Rural Harm Reduction: Spotlight on Edgecombe County, North Carolina
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Background
In eastern North Carolina, between Raleigh and the Atlantic coast, sits Edgecombe County—a mostly rural county with approximately 48,000 residents. Relative to the state and the country as a whole, Edgecombe County has a high proportion of Black residents (56 percent) as well as elevated rates of poverty, incarceration, and unemployment. All of these factors increase the likelihood that people will be affected by the potential harms of drug use and the war on drugs.
Indeed, Edgecombe County has been hit hard by the nation’s ongoing overdose crisis: From 2017 to 2022, the county’s drug overdose death rate was 33 per 100,000 residents (compared to a statewide rate of 27.6). The county is also among North Carolina’s most impacted when it comes to HIV, with 10 new diagnoses in the first six months of 2023, up from six the year before. And hepatitis C—a virus spread primarily through injection drug use—ranked among Edgecombe County’s top health problems and priorities in a 2022 needs assessment.
All of these issues provided fertile ground for harm reduction, a pragmatic approach repeatedly shown to save lives and support health at the population level, where abstinence-oriented interventions often fail.
The Program
Launched in May 2023, the Edgecombe County Community Paramedic Program (ECCPP) is an innovative, tailored harm reduction program primarily funded through opioid settlement dollars, although it has also drawn on funding from the state’s local management entities. The ECCPP is a partnership between the county’s emergency medical services and public health department. Two paramedics provide a variety of mobile overdose response and harm reduction services (and even some primary health care services) from 7:30 a.m. to 6:00 p.m. five to six days per week.
ECCPP Harm Reduction Services
| Overdose Response and Prevention | General Harm Reduction |
| Naloxone distribution | Mobile distribution of sterile syringes, injection equipment, and sharps containers |
| Buprenorphine administration to treat withdrawals; follow-up connection to medication-assisted treatment provider if desired | Wound care |
| Medical management of withdrawal symptoms | Free, anonymous mobile ultrasound-assisted blood testing for hepatitis C, HIV, and syphilis; connections to appropriate follow-up care |
| Drug-checking tool distribution (e.g., test strips) | Transportation to higher-level medical care if appropriate and desired |
| Anonymous drug sample submission for laboratory drug-checking | Referrals to peer support and recovery resources |
This comprehensive range of harm reduction services addresses a spectrum of issues related to drug use and amplified by socioeconomic inequities. In addition to reducing the risks of infectious disease and overdose, syringe and naloxone distribution helps build trusting relationships and facilitate entry to treatment. Thanks to its mobile nature, the program is already reaching harder-to-access populations—such as young Black men—who have been historically underrepresented in harm reduction care and have recently seen some of the highest overdose rates in the state and the nation. The ECCPP also fills gaps in Edgecombe County’s primary care infrastructure by meeting residents-in-need where they are—both literally and figuratively. And the paramedics who staff the ECCPP provide community outreach and education, including naloxone training.
Recent Successes
So far, 2024 has been a successful year for the ECCPP. According to Community Paramedic Program Manager and Logistics Officer Dalton Barrett, the program has:
- Distributed 277 boxes of Narcan and 600 syringes to syringe services program participants between July 1, 2024 and Oct. 7, 2024.
- Made 34 referrals to care from January 2024 through October 2024 (10 referrals in September alone).
- Seen 26 individuals at least once per month, others less frequently.
Policy Lessons
In North Carolina, smart policy lays the groundwork for trusting relationships between first responders and people who use drugs, enabling the provision of more comprehensive care such as that offered by the ECCPP. For example:
- Robust Good Samaritan laws empower people who witness an overdose to respond by administering naloxone and calling emergency medical services without fearing criminal legal consequences.
- Authorizing evidence-based syringe services—including needs-based equipment distribution and mobile operation permitting—allows rural harm reduction programs to tailor themselves to local community needs.
Nonetheless, there is still work to do to reduce the risks associated with illicit drug use. Although the ECCPP provides referrals (and some warm handoffs) to medication treatment for opioid use disorder, North Carolina’s restrictions on the gold-standard medication methadone limit their ability to truly meet patient needs. Relaxing state regulations on methadone—for example, reducing requirements for patients to receive take-home doses, permitting individualized counseling, reducing the number of annual drug tests to align with federal guidelines, discouraging the discontinuation of care when patients have a positive drug test, and more—would improve access to this lifesaving medication.