HICKORY, N.C. — On a chilly spring evening in 2021, Tim Nolan set up a portable addiction clinic next to a McDonald’s dumpster, and he waited. His desk was the dashboard of his gray Prius, his office this parking lot, which smelled like frying oil and trash. The hatchback of the nurse practitioner’s car was full of hepatitis C testing kits, clean needles, fentanyl test strips — and pizzas.
Mr. Nolan’s first appointment of the night was with a middle-aged factory worker named Sammy, who showed up late in a dented old Ford and high on heroin, a broken face mask dangling from one ear. “I’m ready to get off that damn needle,” Sammy told him.
“Why do you want to?” Mr. Nolan asked, gently.
Sammy’s eyes welled. “Sorry, man,” he said. He’d been imprisoned twice, he explained, most recently on drug-related charges. While incarcerated, Sammy faced an additional charge for assaulting a jail guard during what appeared to be a full-blown psychotic episode that Sammy blamed on abrupt withdrawal. A year earlier, his fiancée’s 18-year-old son was killed. He’d just been fired from his job driving a forklift following a fight.
Sammy wiped away tears and vowed to stop injecting heroin before he started his next job. “I’ve never even said all this to anyone.”
Sammy’s experience illuminates why America’s overdose crisis has only continued to worsen: We are a nation that, a quarter-century into the worst addiction crisis in U.S. history, still makes death, incarceration and buying dope far easier to achieve than evidence-based treatment.
It illuminates why a crew of underfinanced, ultra-motivated addiction fighters — many of them volunteers like Mr. Nolan — have been able to make strides and fill treatment gaps caused by government impotence by using innovative, even counterintuitive, strategies in some select cities and rural areas across America. In some cases, these bootstrappers must skirt law enforcement officials to bring lifesaving medicines and harm reduction supplies like clean syringes and fentanyl test strips to the most marginalized in their communities. They operate ad hoc, by and large, and just about all of them are working at the ragged edge of capacity.
Since the introduction of OxyContin in 1996, more than 1 million Americans have died of drug overdose, including a record of nearly 108,000 Americans last year alone. And it’s not slowing down: Overdose deaths are on track to double, to 2 million, by 2030.
As someone who has covered the overdose crisis off and on for a decade, largely from the Appalachian communities where it initially took root, I know that the kind of care Mr. Nolan offers is extremely hard to come by. This is especially true in places already slammed by the decimation of jobs, where a fatalistic culture too often views drug users as moral failures rather than as people with a treatable medical condition.
Last year, West Virginia severely restricted needle exchange programs just as the county home of its state capital, Charleston, was designated by the Centers for Disease Control and Prevention as having the most concerning H.I.V. outbreak in the nation. Roughly 87 percent of Americans with opioid use disorder, or O.U.D., do not receive evidence-based treatment with addiction medicines. Research published in June, in fact, suggests that 6.7 to 7.6 million adults in the United States now live with O.U.D. — roughly four times as many as previously known.
But it was not until I spent a year shadowing Tim Nolan and his harm reduction peers that I began to see what successful addiction care might look like.
Across the nation, harm reduction services look vastly different in rural towns and counties than in, say, New York City, which authorized the nation’s first official supervised-consumption sites last fall. Many rural Americans make do with a hodgepodge treatment landscape that depends entirely on the efforts of individuals. And yet this type of care has been proven time and again to work, and the federal government must take heed if it hopes to truly curb overdose deaths.
Mr. Nolan thanked Sammy for opening up. “That’s how we’re going to work together,” he said. The next day he would call in a prescription of low-cost buprenorphine for his new patient. (Sammy was uninsured, partly because North Carolina is one of 12 non-Medicaid expansion states.) But right now, Mr. Nolan needed his new patient to understand two things:
First, you can get better.
Second, and maybe even more important: “Don’t disappear.”
That meant that Mr. Nolan expected to see Sammy the following week, even if he relapsed. If Sammy’s vehicle broke down and he couldn’t make it to McDonald’s, Mr. Nolan would drive to him.
If Sammy no longer had a home address — a reality for so many addicted Americans — Mr. Nolan was fully prepared to meet him under a bridge, in a tent encampment or in another parking lot of his choosing, as he did for many patients, a practice experts call low-barrier or low-threshold.
Success, as I came to understand it, could be boiled down to two simple edicts: hope and help.
Mr. Nolan volunteers for the Olive Branch Ministry, an organization based in Hickory, N.C., and co-founded by the Rev. Michelle Mathis, a nondenominational Christian minister, and her wife, Karen Lowe. “Ten syringes fit nicely in a box of Nature’s Valley granola when you take out a few bars,” said Ms. Mathis, who has a floral tattoo on her forearm with the words “Acta non verba” — which is Latin, she told me, for “Do shit. Don’t just talk about it.”
Operating the nation’s first queer, biracial, faith-based harm reduction organization, the couple began their work in 2009, seven years before the state legalized needle exchange, under the auspices of a food pantry they ran out of the back of their pickup truck.
Back then, they covertly added sterile syringes, condoms and wound-care kits to the boxes of dry goods they gave out. They tucked in business cards, too, with only a phone number and the ministry’s name, so that if disapproving relatives discovered the cards, they’d think: How nice, they’re going to church.
Mr. Nolan, Ms. Lowe and Ms. Mathis, who struggle against deep-seated prejudice even among those who claim to want to help, are providing critical links to effective evidence-based care. I first met Ms. Mathis three years ago in Surry County, N.C. She’d been called in to advise a network of church volunteers who wanted to ferry people to addiction-medicine treatment and therapy at a clinic in the town of Mount Airy. Most of that region’s drug users lived many miles from the practice and had no way to get to appointments.
