‘If You’re Not Breathing, You’re Not Getting into Recovery’

Other versions of this story were originally published in Mother Jones and 100 Days in Appalachia.

A 45-minute drive northwest of Asheville, Hot Springs, North Carolina, is an iconic Appalachian Trail town – in fact, the trail weaves through the heart of downtown. Hot Springs is rarified air in a Blue Ridge Mountain valley, open-armed, embracing.

But as the temperature rises on a mid-June Saturday morning, in the back parking lot of the Dollar General, corner of Bridge and Lance, a litany of interactions is conducted with utmost discretion.

Ainsley Bryce is here, as she or a colleague is each Saturday morning, to distribute life-saving assets. Bryce has arrived well-stocked. The free items she offers are numerous:

Bryce can also provide information, referrals, a smile, a hug, non-judgment, and kindness.

Bryce is the director of Holler Harm Reduction, based 15 meandering-mountain miles southeast in Marshall, a town of just under 1,000 tucked into the eastern bank of the French Broad River.

Though these interactions are entirely legal, discretion is wise. Most of the folks visiting Bryce are, after all, in active drug use; they’d prefer to remain unobserved by law enforcement and the judging eyes of the community. Many struggle with shame. Among Bryce's objectives is easing it.

Jared, 35, is a resident of Newport, Tennessee, 25 miles northwest of Hot Springs. He's carpooled down this morning with several members of his immediate community, folks he refers to as brothers and sisters. He found his dad hanging in the backyard at age 19 and began self-medicating with drugs soon after. "I thought, ‘Well if I do some kind of drug, it will erase that vision in my head.’ But it didn't." He began injecting at 22 and has since.

Asked what it would take to quit, he says, "I wish I knew. … A lot of support. A lot of support."

The numbers are now frighteningly familiar: More than a million Americans died from a drug overdose in the past two decades. More than 100,000 of those deaths came in 2021, in the middle of a global health crisis.

Americans are now more likely to die of an accidental opioid overdose than in a car accident. But cars would kill 15,000 more people a year were it not for seatbelts – something required by the federal government to be placed in every new car since 1968.

Seatbelts, helmet laws and airbags are what are known as harm reduction strategies. They reduce the negative consequences of risky behavior and have been almost universally accepted in the U.S. as ways to save lives.

For decades, drug policy experts have recommended that we embrace the seatbelts of drug use: overdose-reversing medicine like naloxone, kits that make it easy to test drugs for fentanyl – a synthetic opioid estimated to be up to 50 times stronger than heroin and now found in everything from methamphetamine to weed and crushed into pills – and clean syringes that reduce the spread of deadly diseases associated with intravenous drug use.

Joe Biden is the first president to embrace harm reduction as an essential part of the nation's drug policy. He put $30 million into the American Rescue Plan to support community-based overdose prevention programs, syringe services programs and other harm reduction services. Last May, the Department of Health and Human Services promised $1.5 billion for state and local initiatives to combat addiction, including harm reduction services.

Harm reduction doesn't abet drug use, says Judith Feinberg, a professor of infectious diseases and behavioral medicine at West Virginia University. "It's about reducing the attendant harms of drug use, supporting people in the community and trying to keep them alive and healthy."

"If you’re not breathing," Feinberg says, "you’re not getting into recovery."

Newport is home to most of those who’ve traveled here today. Choice Health Network used to operate a syringe exchange in Newport, but the owner of the property on which it was held rented it to someone who doesn't support harm reduction. Holler is now the closest option. And for these folks, it's a godsend.

Business is brisk this morning. Bryce dispenses her wares from the back of her truck. Folks linger a while to chat. Many are her regulars and now friends. By the end of the day, she will have handed out more than 2,000 syringes.

Jack, 44, of Del Rio, just outside Newport, found Holler on the internet and connected his community. (Jack's name and the names of other active drug users in this story have been changed to protect their privacy.)

"Thank god for these people," he says. Jack lost his wife to an overdose; she died on the bed beside him. He believes his drug use is now manageable and takes every possible safety precaution. He rises each morning and heads to work.

"The science is conclusive," harm reduction services save lives, says Feinberg's WVU colleague Robin Pollini, a substance misuse and infectious disease epidemiologist. Research shows that naloxone access laws have resulted in a 14% decrease in opioid overdose deaths nationwide. And a Seattle study of people who used injection drugs found that new participants in a syringe exchange program were five times more likely to enter treatment than those who weren't in the program.

