Grace Vitalione
Near the end of the recently recessed legislative session, the North Carolina House of Representatives introduced a wide-ranging budget proposal on how to spend some of the funds North Carolina received as part of a national settlement over the marketing of opioid drugs.
North Carolina will receive $750 million over 18 years as part of a settlement with pharmaceutical companies accused of fueling the opioid epidemic. As part of the settlement, state lawmakers will receive 15 percent, while counties will receive the bulk of the funds.
While counties are limited in spending options that force evidence-based interventions, lawmakers are less constrained in how they spend the settlement money they administer.
The House's budget proposal for the fiscal year that began July 1 would provide more than $23 million to 25 counties and $5.4 million to 10 recovery centers, but it offered few details about how the money would be used beyond boilerplate language that “funds will be provided from the Multi-State Opioid Settlement and will be used to address the adverse impacts of the opioid epidemic.”
But not all spending is equal, and some opioid use disorder experts have expressed concern that funding is not primarily directed to facilities that provide evidence-based treatment, such as medication-assisted treatment for opioid use disorder, which has become the “gold standard” of treatment. For example, three facilities on the list do not allow patients to receive medication-assisted treatment for opioid use disorder during their stay at the facility. Some of the facilities in the House proposal are not even certified.
Debates over how these funds can and should be spent have been ongoing since the money began flowing in 2022.
Although larger spending talks have collapsed, the debate over opioid funding in the General Assembly does not appear to be over.
Budget details
Rep. Wayne Sasser (R-Albemarle) said he wants to ensure every county in the state receives at least $1 million to address the opioid crisis. When the House budget failed, 25 counties, mostly those represented by Republicans, were included in the budget.
Sasser said some of the individual recovery centers on the list have asked to be added to the list as well.
Sasser said he also worked with Robin Hayes, founder of Bridge to 100. Hayes previously served as chair of the state Republican Party and pleaded guilty in 2019 to lying to the FBI as part of a bribery scandal. He was pardoned by Donald Trump in January 2021.
Hayes is now running a new nonprofit corporation that aims to secure opioid settlement funding for “faith-based rehabilitation centers” in all 100 counties. Eight of the 10 centers included in the budget are listed as outreach providers on the Bridge to 100 website.
Hayes said he's not opposed to medications to treat opioid use disorder, but he does value belief in recovery. He said there are many options to address the opioid crisis, and centers like this one should be one of them.
Licensed facilities must comply with state requirements. Under current state law, charitable, nonprofit and faith-based adult residential treatment facilities do not have to be licensed unless they receive federal or state funding. But a provision in the House budget bill seeks to allow non-licensed facilities to receive opioid settlement funds.
An NCDHHS spokesperson wrote in an email that the language was added “to provide clarity and ensure that individuals or entities currently exempt from licensing requirements will not lose that status solely because they received opioid settlement payments.” DHHS did not decide on the language, but the spokesperson said the department noted the need for clarification.
Jennifer Carroll, a medical anthropologist at North Carolina State University who specializes in drug use and overdose prevention, said the move is concerning because it could reduce accountability for centers that receive opioid settlement money.
Drugs effective in preventing overdose deaths
Studies have shown that medications for opioid use disorder significantly reduce the risk of overdose death, especially early in treatment.
There are three FDA-approved medications to treat this disorder: methadone, buprenorphine, and naltrexone. Methadone and buprenorphine stimulate the same parts of the brain as commonly abused drugs, helping users reduce cravings without producing the same “high.” Methadone and buprenorphine have been extensively studied, have excellent survival profiles, and ample data supporting their effectiveness.
Naltrexone blocks the body's ability to get high from opioids, but it doesn't stop cravings, and it doesn't seem to do much to prevent overdose deaths, said Eric Morse, an addiction psychiatrist in Raleigh and CEO of the Morse Clinic, which provides medication for opioid use disorder.
With limited funding available from the national settlement, evidence-based treatments such as drug therapy should be prioritised, he argued.
“There's a certain amount of opioid settlement money. We should be using it for life-saving treatments,” he said.
Meanwhile, people who attend abstinence-based inpatient programs are more likely to relapse after they finish, said Blake Fagan, a family physician who oversees the clinic treatment program for substance use disorders at the Mountain Area Health Education Center in Asheville. They're also more likely to have a lowered tolerance by that point, putting them at higher risk of overdose and death, he said.
Carroll studies the lived experiences of drug use and the impact of drug policies on the health and wellness of people who use drugs. In an unpublished study, his team called substance use treatment facilities across the state in spring 2023 to find out whether they allowed patients to use opioid agonist treatments such as buprenorphine in their facilities. Of 68 facilities, only 20 said they did.
Carroll said the most common type of facility the team found was unlicensed, faith-based, abstinence-only facilities that prohibited drug use and required unpaid work for businesses owned or affiliated with the facility.
