A grandmother frantically banged on Joni’s apartment door in Robeson County earlier this year with a desperate plea: “Are you the girl with the Narcan?”
Without hesitation, Joni grabbed two boxes of the medication from her kitchen and ran outside, where the woman’s granddaughter was sitting in a car and barely breathing after overdosing on drugs. Joni sprayed Narcan into the young woman’s nasal passages and watched her wake up.
“The grandmother was crying,” recalled Joni, who asked to be identified by her first name only to protect her privacy. “She was very thankful.”
Joni, who is recovering from an addiction to opioids, was accustomed to administering Narcan, the brand name of naloxone that can quickly reverse opioid overdose effects. When she worked at a local hotel plagued by drugs, she said, she used the medicine on several people who became unconscious after taking too much of the powerful sedative fentanyl.
Later, Joni hung a note at her apartment complex’s mailboxes, encouraging neighbors and passersby who need naloxone to knock on her door. That’s likely how the woman whose granddaughter was in trouble found her. Joni says she gets naloxone from the clinic where she receives medication for her addiction and also from a local harm-reduction worker who distributes the medication, along with clean syringes and fentanyl test strips, to help people use drugs more safely until they are ready to quit. She likes to stockpile it in case someone needs help.
Rural North Carolina has been devastated by opioid addiction since the rise of prescription painkillers in the 1990s. While urban areas have not been immune, the overdose rate in rural areas has been significantly higher, adding to the woes of communities already reeling from high unemployment and an exodus of young people for more prosperous cities.
But the number of people who died of drug overdoses in North Carolina fell by 35 percent between April 2024 and April 2025, according to the Centers for Disease Control and Prevention. The state saw among the biggest drops in the nation, which experienced an overall decline of 24.5 percent during that time.
Experts say other factors are contributing to the drop, including increased access to treatment for substance use disorders—and people like Joni, current or former drug users, or anyone willing to carry naloxone, who step in to protect family members, friends, even strangers.
But researchers and public health officials say federal funding cuts and statewide slashes to Medicaid could undo North Carolina’s progress in saving lives and combating the opioid epidemic, particularly in rural areas that depend heavily on the government-run health care program.
“We have made commendable but modest advances in making interventions available in our communities,” said Jennifer Carroll, a medical anthropologist and associate professor at N.C. State University. “And rolling it back is just the stupidest thing.”
Carroll was among at least five researchers at N.C. State University, the University of North Carolina-Chapel Hill, and Duke University who signed a letter to congressional leaders in May warning about cuts to federal programs that work to reduce overdoses.
President Donald Trump wants to slash the budget of the Centers for Disease Control and Prevention by 53 percent, which could mean less money for North Carolina to treat substance use disorders. The agency awarded more than $7 million in grants throughout the state for overdose prevention efforts in 2023.
Trump also wants to bring the Health Resources and Services Administration and Substance Abuse and Mental Health Services Administration under a new Administration for a Healthy America. It’s unclear what the consolidation could mean for North Carolina, but both agencies award millions of dollars a year to the state. HRSA announced last year a four-year, $9 million grant for new opioid treatment and recovery services in three rural communities.
Meanwhile, North Carolina cut reimbursement rates to Medicaid providers between 3 percent and 10 percent starting October 1. And more than 650,000 people enrolled in the state’s expansion program—including many struggling with substance misuse—are at risk of losing health care coverage.
“It’s almost like this is really cruel to be happening now, to be honest with you,” said Kelly Crosbie, director of the state’s division of mental health, developmental disabilities, and substance use services. “For the first time in forever, this past 18 months, we’ve been like, ‘Whoa, this is amazing. People can get treatment. We’re seeing good things happen. Our money is not so scarce anymore.’
“Unfortunately,” Crosbie continued, “I feel like we’re going to go back to a place where we’re going to be trying to figure out how we can piece together enough money so people without insurance can go to [opioid treatment programs.]”
A Collective Approach
Joni, 51, started doing drugs in her early teens. She said she was sexually abused from a young age, had a strained relationship with her mother, and ended up in foster care. Looking back, she said, she experienced symptoms of anxiety that had burdened generations of her family. She self-medicated by smoking weed with her friends.
“I just finally realized, well, hell, when I get high, I don’t feel so freaking crazy,” she said. “I feel like a normal person.”
Joni soon started snorting and smoking cocaine. She moved to Florida in 2000 and got hooked on OxyContin. Like many people who became dependent on prescription painkillers that were widely available until they weren’t, she turned to heroin and then fentanyl.
After returning to Robeson County in 2017, Joni experienced her own overdose scare in the restroom of a laundromat, where she injected fentanyl. The next thing she knew, her boyfriend at the time was standing over her, urging her to wake up, while people who had gathered around were taking videos with their cell phones.
