Rather than a progressive place with an innovative approach to substance use, Asheville has created a culture that exacerbates the overdose crisis. An inside look at how a city zoning crackdown can cost locals their health and lives
Above: A pro-harm reduction message painted on the front of Firestorm Books and Coffee, where Steady Collective operates a 2.5-hour a week needle exchange and outreach program. The city of Asheville has tried to shut the program down, claiming it constitutes an illegal homeless shelter. Photo courtesy of Steady Collective.
I have been a part of Steady Collective, a local syringe access and overdose prevention program, for just over two years. I’ve done different things at Steady in its short history. But the thing that I have done most consistently is work an outreach event on Tuesday afternoons at Firestorm Books and Coffee.
So I was there the very first Tuesday we set up in November of 2016. I was there the Tuesday after Asheville’s zoning enforcement department strangely characterized our long running outreach event as “most like a shelter” according to the city’s zoning rules and threatened $100 a day fines. With a handful of exceptions, I have been at Firestorm distributing naloxone, clean injecting equipment, and wound care kits every Tuesday for two years.
Syringe access programs help stop the spread of HIV and Hepatitis C. Studies have found that “the majority of people who perform overdose reversals using naloxone received from overdose prevention programs are people who use drugs.” Steady intentionally does outreach in areas with high rates of drug use and overdose, like West Asheville, and exclusively provides naloxone overdose reversal kits to folks using and their loved ones. Community members seemed to understand the necessity of our service.
For over a year and a half we received no complaints about our outreach at Firestorm. But then in July of this year I was forwarded an angry email from a West Asheville property owner (originally sent to the landlord and tenants of 610 Haywood Rd). Among other things, the property owner complained about public urination, camping in the garden space at 610, and improperly discarded syringes.
All the organizations that rent that space — Kairos West, 12 Baskets, and Firestorm Books and Coffee — began meeting with neighbors and West Asheville business owners immediately to address the issues outlined in this individual’s letter. Though Steady is not a renter at 610 Haywood I also attended these community meetings (held in the same space in Firestorm where Steady does outreach on Tuesdays). Sara Henry from Asheville’s strategic development office was present for some of these gatherings but at no point was I led to believe that our harm reduction program was at risk of any sort of legal action from the city.
Officially Steady Collective received its original notice of zoning violation (NOV) on Aug. 8 and an amended NOV a little over a week later on Aug. 17. I talked to Asheville’s principal planner, Shannon Tuch, on the phone on Aug. 8.
Photo courtesy of Steady Collective
But despite these attempts to address concerns and keep open lines of communication, I wasn’t actually sent a copy of the notice until the following morning, just an hour and twenty minutes before I was to speak at a community-wide meeting that the city had arranged for the stated purpose of “working together” to “find balanced solutions” to the issues already being resolved in the meetings that began in July.
I was surprised by the NOV. But by the afternoon of Aug. 9, the surprise had worn off and I had fit the notice into a complicated local landscape that I only understand because I work in harm reduction in Western North Carolina. Here’s what that terrain looks like.
The Asheville approach
For two years our program participants have been telling me, in so many words, that not only is Asheville not forward thinking when it comes to addressing the overdose crisis, this city is a particularly dangerous place for people with substance use disorder. Talking about the targeting of Steady Collective’s weekly two and a half hours of outreach in West Asheville is one way to illustrate this. But there’s another example, perhaps even more striking, that predates the current issue with zoning.
Late last year a regular participant came in on a Tuesday afternoon. He hadn’t been by the week before. He mentioned that he had gone to Neil Dobbins, a local RHA Health Services crisis center, to detox only to be arrested on site. I thought I had misunderstood him until a week later a different participant refused to be referred to Neil Dobbins because they had been arrested at the facility in the past. Other participants told me that the center, opened more than 30 years ago, consistently ran patients for warrants.
In February I went to tour Neil Dobbins with the intention of understanding what was going on. At the end of the open house tour I asked the staff person leading the group what they did about folks with warrants. She calmly stated that Neil Dobbins contracted with the Buncombe County Sheriff’s department to run everyone for warrants at the time of admission. On my way out of the building, I passed a deputy sitting at the front desk.
We stopped referring participants to Neil Dobbins immediately and I began to publicly address the practice of running people seeking treatment for warrants. I received an email from Neil Dobbins’ director shortly after I spoke about the practice at a harm reduction forum.
In the correspondence she confirmed that they did run everyone for warrants and people were arrested on site who had been issued orders for arrest. But she assured me that orders for arrest are uncommon. In fact, these orders are issued for such common offenses as probation violation and failure to appear. I called NC Department of Health and Human Services and as a result, the state Department of Mental Health began investigating. In July of 2018, NC DHHS informed me that Neil Dobbins “will no longer be conducting warrant checks” and to reach out again if we heard that the practice of running for warrants was happening at other local treatment and detox facilities.
