By Sarah Nagem
This story is a collaboration between the Border Belt Independent and The Assembly.
Carisa Collins-Caddle pulled her Ford Edge into a Food Lion parking lot in Lumberton, a city in Robeson County, North Carolina, and looked down at her phone. A young woman struggling with drug use had reached out to her earlier about meeting to get clean syringes.
A few minutes later, the woman’s boyfriend approached and Collins-Caddle popped open the SUV’s hatch. Inside, organized and labeled like art supplies in a school classroom, were needles, alcohol swabs, at-home fentanyl test strips, and naloxone, which can reverse the effects of a drug overdose.
“Don’t share needles, don’t reuse,” Collins-Caddle reminded the soft-spoken man as she added condoms, sanitary pads, and tampons to a plastic bag for him and his girlfriend.
This is how most of Collins-Caddle’s Monday mornings begin. As the only outreach worker in Robeson County for the North Carolina Harm Reduction Coalition, she starts her work week driving about 100 miles along back roads to meet clients who misuse opioids and other drugs. Her goal, she says, is to teach people who are already addicted how to administer drugs safely until they are ready and able to get the help they need to stop using.
There are many challenges in Robeson, a sprawling southeastern county of 116,000 people and an epicenter of the opioid epidemic in North Carolina. The state saw a 22% increase in drug overdose deaths between 2019 and 2021; Robeson saw a 49% increase.
The county, one of the poorest in the state with one of the highest violent crime rates, checks many of the boxes associated with the risks of drug misuse: Poverty. Racism. Trauma.
Collins-Caddle said stigmas surrounding harm-reduction practices, including syringe exchange programs, complicate efforts to improve the health and safety of the communities she serves.
One Monday in April, I accompanied Collins-Caddle as she made her rounds and checked in on clients. In interviews, many told me that heroin has become harder to find in Robeson County. So they use fentanyl, a synthetic opioid that is up to 50 times stronger. They worry the drugs might be mixed with other substances, including xylazine, a sedative used in veterinary medicine.
Some described instances where they felt disrespected by law enforcement and health care professionals because of their drug use. They said the county needs more methadone clinics where they can access controlled amounts of opiates to ease their withdrawal symptoms. One woman who has been staying in an abandoned home said she and her friends, some of whom have turned to sex work to make money, need stable housing.
North Carolina is getting nearly $1.4 billion from legal settlements with drug companies, pharmacies, and other businesses accused of exacerbating the opioid epidemic through the widespread distribution of painkillers. The money, which will be dispersed over 18 years, is meant to help people struggling with addiction gain access to crucial wraparound services, from detox centers to jobs.
But behavioral health researchers, doctors, or social workers don’t have the final say in how to spend the funds. It’s up to elected leaders in 117 counties and towns across the state to decide which efforts and organizations are worthy of a piece of the pie.
While county commissioners and city council members are responsible for big budgets that dictate tax rates and local school funding, few have experience in adopting best practices to reduce the effects of opioids in their communities.
“Now we’re just throwing a bunch of dollars at them,” said Frank McStay, assistant research director at the Margolis Center for Health Policy at Duke University. “So they feel unprepared to tackle this.”
Aid From Experience
Collins-Caddle, 46, knows what it’s like to be hooked.
She spent 22 years in active addiction, which began when she took a prescribed painkiller for a migraine. She said her “soul stopped hurting,” and the drug eased her anxiety and helped her become more social.
“And before I knew it, I was out here eating them,” Collins-Caddle said of the pills. “I wouldn’t go to work if I didn’t have 20 of them in my pocket.”
Photos by Sarah Nagem
Seeking help, she checked into psychiatric units at local hospitals several times only to be discharged a few days later. Finally, when she got health insurance nine years ago, a doctor diagnosed her with bipolar disorder. She spent a year in intensive therapy working through traumatic childhood experiences and other issues, and she also underwent in-patient drug treatment.
Collins-Caddle, a confident and chain-smoking woman who still lives in the Red Springs neighborhood where she grew up, decided to help others who were struggling in Robeson County. She started distributing naloxone to anyone who would accept it. A year later, in 2021, the grassroots organization North Carolina Harm Reduction Coalition asked her if she’d like to continue her efforts—and get paid for them.
The coalition, which has about a dozen employees and more than 50 volunteers, distributed more than 2 million syringes and served nearly 5,000 participants in 2021 and 2022, according to Program Manager Voni Goodson-Simpson.
When I met Collins-Caddle outside her home, she approached wearing shorts, Adidas sneakers, and a hoodie with the words “WAR ON DRUGS = WAR ON US.” She barely said hello before shoving a lock box full of naloxone into the front seat of my car. You never know, she said, when you might encounter someone experiencing an overdose.