“A number of licensed facilities have explicitly misrepresented things about these drugs to callers in an attempt to discourage them from seeking these drugs there or elsewhere,” she said. “I find that particularly troubling.”
Some legal experts have said mandating unpaid work is legally questionable, as a U.S. Supreme Court decision suggests nonprofits that operate without paying employees could be in violation of the Fair Labor Standards Act, NC Health News previously reported.
Three facilities listed in the House budget bill prohibit clients from using drugs on-site, including Gateway of Hope Addiction Recovery Center, Adult and Teen Challenge of the Sandhills and Charlotte Rescue Mission.
Bethel Colony of Mercy was also listed in the budget. The center allows patients already taking naltrexone to continue using it, according to executive director Rev. Paul Pruitt, but not the other two drugs because they are “overused by addicts,” he said in an email.
Freedom House in Greensboro does not allow patients to take buprenorphine, according to Carroll's team, and the center did not respond to a request for comment.
Some medical and legal experts say denying recovery services such as housing to people who are taking medication for opioid use disorder violates the Americans with Disabilities Act.
Drug costs
Hayes noted that medications can be expensive, and Bridge to 100's goal is to support low- or no-cost centers, he said.
Place of Grace in Rockingham is one of the centers that provides housing and services free of charge, according to the Rev. Gary Richardson.
CEO Josh Trubich said Christian Recovery Center is free until the final stage of the program, at which point it charges $170 a week.
Carroll countered, saying the cost of drugs is a symptom of larger problems in the health care system.
“Just because insulin is too expensive doesn't mean we should stop treating our diabetes,” she says.
Morse, the Morse Clinic CEO, noted that if a patient doesn't have insurance, it costs $80 a week to get the medication at the clinic, which is consistent with reports from other clinics: At Mountain Area Health Education Center, for example, a month's supply of medication can cost anywhere from $55 to $120 if you don't have insurance, Fagan said.
Combined approaches
Most of the recovery centers listed in the House budget bill don't offer medications to treat opioid use disorder, but three allow patients to take opioids while receiving services, including Place of Grace, Will's Place and Bethel Colony of Mercy, which allows naltrexone.
Christian Recovery Center provides the medication through a partnership with Southeastern Integrated Care, said Trbic, who said clients can take the medication for the first four to six weeks and then gradually taper off as they move through recovery.
Torbic said the rate of people dropping out of the first period, called the “motivational track,” has fallen by about 23 percent over the past three months since the program combined clinical services with medication.
“We are one of the few facilities that I know of that offers clinical treatment services, 12-step programs, etc. [Alcoholics Anonymous]”We're still a faith-based model,” he said.
As for why he encourages clients to taper off their medication, he said the program aims to help people who want independence from medication, such as working to appointments.
Morse said even centers that say they allow drug treatment may make it difficult to access it, such as by not providing transportation.
Hayes said he hopes new research from the Institute for Social Innovation and Entrepreneurship at the University of North Carolina at Chapel Hill's School of Social Work will document the success of faith-based recovery centers.
Director Gary Nelson said the research team will begin designing the evaluation in June to implement it in three pilot programs: Ground 40, Hope Center Ministries and Christian Recovery Center. The team will bring together stakeholders to help come up with some outcomes to define success, Nelson said.
“Lasting” recovery usually involves multiple factors, he said, including faith, which he said can give a person a sense of direction or the belief that someone has their back.
Which centres/counties need funding?
Montgomery County had budgeted to receive $1.5 million from lawmakers to combat the opioid crisis.
Montgomery County Commission Chairman John Shaw said drug overdose deaths are a significant problem in the county.
“I'm tired of going to funerals,” he told NC Health News.
Montgomery County received a grant to purchase naloxone, also known by the brand name Narcan, and hire peer support specialists to help people recovering from mental illness or substance use disorder and those struggling with similar issues, he said.
Shaw said the additional funding from the Legislature will help the county launch a Law Enforcement Assisted Diversion Program, which will allow law enforcement officers to direct low-level drug-involved offenders to community-based services.
Hyde County was allocated $1 million in funding, and the county has three peer support specialists and also operates a syringe exchange program and a naloxone program, said Luana Gibbs, health director for the county health department.
Gibbs said more funding would allow Hyde to strengthen those programs.
Gibbs said her son, Ryan, died of a drug overdose in 2017 at age 23. Ryan and his girlfriend thought they were buying cocaine, but it was heroin laced with fentanyl, Gibbs said.
Gibbs said that was what inspired him to tackle Hyde's opioid crisis, and that educating young people about drugs is important.
“People like my son, Ryan, need to know and understand,” she said. “You can't just say, 'Just say no,' that doesn't work.”
You may republish our articles free of charge online or in print under a Creative Commons license.