I reported Neil Dobbins because treatment and healthcare facilities should not act as extensions of the prison system. For many years, substance use and addiction were considered moral failings and signs of weakness. The now more widely accepted disease model of addiction, a model publicly embraced by Buncombe County’s government, maintains that substance use disorder is an illness. Others assert that the adaptive model of addiction, the theory that drug use is a way of coping with one’s situation or environment, makes the most sense. Both the disease model and the adaptive model are evidence-based. Whether an illness or an adaptive strategy, it is clear to most that addiction cannot be punished away.
But the numbers indicate that a lot of people in Asheville are detoxing in jail rather than in the care of therapists, doctors, and addiction specialists. In 2016 Buncombe County Detention Center reported having about 600 prisoners on a detox protocol*. In 2017 the number jumped to 1396. This uptick seems to make sense. What is happening in the jail is representative of what is happening in the general population.
If, as is asserted on the North Carolina Department of Justice website, we can’t arrest our way out of an overdose epidemic shouldn’t we anticipate a decreasing trend in detox protocol numbers? If imprisoning a person with substance use disorder is four times the cost of sending that same person to treatment shouldn’t we see divestment from prisons and policing and greater investment in treatment options?
The need for treatment in North Carolina, Buncombe in particular, is clearly demonstrated in recent data. North Carolina had the second highest increase in overdose deaths in the country last year. In the first half of 2018 Steady Collective, which mostly serves people from Buncombe, received 188 overdose reversal reports from participants who used naloxone kits they received from us during outreach. Over the last ten years Buncombe has reported 54 meth-related deaths, the highest number in the state.
Doubling down
These local systems know the magnitude of the overdose crisis and could work together to use evidence-based approaches to support people using drugs and people with substance use disorder. But it’s hard not to question whether the institutional will to adopt new, compassionate policies exists. Neil Dobbins policy of running patients for warrants appears to have been long-standing.
Not all troubling policies are so dated. In August of this year, Mission Hospital adopted a new unsettling policy for people admitted who inject drugs (PWID) that prohibits visitors and access to personal belongings (including cell phones) and requires that the person have a “sitter.” Internal memorandum about the new policy (automatically applied to PWID whether they are coming for treatment of an illness related to their use or for something unrelated) states “we anticipate the current AMA (leaving against medical advice) rate of 20 percent in this population will continue/increase with these heightened restrictions.” Rather than attempting to curb a staggering AMA rate, Mission has adopted a policy that feels paternalistic and punitive and that even hospital administrators admit will increase the AMA rate.
This doubling down on harsh approaches to people with substance use disorder is an established local trend in these mountains, and so far the city of Asheville is making things far worse, not better. On Aug. 30 I went to city hall to meet with Tuch and Robin Currin, Asheville’s attorney at the time the NOVs were issued. They informed me that in addition to citing us they had plans to write “syringe exchange” into the zoning code as a particular land use so they can regulate where we can and can’t be.
If Asheville goes through with this plan, it would be the first city in North Carolina to regulate where syringe exchanges can operate. In the short term, this new regulation would create problems for Steady Collective and Needle Exchange Program of Asheville (housed in Western North Carolina AIDS Project). In the future, other cities might emulate Asheville, altering their own zoning regulations to hamper the movement of existing syringe access programs or the establishment of new programs.
People who use illicit drugs, particularly people who inject those drugs, already face a level of stigmatization and institutional violence that should offend us and propel us to action. Simply because of their drug use, often done to treat physical and/or emotional pain not being effectively treated by medical systems that continue to prove themselves to be inaccessible and biased, people with substance use disorder live in constant fear of arrest and incarceration.
Rapid gentrification in a city with an occupancy rate the hovers above 97 percent has led to rising rates of homelessness. Homelessness contributes to relapse for folks with a history of drug use. Many long term residents of Asheville are now learning that the resources that could have been used to support housing and treating them have been spent to entice and protect tourists.
If syringe access is limited, either because pharmacists refuse to sell syringes to people without a prescription or because syringe exchange programs aren’t available or well-funded, PWID receive the message that they don’t deserve access to basic supplies that keep them disease and injury free. When overdose prevention programs like Steady Collective are shut down or police departments and other first responders refuse to carry and administer naloxone, we are collectively telling members of our community that they don’t deserve to live.
Evidence says that programs like Steady Collective work to curb the spread of disease, prevent overdose, and get folks into treatment. At this juncture, Asheville has a choice to make. Will a city that has branded itself as progressive and tolerant actually live up to those values? Will they take up the mantle of harm reduction in the midst of an overdose crisis and support folks in need? Or will Asheville maintain its reputation as a dangerous place for people with substance use disorder? So many people depend on Asheville enthusiastically choosing the first option.
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Originally from Alabama, Hillary Brown moved to Asheville 7 years ago and is the director of Steady Collective. Their writing about harm reduction has also been featured on Public Health Post, HuffPo, and The Hampton Institute.
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