Collins-Caddle’s voice softens when she talks to her clients, asking about their families and living situations without sounding intrusive. Many of the conversations that day were centered on Megan Locklear, whose body was found inside a vehicle at a used-car lot in Lumberton on April 7, two months after she was reported missing. Lumberton police said Locklear “appeared to have gone to sleep in the car and never woke up,” adding that she had likely been dead for several weeks.
Collins-Caddle, who met with Locklear a couple of times before her death, wondered how a body could go undetected in a residential neighborhood for so long.
Death is a familiar part of Collins-Caddle’s job. She said 11 of her clients died last year, and four or five have passed away so far this year. Many experienced fatal overdoses, she said, and others died as a result of complications related to infections.
Education is key in erasing stereotypes, according to Collins-Caddle. In general, she said, those who misuse substances want to improve their lives. But they need the right resources to get started.
She hopes more churches, which play a vital role in this community deeply rooted in Christian faith, will step up and join the fight.
“We need to stop with all the prayers and start making some actions,” she said. “Yes, prayer is a wonderful thing, but at the same time let’s do something tangible that is making a difference.”
Robeson County commissioners have not yet decided how to spend most of its roughly $16 million share of the settlement money. The Robeson Rural Communities Opioid Response Program, a consortium of more than three dozen organizations that include law enforcement, health care agencies, and faith-based programs, is guiding them through the process.
The group recommends giving an initial $475,000 to 13 organizations, including more than $37,000 to drug courts aimed at helping drug users accused of crimes. Its proposal includes $12,500 for the North Carolina Harm Reduction Coalition, which has outreach workers across the state.
The Margolis Center for Health Policy at Duke has conducted dozens of interviews with stakeholders across the United States to compile guidelines and a list of best practices for governing boards, according to McStay. In one county outside North Carolina, he said, someone suggested using the settlement money to expand the local mortuary—an idea met with dismay by researchers.
Health care providers and researchers say there’s no one-size-fits-all way to treat opioid misuse disorders. But McStay said the most effective method is “whole-person care” that focuses on harm reduction practices, such as syringe programs and naloxone distribution, medication-assisted treatment, and after-care support for housing and employment.
North Carolina has set similar parameters for local governments to invest their money and efforts. But priorities will vary based on where you live—and your local elected leaders’ philosophies on how to combat a crisis that claims an average of eight lives every day in North Carolina.
Disparities already exist.
Only 27 of North Carolina’s 100 counties have drug courts, special programs through district attorneys’ offices.
Some studies have found that drug courts reduce recidivism rates by about 12%, with the most effective programs reducing rates by 85%.
Seven years after the General Assembly legalized needle exchange services, the N.C. Department of Health and Human Services lists more than 50 syringe programs across the state. An analysis shows that nearly half of the counties served by the programs are considered urban, and about 10 are in the far western part of the state, where Appalachia’s struggle with opioids has been the focus of much national attention.
In southeastern North Carolina, New Hanover County, home to Wilmington, and adjoining Brunswick County are served by syringe programs. But most of the deepest rural southeastern counties—which make up one of the poorest areas in the state—are not.
In Columbus and Bladen counties, county commissioners had lots of discussions about syringe programs when deciding how to spend their settlement money, said Cynthia Wiford, principal consultant for ACT Associates, an addiction consulting firm hired by both counties. Ultimately, she said, they decided against funding such services.
“Each county has its own personality. You have to respect their culture and where they are in the process,” Wiford said. “They’re very concerned (about) sending a message that using drugs is OK.”
John Cummings, vice chairman of the Robeson County Board of Commissioners, says he worries that such programs lead to discarded needles in neighborhoods. “You don’t want people to empower them,” he said of those who use drugs intravenously.
The Centers for Disease Control and Prevention says syringe services are “proven and effective community-based prevention programs” that do not lead to higher rates of drug use or crime. The services are linked to a roughly 50% reduction in the incidence of HIV and hepatitis C, according to the agency.
North Carolina saw a “more than tenfold” increase in the number of hospitalizations and surgeries for drug-associated cases of endocarditis between 2007 and 2017, according to researchers at the University of North Carolina School of Medicine. Endocarditis is a heart infection that can develop when bacteria enters the body through drug injections.
Robeson County had the ninth-highest average rate of newly diagnosed HIV cases in the state between 2019 and 2021, DHHS data shows.
Controversial Programs
The Robeson Rural Communities Opioid Response Program’s proposal does not include funding for Hope Alive, a church-based organization that plans to operate an in-patient drug treatment center in Robeson County.
Controversy has surrounded the organization from the start.
The state legislature gave Hope Alive $10 million in 2021, sparking questions about why a nonprofit with no experience in treating substance use disorders would receive such a windfall.
Then, media reports surfaced about Ron Barnes, pastor of Greater Hope International Church, which is linked to Hope Alive. Barnes reportedly pleaded guilty to embezzlement charges in Virginia over a 12-year span ending in 2004. Barnes died unexpectedly last fall.
