The Collective Approach: Facing the Substance Use Disorder Epidemic in North Carolina and the Region

Introduction

In 1854, John Snow, MD, published “certain conclusions” about cholera and the water supply of London’s south dis­tricts in the summer of 1849.¹ Dr. Snow was a pioneer in the field of epidemiology; 170 years later, the tools of epi­demiology have adapted to work in 2024. The evolution of society has necessitated the need for the evolution of public health practices. Today’s understanding of health outcomes is visible in the model of population health developed by the University of Wisconsin Population Health Institute and County Health Rankings and Roadmaps.² Health behav­iors make up 30% of the factors that drive outcomes; 40% come from social and economic factors, often known as social determinants of health (SDOH).² Many of the fac­tors in that 70% influence today’s substance use disorders. In the United States, the age-adjusted rate of drug over­dose deaths has increased precipitously over the last two decades. In 2022, the drug overdose death rate was 32.6 per 100,000.³ In that similar period, we lost more than 36,000 North Carolina citizens to overdose death.⁴

The COVID-19 pandemic made SDOH worse for those living in Appalachia. Whether from isolation, the novel dis­ease itself, or both, people suffering from substance use disorder were at higher risk during the pandemic for poorer health outcomes from COVID-19, making a terrible situa­tion worse.⁵ Further SDOH in the region included pov­erty, housing and food insecurity, increased lack of access to care, and increased complications from complex chronic conditions.⁶ In Burke County’s most recent community health assessment, substance use disorder (SUD) and men­tal health concerns were overwhelmingly the top priorities for this community, and the two are intricately related.⁷ Furthermore, North Carolina, much like the rest of the coun­try, has seen significant increase in rates of premature death from overdoses that began with prescription drug abuse and have now morphed into illicit use of drugs like fentanyl and methamphetamine.⁸ National, state, regional, and local data paint a less than pleasant picture of what SUD can do to a community. COVID-19 coupled with the introduction of more substances and increased availability of those sub­stances has increased the rate of SUD, and with it the rate of mortality.⁵

Over the last few years, cases in the court system have been aggregated into national settlements that have cre­ated a revenue source for communities across the country to combat substance use disorder. These settlements are in response to the role companies played in creating the crisis. Across the country, tens of billions of dollars are flowing to communities, including $1.5 billion to North Carolina.⁹ Burke County itself, where this author serves as the Public Health Director, will receive an excess of $24 million over the next two decades.¹⁰ The North Carolina Memorandum of Agreement that governs these settlements outlines how much each community will receive and how the funds may be used. Unlike most states, North Carolina’s agreement will distribute most (85%) of the money directly to the counties and municipalities affected. These local governments must spend the money in proven, effective ways to combat SUD and limit overdose deaths.⁹

Policy Efforts to Combat the Opioid Crisis

In this edition of the North Carolina Medical Journal, you will hear from a series of experts on SUD policy. Steve Mange, an attorney at the North Carolina Department of Justice, writes about North Carolina’s model for distributing opioid settlement funds.¹¹ Jill Rushing, Elizabeth Brewington, and Nidhi Sachdeva of the North Carolina Association of County Commissioners explain how local governments are being equipped to respond to the opioid crisis across our state.¹² Dr. Katie Varnadoe of Burke County Public Health gives the local public behavioral health perspective, highlighting efforts to address substance use trends as they emerge, with a well-developed collaborative of community partners.¹³ Kelly Crosbie of the North Carolina Department of Health and Human Services explains the department’s role in this work at the state and local level as well.¹⁴ The justice sys­tem is also an important part of the calculus for this complex problem. Recovery courts give people facing drug charges an opportunity to be sentenced to treatment. Chief Justice Paul Newby of the North Carolina Supreme Court gives his perspective on the role of recovery courts in our state.¹⁵

Dr. Rahul Gupta, Director of the White House Office of National Drug Control Policy (ONDCP), discusses federal SUD policy and his view of North Carolina’s role.¹⁶ The White House prevention priorities include expansion of access to evidence-based prevention, harm reduction, treat­ment, and recovery. Further, federal policy from ONDCP aims to disrupt the supply of illicit drugs and work with the United States Congress to develop a comprehensive pro­posal for severe penalties on suppliers of illicitly produced fentanyl analogues.¹⁷

Policy is most effective when backed by data. Jeremy Kourvelas of the University of Tennessee share lessons learned from using data to make substance use-related pol­icy decisions in their state.¹⁸ Alexis French and coauthors from Duke University, UNC, and the Women, Infant, and Community Wellness Section of the North Carolina Division of Public Health “run the numbers” on behavioral health trends among perinatal North Carolina Medicaid beneficia­ries, a particularly vulnerable community facing SUD.¹⁹

Lifting Up Lived Experience

No discussion on SUD is complete without the view from those persons with lived experience. As PA Amy Ford writes, stigma still presents a challenge, and “patients with substance use disorders present to every medical specialty, especially primary care, yet many primary care providers feel unprepared to handle these patients”.²⁰ In this edi­tion of the journal you will get the firsthand experience of Dr. Stephen Loyd, a physician, national thought leader, inspira­tion for the character Dr. Finnix (played by Michael Keaton in the Hulu television series Dopesick), and a person in active recovery.²¹ Dr. Joe Jordan, CEO of the North Carolina Professionals Health Program, gives a wider view of the chal­lenges and resources available to medical professionals who experience SUD.²²

Devin Lyall, a North Carolinian in active recovery, describes her path to founding Wilkes Recovery Revolution, Inc., a nonprofit that brings peer specialists to the sub­stance use recovery and mental health community in Wilkes County, with a harm reduction model.²³ Ashley Wurth, Mollie Bolick, and Tyler Yates of the North Carolina Division of Public Health’s Injury and Violence Prevention Branch give some additional context on harm reduction and its evolution.²⁴

Conclusion

It is unclear whether Dr. Snow would recognize modern public health, or the epidemiology of substance use disorder. However, a robust 21st-century public health system must be working in concert with policymakers, law enforcement, health care providers, and communities to give hope to those suffering from this plague. Whether or not Dr. Snow would recognize it, the reader of this edition of the NCMJ should get an excellent primer on SUD in the region and what state leaders are doing to solve this complex issue.

Disclosure of interests

The author disclosed no conflicts of interest.