MARION, N.C. -- Rural North Carolina is battling two health epidemics - substance abuse and COVID-19 - as treatment centers navigate shutdowns and internet-access challenges to address addiction and mental-health issues.

In McDowell County, Jacqueline Fox heads McDowell Impact, a peer-support specialist network. Her organization is working to place specialists with key agencies that work with people battling addiction and related challenges such as family separation, finding housing and infectious disease. She said building a strong network of resources and educating people is critical to reducing the long-term societal effects of COVID-19.

"In McDowell, we're kind of resource poor," she said. "We have one mental-health provider. And when you're working with people who struggle with substance misuse, you have a small timeframe when they're ready and seeking help. Transportation is always an issue. Medication was always an issue, the cost."

A new report from the North Carolina Division of Public Health found that emergency-room visits related to drug overdose have jumped by 22% compared with last year. The highest rates of overdose occurred in rural counties among the hardest-hit by COVID-19.

Fox added that prolonged social isolation and economic hardship will affect families differently, so treatment centers and social-service agencies will have to work to meet individual needs.

"When you isolate folks and you take away their connection to community, to churches, that's just going to have far-reaching effects," she said. "It's going to have a ripple effect on their life. Maybe they're not able to afford meds, or they are having to seek out those services for food, they become food insecure. So, I don't think there's really one thing that we can pinpoint to focus more on."

Anthony Tyre, a behavioral health counselor and founder of the Eastern Community Care Foundation, said the stigma surrounding mental health and substance use, combined with fear of COVID-19, deters people from seeking help. Also, many rural residents lack reliable home internet and can't have online appointments. So his organization checks on clients at home, in what he called COVID-safe "front-yard visits."

"We're kind of seeing a lot of the kids going through major depression," he said. "A lot of the folks who are living with substance-use disorder and trying to battle that, they're struggling because they're having difficulties getting in to their appointments."

This summer, the Centers for Disease Control and Prevention reported more Americans are experiencing worsening mental health linked to the pandemic, especially among younger adults, people of color, essential workers and unpaid family caregivers.


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The Kentucky Board of Medical Licensure recently proposed new changes to regulations around the prescribing and dispensing of buprenorphine, also known by its brand name Suboxone, a Food and Drug Administration approved medication used to treat opioid-use disorder.

Experts say the changes would increase barriers for people who rely on it to keep their lives stable.

Michelle Lofwall is a professor in the Departments of Behavioral Science and Psychiatry at the University of Kentucky. She said the stricter rules send a discouraging message to people in recovery.

"And we know," said Lofwall, "low-barrier care, where patients can really get access to the medication and they can add on what's needed when they're not doing well, is really important."

The new regulations would limit doses patients can receive, mandate participation in counseling services, and require frequent drug testing, among other changes.

Critics of expanding access to buprenorphine, classified as a schedule III substance, argue the drug itself is an opioid that people can become addicted to - and don't address the root causes of substance-use disorders.

The board did not respond to an email request for comment for this story.

Lofwall pointed to the numerous reasons why requiring regular counseling and drug testing can prevent people from being able to access the medication they need.

The new rules would require clinicians see patients using buprenorphine every ten days, or at two-week intervals, in the first few months - and then every few months after two years of treatment.

"A lot of people have jobs that don't let them take off from work to come every week," said Lofwall. "They can be discriminated against because, all of a sudden, they're late, or they just don't have the benefits of a job that allows sick days."

Lofwall said she's confused by the board's actions, given the research showing significant declines in overdose deaths among people taking buprenorphine.

"The Kentucky Board of Medical Licensure just really has had a lack of transparency, I think," said Lofwall, "about the rationale for some of these changes."

According to the Centers for Disease Control and Prevention, in 2023 Kentucky ranked among the top five states for buprenorphine dispensing rates nationwide, along with West Virginia, Vermont and Maine.

Support for this reporting was provided by The Pew Charitable Trusts.




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The incidence of drug overdose is decreasing in Indiana and one reason could be the efforts of an organization offering free training to anyone willing to help someone struggling with addiction.

Indianapolis-based Overdose Lifeline works to address the basic needs of families, individuals and communities, showing them how to administer the overdose reversal drug naloxone, or Narcan.

Justin Phillips, founder and CEO of the Overdose Lifeline, explained naloxone can reverse the effects of fentanyl, currently the most prevalent synthetic opioid in the drug supply.

"We want to make people understand opioids and the class and family of opioids," Phillips emphasized. "Then we talk about stigma and harm reduction, and we give people the signs and symptoms of an overdose, and then we provide them with free overdose reversal kits."

She pointed out with proper training, someone can be better suited to reverse an overdose than administer CPR. The training lasts about an hour. In the second quarter of last year, the Marion County Public Health Department reported 124 overdose deaths. It said 56 happened at a residence and 28 at a hospital, 25% fewer than the same time in the previous year.

Phillips noted anyone may know someone who is struggling with addiction. But conversations about drug use and overdoses can be uncomfortable, which she argued reinforces the need for training.

"Sometimes, we're not as willing to go to a pharmacy to acquire Naloxone or talk to our doctor," Phillips acknowledged. "Which is why we do these community events and we make it available, easily accessed in the community, so that you can avoid some of that stigma and judgment."

She added Overdose Lifeline also partners with CareSource for a free program to support Indiana school nurses to implement a naloxone Emergency Preparedness and Response Plan in schools. The program provides free naloxone, emergency medication boxes and staff training.


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As opioid settlement money continues to flow into Kentucky, counties are having to make major decisions on how to spend it.

Half of it goes to the state's Opioid Abatement Advisory Commission, which allocates funds through a competitive grant making process.

Margaret McGladrey, assistant professor of public health at the University of Kentucky, pointed out smaller counties with fewer resources face greater challenges seeking community input on how to use the funds.

"I think there's certainly a capacity issue when we're asking each of these local governments to engage in communities in decision-making and then spend the money in accordance with that decision-making," McGladrey observed.

The Commonwealth is slated to receive around $900 million statewide across the various settlements involving companies distributing opioids, such as CVS, Walgreens, and Walmart, and pharmaceutical companies such as Purdue Pharma and the Janssen Pharmaceutical Companies of Johnson & Johnson.

According to the Appalachian Opioid Remediation tracker, the state's Opioid Abatement Advisory Commission requires local governments to submit a quarterly form certifying funds were used for their intended purposes but does not ask for specific details about expenditures.

Kate Boulton, senior legal technical adviser for the public health organization Vital Strategies, argued it important to distinguish between state spending inconsistent with the terms of the national settlements or state laws, and spending which is not evidence-based.

"In the first category, I would flag things like shooting ranges, ballistic vests, drug sniffing dogs and vehicles for law enforcement," Boulton outlined. "Those are all real life examples from various parts of the country."

McGladrey recommended to keep families intact and reduce the negative consequences of involvement in criminal legal and child welfare systems, counties should consider using funds for comprehensive medication-assisted treatment.

"Where we can have the most impact with these opioid abatement funds, is supporting our county correctional facilities in implementing medication treatment for opioid use disorder," McGladrey urged.

According to the Kentucky Youth Advocates Opioid Dashboard, in 2020, more than 30% of Kentucky children said they have lived with someone who had a problem with alcohol or drugs.


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