When Robeson County commissioners denied a special-use permit that would allow Hope Alive to open an 82-bed facility in a former nursing home near Parkton, the organization sued—and won. A Superior Court judge sided with Hope Alive in March, frustrating neighbors who said they were worried about safety and property values.
“I think the biggest concern is the size of the facility for what it would be used for,” said County Commissioner Lance Herndon.
Cummings, another commissioner, said he has no problem with the services Hope Alive promises, including medication-assisted treatment and a working farm aimed at helping participants re-enter society. But he said nearby “drug houses” could serve as a temptation for those at the facility.
“The location was wrong,” Cummings said. “It was in a residential neighborhood with drug houses right down the road.”
Multiple phone calls and emails to Hope Alive for this story went unanswered. A woman who answered the phone at the organization’s office on Wednesday said the facility was set to open in late September or early October.
Robeson Health Care Corporation, which operates clinics in four counties, has said it is working closely with Hope Alive and supports the organization’s efforts. Bart Grimes, chief of behavioral health services at RHCC, said the goal is to provide wraparound services.
“We feel like that’s what it’s going to take for the community, to help heal,” Grimes said in March after the judge’s ruling.
Medication-assisted treatment would be key to Hope Alive’s program, Grimes said. Commonly called MAT, the treatment is widely considered a crucial tool in treating opioid use disorder. Methadone, buprenorphine, and naltrexone—all approved by the U.S. Food and Drug Administration—ease withdrawal symptoms such as vomiting, diarrhea, insomnia, and anxiety.
“Essentially what these medications provide is just a stable start to each day,” said Kat Humphries, program manager for Vital Strategies’ overdose prevention program in North Carolina. “And then the person can go along with their life—if they want to go to their job, if they want to go volunteer with their church, or whatever it is, they can do that because they start their day in a stable place.”
Vital Strategies, an international health initiative based in New York City, announced in January that it awarded $1.5 million to organizations serving 12 North Carolina counties. The money will help with harm reduction, including the distribution of naloxone.
Collins-Caddle said she didn’t use methadone or other substances as she overcame drug addiction. But she’s happy the option exists, not just for her clients but for herself. She said she has grown increasingly skeptical of abstinence-based programs such as Narcotics Anonymous.
When she returned to Robeson County from treatment nearly a decade ago, she said, she enrolled in a local 12-step program. A young man who had been attending meetings resisted medication and ultimately died of an overdose, according to Collins-Caddle.
“That was it for me,” she said. “I raised hell in there.”
And she left.
How Much Is Enough?
Experts agree the settlement money isn’t enough to solve the opioid crisis. But they say it’s a good start.
Meanwhile, health officials are tasked with keeping up with the epidemic’s latest trends.
Multibillion-dollar drug companies that make painkillers such as oxycodone are largely considered responsible for sparking the crisis in the 1990s and early 2000s. But new rules limiting prescriptions led many people to turn to heroin. Then fentanyl.
Now, Collins-Caddle said, some drugs are being mixed with xylazine, which is approved by the FDA only for use in veterinary medicine.
In an October report, the federal Drug Enforcement Administration said xylazine has been “detected in a growing number of overdose deaths.” The South saw an increase of 1,127% in overdose deaths involving xylazine in 2021, according to the DEA, marking the biggest jump of any U.S. region.
Collins-Caddle said she suspected xylazine right away when one of her clients developed open wounds on her skin—a common side effect of the drug also also known as “tranq.” She said doctors wanted to amputate the woman’s leg but ultimately decided against it.
During the hours I spent with Collins-Caddle, several people eagerly produced their drugs for testing at a lab at UNC.
Robeson County leaders, like those across North Carolina, now have a chance to pour money into efforts to reduce overdoses, which strain medical and law enforcement resources. Collins-Caddle said it’s imperative they spend the money wisely.
N.C. Attorney General Josh Stein, who was instrumental in the legal settlement with drugmakers, said there is some concern among state officials about how funds will be used. But, he said, each county’s elected leaders are best equipped to tailor needs to their residents and neighborhoods.
“The crisis is felt differently in different communities,” said Stein, who announced his Democratic bid for governor in January. “It’s their emergency departments, it’s their EMTs, it’s their jails, it’s their department of social services, it’s their department of public health that are on the front lines responding.”
Stein’s office launched an online dashboard that he said will eventually provide information about how the money is being spent. That way, he said, elected leaders will be held accountable and residents will get a sense of what’s happening in their communities.
Collins-Caddle knows what’s at stake.
The client who nearly lost her leg saw her own father die of an opioid overdose. The crisis has lasted so long, Collins-Caddle noted, that many families have two generations afflicted.
One of Collins-Caddle’s clients, a mother who said her son also struggles with drug misuse, said most people don’t understand the epidemic. She said she hoped to enter a drug treatment center soon.
“Most people unintentionally get addicted,” she said. “And once you’re addicted, there’s nothing for help here.”