Robeson County in southeastern North Carolina has struggled for years with drug misuse, a social ill exacerbated by poverty. About 28 percent of Robeson County’s 116,000 residents live below the federal poverty line. The county is one of the most diverse in the nation and serves as the headquarters for the Lumbee Tribe of North Carolina, the largest Native American group on the East Coast.
In 2023, Robeson had an overdose death rate that was nearly two and a half times the statewide rate. But the county saw a 55 percent drop in fatal overdoses last year, bigger than the 32 percent decline statewide, according to the state Department of Health and Human Services.
Robeson County still has one of the highest rates of fatal overdoses in the state. But health advocates and local officials have been “throwing the kitchen sink” at the drug problem, said Bart Grimes, chief of behavioral health services at Robeson Health Care Corporation, a nonprofit that provides medical, dental, and behavioral health services. Using money awarded from national lawsuits against drugmakers, county commissioners have allocated funds for medication-assisted treatment at the local jail and for the local bus system to take people with opioid use disorders to treatment or work.
Grimes said Robeson Health Care Corporation has received hundreds of thousands of dollars in grants since 2019 from the Health Resources and Services Administration to form a consortium of health care, law enforcement, education, and outreach organizations. Much of the group’s work is focused on reducing the stigma surrounding drug misuse in Robeson County, where many people hold deeply conservative social views.
“There was resistance for us putting up our first Narcan vending machine, because people thought it was addictive drugs,” Grimes said. “So they didn’t want it in their community, until lives started to get saved and more education was shared about it.”
Grimes said the consortium now has half a dozen machines across the county that dispense Narcan at no cost. It also hosts training sessions for stakeholders and community members about the effectiveness of medications like methadone and buprenorphine in treating opioid addiction.
Now, Robeson Health Care Corporation is feeling the effects of the recent cut to the Medicaid reimbursement rate. The organization runs a nine-bed facility where men struggling with drug misuse can receive treatment for up to 90 days. Before the General Assembly expanded Medicaid in 2023, about 10 percent of patients at the treatment center were enrolled in a federal health care program, Grimes said. About 85 percent of patients are covered now.
The influx of Medicaid payments has allowed RHCC to offset losses and make improvements to its facilities, Grimes said. “It made a huge difference in our ability to collect reimbursement.”
No Fall Back
Health advocates worry that Medicaid reimbursement rate cuts will lead primary care providers to accept fewer patients enrolled in the program and prioritize those with private insurance. The cuts are particularly devastating to addiction-care providers who rely on Medicaid for up to 90 percent of their revenue, Crosbie said.
“They don’t have a payer mix to fall back on,” Crosbie said. “And so we are pretty concerned.”
The cuts came after the General Assembly passed a “mini budget” in July that fell $319 million short of the state health department’s request to fund Medicaid payments. Lawmakers say they are willing to spend more, but they haven’t passed an official budget because the state House and Senate can’t agree on a plan to fund a children’s hospital in Wake County.
Gov. Josh Stein, a Democrat, told lawmakers to return to Raleigh on November 17 to approve more Medicaid spending, but Republicans refused to show up.
Along with the Medicaid rate cuts, state lawmakers slashed millions of dollars for mental health and substance use services in the mini-budget, Crosbie said, including more than $18 million for uninsured patients seeking care and $10 million for programs aimed at keeping people out of jail. They reduced funding for behavioral health crisis services by $15.6 million.
Nonpartisan analysts have predicted that North Carolina will face a roughly $2 billion annual shortfall starting in the 2027-2028 fiscal year, partly a result of planned tax cuts.
State Senate leader Phil Berger did not respond to a request for comment.
Now the future of Medicaid expansion, which Crosbie said has allowed 20,000 additional North Carolinians to get treatment for substance use disorders, is murky.
State Republican lawmakers long resisted the program after the Affordable Care Act was signed into law by President Barack Obama in 2012. When North Carolina became the 40th state to approve the measure more than a decade later, the General Assembly put in place a “trigger law” that eliminates Medicaid expansion if the federal government fails to pay 90 percent of the costs.
Changes to Medicaid under the One Big Beautiful Bill Act that President Trump signed into law in July threaten the program, largely because they established a work requirement for enrollees. Without additional federal funding to track employment status, North Carolina will be on the hook for implementing a costly system.
Ted Budd, a Republican U.S. Senator from North Carolina, said at the time that he voted for the bill because his constituents “deserve more of their hard-earned wages, a more secure border, a reinvigorated military, responsible spending reforms for government programs, and a thriving economy.”
