment programs in legislators’ own districts. The problem is that oftentimes the programs funded weren’t best practice. In fact, by the calculation of advocates here in North Carolina, some $35 million went to abstinence-only programs. In terms of scale, this is even more than the entire historic $30 million federal allocation for harm reduction funding. If you look at the websites of the programs that were funded, you will see that many of them rely on prayer and do not provide medications or facilitate their provision. Some even have language disparaging medications for opioid use disorder (MOUD). This is dangerous because it spreads misinformation about what works for treatment, and because programs based on unproven methods may actually increase risk of overdose by lowering tolerance.

Tell us about the change the legislature made this legislative session. What happened and how did this change come about?

The 2022 state budget was much more promising in terms of opioid-related spending. This time we did not see earmarks from individual legislators, but we did see the tranche of opioid settlement funds coming into the state being allocated. The things prioritized included money for low-cost (meaning generic injectable) naloxone, money for all three FDA-approved forms of medications in jails and prisons, and funds for drug checking, which is so important with our contaminated drug supply. And importantly, there is money for treatment, but this time the budget language stipulates that it is for programs that offer medications or facilitate provision of it. This change came about because, following the 2021 budget, advocates made a point of meeting with health committee leadership in the legislature to flag concerns and emphasize the importance of medications. Advocates also approached the media, who covered the misspending. Legislators clearly got the message.

What advice would you have for people in other states who want to push for investments in evidence-based programming?

My advice is to develop relationships with decision makers. Legislators love to hear from programs doing good work in their district. In North Carolina, when advocates arranged meetings, they included a combination of researchers from local universities and people running programs. Legislators were generally very receptive and eager to hear from experts about what is most effective. The same thing goes at the county level if that is where decisions about funding are happening. Reach out to county commissioners and invite them to tour your program. One bright spot of the 2021 earmarks was that a harm reduction program received $500,000 because their state representative went to bat for them after touring their program. If you don’t ask, the answer is always no.

Are there other areas where you see an opportunity for North Carolina to invest in evidence-based programs with the opioid litigation dollars?

North Carolina is lucky to have more than 40 syringe service programs throughout the state, which is a lot compared to surrounding states, but this still means that more than 50% of our counties do not have a program. Programs that do exist are grossly underfunded and under-resourced. Through an education series that our department of health, department of justice and counties association organized, I think county officials are beginning to understand the benefits of these programs, which are the first line of defense against overdose and infectious diseases. Policy makers should fully fund them so they can staff up. So many of these programs also lack basic supplies; people running the programs are often still purchasing syringes with their own personal funds, which is unconscionable at a time when money to address opioids is coming into the state at levels never before seen. It would be helpful if decision makers would put money toward a standing fund for supplies.

Naloxone is another area that needs greater funding – new modeling in the Lancet shows that no state outside of Arizona is currently meeting the need for naloxone. States could maximize spending by collaborating with an entity like the nonprofit Remedy Alliance to get low-cost product.

Housing is also a constant challenge. While policy makers often like recovery housing, we need “housing first” programs for people currently using drugs. It’s hard to sustain positive change in your life when you don’t have a roof over your head.