GREENSBORO, N.C. — The thin young man quietly took in the room as he waited for the free supplies meant to help him avoid dying: sterile water and cookers to dissolve illicit drugs; clean syringes; alcohol wipes to prevent infection; and naloxone, a medicine that can reverse overdoses. A sign on the wall — “We stand for loving drug users just the way they are” — felt like an embrace.
It was the first day the drop-in center in a residential neighborhood here had opened its doors since the coronavirus forced them shut in the spring of 2020. “I’m so glad you all are open again,” the man, whose first name is Jordan, told a volunteer who handed him a full paper bag while heavy metal music riffed over a speaker in the background. He asked for extra naloxone for friends in his rural county, an hour away, where he said it had been scarce throughout the pandemic.
Overdose deaths rose by nearly 30 percent over the 12-month period that ended in November, to more than 90,000, according to preliminary federal data released this month — suggesting 2020 blew past recent records for such deaths. The staggering increase during the pandemic has many contributing factors, including widespread job loss and eviction; diminished access to addiction treatment and medical care; and an illegal drug supply that became even more dangerous after the country essentially shut down.
But the forced isolation for people struggling with addiction and other mental health issues may be one of the biggest. Now, with the nation reopening, the Biden administration is throwing support behind the contentious approach that the center here takes, known as harm reduction. Instead of helping drug users achieve abstinence, the chief goal is to reduce their risk of dying or acquiring infectious diseases like H.I.V. by giving them sterile equipment, tools to check their drugs for fentanyl and other lethal substances, or even just a safe space to nap.
Such programs have long come under attack for enabling drug use, but President Biden has made expanding harm-reduction efforts one of his drug policy priorities — the first president to do so. The American Rescue Act includes $30 million specifically for evidence-based harm reduction services, the first time Congress has appropriated funds specifically for that purpose. The funding, while modest, is a victory for the programs, both symbolically and practically, as they often run on shoestring budgets.
“It’s an enormous signal, recognizing that not everybody who uses drugs is ready for treatment,” said Daliah Heller, director of drug use initiatives at Vital Strategies, a global public health organization. “Harm reduction programs say, ‘OK, you’re using drugs. How can we help you stay safe and healthy and alive first and foremost?’”
Although some programs like this one, run by the North Carolina Survivors Union, managed to keep providing some supplies during the pandemic — handing them through windows, offering curbside pickup or even mailing them — virtually all stopped inviting drug users inside. Many clients, like Jordan, stopped coming, losing a trusted safety net.
Some former regulars at the Greensboro center have died or disappeared. Many lost housing or work. At the same time, the center has been inundated with new clients and is now having trouble keeping enough supplies on hand.
“The amount of struggle people are having in this moment, unrecognized and unanswered, is really difficult,” said Louise Vincent, executive director of the Survivors Union.
Still, many elected officials and communities continue to resist equipping people with supplies for drug use, including the recent addition of test strips to check drugs for the presence of illicitly manufactured fentanyl, which shows up in most overdose deaths. Some also say that syringes from harm reduction programs end up littering neighborhoods or that the programs cause an increase in crime. Researchers dispute both claims.
West Virginia just passed a law making it far more difficult for syringe service programs to operate, even though it is seeing a surge in H.I.V. cases driven by intravenous drug use. North Carolina’s legislature weighed a similar proposal this spring, and elected officials in Scott County, Ind., whose syringe exchange helped curb a major H.I.V. outbreak six years ago, voted this month to shut it down. Mike Jones, a commissioner there who voted to end the program, said at the time that he feared the syringes it distributed could be contributing to overdose deaths.
“I know people who are alcoholics, and I don’t buy them a bottle of whiskey,” he said. “And I know people who want to kill themselves, and I don’t buy them a bullet for their gun.”
Many harm reduction programs are run by people who have used drugs in the past or still sometimes do, and their own struggles with addiction, mental illness or other health issues also flared up during the pandemic. In Baltimore, Boston, New York and elsewhere, beloved leaders of the movement have themselves died from overdoses, chronic health problems and other causes over the last year, their deaths leaving holes in efforts to keep providing services.