Around that time, Surry County had the highest overdose rate per capita in the state. Its jail was so full of addicted people that recent arrestees who were dope sick clutched vomit buckets in an intake area, and surplus inmates had to be bused to other counties. The county had hundreds of job openings it was struggling to fill, in part because many applicants couldn’t pass a drug test.
By 2019, Olive Branch was running three needle access sites in the state’s former furniture factory belt and had a team of peer support specialists — people in recovery who are trained to triage the addicted and connect them to services. One peer roamed the back roads and under-the-bridge encampments in her car, handing out food, safe-injection supplies and even pet food for one client who lived with her cat.
Soon the organization would also offer low-barrier addiction medicine (buprenorphine, often called bupe for short), which stems opioid cravings, to people who were already using their syringe services. As a volunteer for Olive Branch, Mr. Nolan started out delivering needles and other supplies to people at truck stops and fast-food parking lots. Even if some participants weren’t ready to stop using drugs, many wanted to be cured of their life-threatening, energy-zapping hepatitis C.
Several patients later began hosting hepatitis C testing treatment gatherings in their homes, with pizza, helping their friends access the same hard-to-get services, including clean needles and naloxone, the overdose-reversal drug.
Fast-food parking lots, trailers and tents soon turned into de facto addiction triage centers in a small corner of Appalachia, filling in for the failures of local health departments hampered by budget cuts and the continued unwillingness among many health care gatekeepers to treat those with addiction.
As Mr. Nolan built trust among his Olive Branch clientele, strangers began texting on a near-hourly basis, asking him to “fix my hep” or “get me off the needle.”
The harm reductionists I followed were equal parts exhilarated and exhausted. They crafted treatment regimens on the backs of envelopes, politicked back channels and butted heads when bureaucrats and elected leaders refused to acknowledge the data on harm reduction and make change.
Grieving relatives were among the grittiest treatment champions — moms and sisters, especially. In Peoria, Ill., Dr. Tamara Olt, an OB-GYN who’d lost her 16-year-old son to overdose, started a naloxone distribution program that grew to offer access to clean needles and low-barrier bupe. It was her first time treating men.
When overdoses soared by an estimated 40 percent during the first months of the pandemic, Dr. Olt’s harm reduction project blanketed the area with naloxone, increased outreach to addicted sex workers (hand-delivering condoms and lubricants) and took over food distribution when a neighborhood food pantry closed.
In Northern Virginia, a woman who’d lost her brother to overdose started a harm reduction group in his name — the Chris Atwood Foundation — which now also meets regularly with addicted inmates, who are provided counseling as well as bupe by the jail, a rarity in the United States, with thanks to a sheriff who dared to change jail protocols over some of her own deputies’ objections. Peers arrange the inmates’ follow-up care and even transport them to housing when they’re released — a critical moment when people are far more likely to overdose and die.
In upstate New York, one mother worked tirelessly to force county leaders to stop undercounting overdoses after having families self-report overdose deaths directly to her via Facebook. At a news conference she organized for relatives of the dead in front of city hall, they demanded action against a backdrop of corrugated-plastic tombstones they made to represent their lost loved ones.
But the families of drug users and their peers shouldn’t have to be responsible for fixing this problem or convincing leaders there is one. The federal government should take heed of what’s working in patchwork segments of the country and elsewhere in the world, like Portugal and Switzerland, where harm reduction strategies have long been the norm. It should make amends for its failure to stop this man-made crisis, which began in the hinterlands but whose victims now know no political or demographic bounds.
Harm reduction isn’t harm eradication, but it works to prevent the spread of H.I.V. and hepatitis C and to prevent overdose deaths — and the government should acknowledge its efficacy: People who recently started using syringe service programs, which can provide crucial and nonjudgmental bridges to care, are five times as likely as those who don’t to enter treatment and three times as likely to stop using drugs altogether.
As opioid litigation settlement money from drug makers and distributors begins to land in communities, I worry that it will be wrongly sucked up by abstinence-based programs and incarceration-first models that remain our nation’s de facto response to O.U.D. Most residential treatment programs still don’t offer addiction medicines for long-term use, and too many regions of the country are run by politicians and law-enforcement leaders who equate offering addiction treatment in jail as coddling inmates.
To turn back overdose deaths, Congress and the Substance Abuse and Mental Health Services Administration should attack the problem with urgency and innovation. While the Biden administration recently pledged significant financial support for harm reduction, and the drug czar Rahul Gupta appears to be championing harm reduction strategies — after disastrously presiding over the closure of an important harm reduction program in Charleston, West Virginia, in 2018. President Biden should make good on his campaign pledge to shepherd long-term funding that would make treatment on demand the rule rather than the exception. He should also elevate the drug czar’s job to a cabinet-level position, as it once was, and together our leaders should encourage all health care providers to treat addiction with medicines that can dramatically improve outcomes. As cases grow less acute, patients transition from emergency or low-barrier care — ideally paired with peers, counseling services, housing and other social supports.
Until that happens, scrappy organizations like Olive Branch, currently operating on duct tape and glue, desperately need more support. Cutting-edge care shouldn’t be left to volunteers working from their cars.
Beth Macy is the author of the forthcoming book “Raising Lazarus: Hope, Justice, and the Future of America’s Overdose Crisis,” from which this essay is adapted.
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