Vance County in North Carolina is a rural place with wide-open spaces and vast wooded areas punctuated by farms, trailers and houses. Henderson, the county seat, is a timeless small town with a clock tower—and a central business historic district. But the county has been in a long, slow decline. Jobs have slipped away. Farming has largely disappeared. So has industry. More than a quarter of the people live below the poverty line. The median household income is a little more than $35,000 annually.
Because one town in Vance is a distribution hub for heroin from 2010 to 2016, the death rate from heroin overdoses increased by 1,300 percent, according to a Duke University study.
“There just isn’t a lot of work for folks,” says Loftin Wilson. “Heroin has become one of the main economies of the country.”
For years, Loftin has been sitting down with families, walking up to strangers in parking lots, dropping by motels, hoping over time to make the connections and build the trust that saves lives. Anywhere he can, he meets opioid users who have slipped into the chasm of a nationwide epidemic. In rural areas, especially, helping them climb out is a formidable challenge.
Loftin is the rural program coordinator for the North Carolina Harm Reduction Coalition. He has worked his way up to supervisor, overseeing outreach workers and coordinating the coalition’s rural programming. But he still does weekly outreach in Vance County. He can’t stop. It’s in his DNA. Like other workers in other rural counties, he counsels users on overdose prevention, HIV and hepatitis prevention, and provides them with clean syringes and naloxone, also known as NARCAN, the overdose reversal drug.
“We’ve focused on saturating the community with naloxone,” he says. “There are studies saying you can reduce the overdose rate by making sure naloxone is in every possible hand of people who are using or who know people who are using.”
Because one town in Vance is a distribution hub for heroin, Loftin has seen people drive from other counties to buy heroin there, and then use on the spot—sometimes overdosing. Throughout the state, the coalition has distributed more than 105,000 overdose kits since 2013, with more than 13,400 reported overdose reversals, nearly all in the last three years. The increasing addition of fentanyl, a powerful synthetic, into the drug supply means the window to act on an overdose has shrunk, an often deadly combination in rural areas where a hospital may be more than an hour away.
Thanks to a $1 million grant from the Aetna Foundation, Loftin and the coalition has been able to expand its work to four other rural North Carolina counties also hard hit by the overdose epidemic. The counties are spread across the state from Brunswick in the south to Haywood on the Tennessee border in the west to Vance along the Virginia border in the north. Loftin makes a loop, meeting people where they live, even if it’s in a car or a motel, delivering naloxone, clean syringes, fentanyl testing kits, and just listening to their news, good and bad.
To date, the coalition distributed 9,656 naloxone kits in the five counties and had 904 reversal reports.
“Doing outreach work is more of an art than a science,” Loftin says. “The more you practice it, the better you get. There’s a process of trust-building that has to occur. Once you’re good with somebody, that person will connect you to two or three or four or five other people.”
Loftin remembers one woman he met in a Walmart parking lot in Vance County a couple of years ago. She was homeless, using heroin and methamphetamine; after they met, she learned through testing for sexually transmitted diseases that she was pregnant. She immediately decided to enter a methadone program, but soon left. Less than a week later, she called to say she wanted to go back into the program. This time she stayed, had a successful birth, and gave the baby up for adoption. She landed a job and stabilized her life.
“There are all kinds of changes we struggle to make,” Loftin says, “one step forward, two steps back. It’s not easy and it’s not straightforward. There might be twists and turns in the road that go on for years.”
Gina Musa is another person who does outreach. She came on board in February as a linking-to-care coordinator, a position funded by the Aetna Foundation grant. Loftin says her position has dramatically increased the number of people the coalition has been able to place into services and has relieved the burden on outreach workers who were struggling to fill a dual role.
Gina likes to say she has a gift for the job. She learned the system the hard way. After surgery for cervical cancer in 2005, she got hooked on painkillers and eventually heroin. She became a sex worker to fund her habit. More than once, naloxone saved her life.
“The substance abuse is what we see,” she says. “Breaking the mentality that this is who you are, this is all you deserve, that you’re never going to be worth it, that is the hardest thing.”
She finally decided she no longer wanted to live that life, got clean, and then graduated from a training program. “My purpose is to be there for individuals who are struggling to find a way out,” she says.
That means helping them in whatever ways they will accept. She might start with syringe exchange. She might use her connections to find them a program for medically assisted treatment with methadone or buprenorphine. In her first month on the job with the NCHRC, she linked two women to high-risk obstetrical care, seven people to medically assisted treatment, two to long-term in-patient care, and referred two for hepatitis C evaluation. She knows whom to call to find out if there’s a bed available. She understands a program that’s a good fit for one person may not be a good fit for another.
“I’m the hope dealer,” she quips, available at all hours for texts or calls.
Reality isn’t neat and clean. Success may mean simply engaging a person in a conversation about harm reduction, building a relationship until they are ready to take another step.
“I have girls actively using. They will look at me and say, ‘I’m not done yet,’” she says. “I respect that. The people who are struggling but continue to engage with us are successful to me. I’ve seen people get better, but I promise it never comes in a bow wrapped under a Christmas tree.
“I always tell them I just need you to live,” Gina adds, “because I cannot work with the dead.”