North Carolina’s other U.S. senator, Republican Thom Tillis, voted against the bill, saying it would cost the state billions of dollars and gut Medicaid. He is not running for re-election next year.
“It’s really scary, because we know harm reduction works. We see it in the data. We know this is what is driving the decline in people dying.”
Elyse Powell, executive director of the North Carolina Harm Reduction Coalition
While work requirements would pose a new challenge to the state, they would also put patients at risk of losing treatment, Crosbie said. Some people struggling with substance use disorders would likely qualify for an exemption, but they could easily become frustrated by the bureaucracy.
“It becomes burdensome, and it is the exact opposite of what we always try to do in substance use care: low barrier,” Crosbie said. “Work requirements and paperwork, they just create really unnecessary hurdles for folks who desperately need treatment.”
Like other health officials across the state, Grimes hopes the General Assembly will preserve Medicaid expansion.
“It is expensive,” he said, “but I think over the years it’s more expensive to have an unhealthier community, an unhealthier state.”
Keeping People Alive
More than 45,000 people in North Carolina have died of drug overdoses in the past 25 years.
Drug manufacturers began to push opioid painkillers like OxyContin in the 1990s, leading doctors across the nation to prescribe more and more of the drugs. In 2015, half of the roughly 1,500 fatal drug overdoses in North Carolina were linked to prescription opioids.
In an effort to reduce the supply of the drugs and crack down on so-called pill mills, state lawmakers passed the North Carolina Strengthen Opioid Misuse Prevention (STOP) Act in 2017. Under the legislation signed into law by then-Gov. Roy Cooper, doctors cannot prescribe opioid medications for more than five days for acute pain and seven days for post-surgery recovery. The law also mandates that doctors send opioid prescriptions electronically to pharmacies.
By the time the law went into effect, many people who were hooked on painkillers years earlier had already turned to heroin. When fentanyl, a cheaper and more powerful synthetic opioid, became widely available, overdose deaths skyrocketed and peaked during the COVID-19 pandemic. In the 12 months ending in July 2023, a record high of nearly 4,300 overdose deaths were reported in North Carolina.
As attorney general, Stein joined other states in suing pharmaceutical companies for their role in the opioid crisis. In 2022, North Carolina started receiving $1.4 billion in settlement funds from multiple lawsuits. Most of the money, which will be disbursed in chunks through 2038, goes to counties and cities where local elected leaders decide how to spend it within parameters set by the state.
Researchers say the settlement money won’t make up for lost federal funding but can build on successes communities are already seeing. Many local governments have spent their money on evidence-based treatment like medications for opioid use disorder, recovery support services, housing support, and harm reduction, which is an effort to lessen the negative social, health, and legal impacts of drug abuse.
Some cities across the United States, including San Francisco and Philadelphia, have shifted away from harm-reduction measures aimed at distributing naloxone, clean syringes, and fentanyl strips to drug users. Trump criticized harm reduction in a July executive order on “ending crime and disorder on America’s streets,” saying he did not want the Substance Abuse and Mental Health Services Administration to award grants for “efforts that only facilitate illegal drug use.”
“For the first time in forever, this past 18 months, we’ve been like, ‘Whoa, this is amazing. People can get treatment. We’re seeing good things happen.’”
Kelly Crosbie, DHHS
“It’s really scary, because we know harm reduction works,” said Elyse Powell, executive director of the North Carolina Harm Reduction Coalition. “We see it in the data. We know this is what is driving the decline in people dying.”
Powell said harm reduction is so powerful because it paves the way for outreach workers—some of whom have a history of drug misuse themselves—to talk to drug users about their health. Those interactions can ultimately lead to treatment.
“You’re helping people make that first appointment, that phone call, that enrollment in Medicaid, that housing support,” she said. “Harm reduction is a lot more than just the supplies we distribute. It’s about engaging people who have, for a very long time, been totally left out of the health care system.”
Some organizations across the state working hard to form these lifesaving relationships are now at risk of losing federal funding.
Carroll, the N.C. State researcher, said the cuts are nonsensical, especially as researchers understand better than ever how to keep people alive.
“The only way in which this kind of policy makes sense,” she said, “is if the people who are making the policies honestly believe in their heart of hearts that it’ll never happen to them.”
In Robeson County, Medicaid covers Joni’s health care expenses. She said she better understands now how trauma contributed to her drug use. After being homeless for three years, she has an apartment and a car, and she hopes to start working soon.
Joni could have been among the 285 people who died of drug overdoses in Robeson County between 2022 and 2024. She’s grateful she is alive.
“But that doesn’t mean a hill of beans,” she said, “when there are still so many people out here freakin’ suffering and being treated like shit.”