Ms. Vincent, whose own addiction to opioids stemmed from a long struggle with bipolar disorder, briefly returned to using illicit drugs this spring. She was anxious to stave off withdrawal, she said, after trying unsuccessfully to switch from methadone to another anti-craving medication, buprenorphine. She later learned that the small amount of fentanyl she used was mixed with xylazine — an animal tranquilizer that can cause oozing skin ulcers. She landed in the hospital, her hemoglobin level so low she needed a blood transfusion.
Early in the pandemic, Ms. Vincent said, the price of street drugs soared. Then drugs being sold as heroin, methamphetamine or cocaine started getting cut with unfamiliar additives. Fentanyl was ever-present — including, increasingly, in counterfeit pills sold as prescription painkillers or anti-anxiety drugs. But so were substances like xylazine, which has been showing up in illicit drugs from Philadelphia to Saskatchewan.
“It’s just poison,” said Ms. Vincent, who is back on methadone treatment. “The drug supply is like nothing we’ve ever seen before.”
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On the afternoon of the center’s reopening, a young woman asked for a refresher on how to inject naloxone, and if Ms. Vincent could explain what a meth overdose looked like. An older man asked if there was any food to be had along with clean syringes; a volunteer stuck a pastry in the microwave for him.
In addition to running the program here, Ms. Vincent promotes harm reduction services around the country as executive director of the National Urban Survivors Union, a larger nonprofit. In 2016, her 19-year-old daughter died from a heroin overdose while she was at an inpatient treatment center that had no naloxone on hand, she said.
Naloxone is more widespread now, but Ms. Vincent would like to see another lifesaving tool become common: drug-checking programs that would allow people to find out exactly what substances are in illicit drugs before they take them. Such programs exist legally in other countries, including Canada, the Netherlands and New Zealand. Another type of harm reduction program used in other countries — where people use illicit drugs under medical supervision in case they overdose — remains illegal here after a group seeking to open one in Philadelphia has lost in court so far.
“We could have a real time surveillance system instead of waiting for coroner death reports,” Ms. Vincent said. “It would change the game, right?”
She found out about the xylazine in the drugs she took recently with a device a called a Fourier transform infrared spectrometer, which a donor gave her group this year. It can determine within minutes what substances samples of street drugs contain.
Jordan, who is 23, had traveled from Stokes County, near the Virginia border, where the rate of overdose deaths even before the pandemic was almost twice as high as the state average. His cousin, he said, had been hospitalized weeks earlier after overdosing on “a real bad batch” of fentanyl that testing found contained traces of heavy metals.
“At least 50 people in my area have been saved by Narcan from here,” he said, taking several boxes, each containing 10 vials of the injectable form of the antidote. “Even my grandmother knows how to administer it.”
Many harm reduction programs, including this one, help connect people with medication treatment or even sometimes provide it. But Jordan counts himself among the many drug users who are not interested in that path, at least right now. The closest programs are in Greensboro or Winston-Salem, each a healthy drive from his home. And treatment with anti-craving medicines like buprenorphine or methadone, while proven to save lives, “doesn’t really work for me,” he said.
The county that includes Greensboro, the third-largest city in North Carolina, saw 140 fatal overdoses last year, up from 111 the year before. The numbers do not include people who died from infections caused by injecting drugs, including the fiancé of a woman who walked into the center around dusk the day of the reopening, calling out for Ms. Vincent, “Where’s Louise?”
She met Ms. Vincent when both were patients at a methadone clinic six years ago, and came to the center regularly for syringes and naloxone. She and her fiancé had tried to stop using drugs during the pandemic, unnerved by the strange new adulterants showing up in the supply. But her fiancé started spiking high fevers last December and was admitted to a hospital intensive care unit, critically ill with endocarditis, a heart valve infection that can result from injecting drugs. He died just before Christmas.
“Are you all having a meeting tonight?” the woman asked Ms. Vincent, referring to the support groups that the center held several times a week before the pandemic.
“They’re going to start back up soon,” Ms. Vincent assured her. “Being connected is way more important than any of us considered.”