Syringe service programs are also proven to reduce transmission of HIV and hepatitis C.

Notably, some of the best data we have on just how effective harm reduction can be was facilitated by former Vice President Mike Pence. In 2015, rural Scott County, Indiana, was experiencing one of the worst recorded outbreaks of HIV among injection drug users – an incidence rate more than 50 times the national average. Then-Governor Pence reluctantly approved the state's first syringe exchange program.

A team of epidemiologists worked with Scott County's department of health on a study gathering local data and found that discontinuing the program would result in an increase in HIV infections of nearly 60%. Nevertheless, in 2021, local officials voted to shutter it.

Central Appalachia has suffered disproportionately from our crisis of addiction. But over the past five years, politicians throughout the region have put policies in place that counter the research in addiction science, limiting communities from implementing proven policies.

Meanwhile, nationwide, the promise of a new era of drug policies is being countered with conservative backlash – this despite the fact that it was Republicans, including Kentucky Senator Mitch McConnell, who advocated in 2016 to remove a federal ban on funding for syringe exchanges.

Heightened hysteria took root in 2022 when conservative media ran with a story that the government planned to use American Rescue Plan money to "distribute crack pipes." Though research indicates glass pipe exchange is a solid harm reduction strategy, the Biden administration's flat-footed response to the stigmatizing report ignited a media firestorm. During the ensuing outrage, Senator Joe Manchin – a Democrat from West Virginia, the state with the nation's highest rate, by far, of fatal overdoses – joined with Republican Senator Marco Rubio to introduce a bill prohibiting the use of federal funds for syringe and other exchange services.

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Holler Harm Reduction operates on a tight budget: one grant through AIDS United, another from an Asheville-based health trust. They haven't applied for a grant through the federal Substance Abuse and Mental Health Services Administration. With a staff of three, two of whom are part time, they just don't have the resources to slog through the federal application process, Bryce says.

Meanwhile, they experienced a 4,000% increase between April 2021 and April 2022 in the number of people they serve, partly due to the closure of the syringe exchange in Newport, but also to growing awareness that their services are available.

In addition to scheduled drop-in days, they deliver supplies anywhere in the county, assisted by a few people in active drug use who extend Holler's reach.

Bridget, 33, is among them. She lives outside the town of Mars Hill with her boyfriend and a menagerie that includes her goats – Big Dote, Alice (because he looks like Alice Cooper) and Wenne (Wednesday Adams and Winifred Sanderson mashed together) – on a peaceful plot of land in a snug valley.

Bridget grew up around addiction. "My dad, that's all he wanted was a needle," she says. "He picked it over me and picked prison over me for years."

She was diagnosed with ADHD as a kid, and she self-medicates the disease. She says small doses of meth allow her to function. "I could put it down, but I’d have to really want to put it down." For now, she doesn't. Bryce says she's a careful user. "She really takes care of herself."

"They’re my friends," Bridget says of Bryce and Holler coworker Alonza Lasher. "They’ve pulled me out of places that I’d been stuck in for a long time." They listen to her and answer her questions. "I like to ask questions. I want to know it all."

Fifty-five-year-old Daisy also provides outreach. She tried cocaine at 18 – "Scared the devil out of me" – and then nothing more till she was 42, in the course of a very bad year in which she got divorced and lost custody of her kids. She was suddenly alone. Then it was "cocaine, methamphetamine, pills" to cope with the overwhelming sense of loss.

Daisy overdosed on heroin three times in August 2012, was in recovery for five years, then started using again after contracting lung cancer. She no longer injects, but she smokes meth. "I don't get high anymore. It's more like just maintaining the feeling of being okay."

Daisy plays an important role in Holler's network: She's a link to people otherwise unlikely to find their services. She takes in young people who have no place to go. "If they need somewhere to lay down, they sleep at my house – and if they need food or a shower or whatever." She brings home Holler's supplies and hopes that with her small interventions she might change the course of someone's life.

"It's wrong for somebody who's making bad decisions when they’re young to have to deal with it for a lifetime when you can give them what they need to be safe, and hopefully get out of it and move on," Daisy says.

Back at the Holler office (just a couple doors down from Madison County Republican Party headquarters), Lasher reflects on how so many of their participants "come to us carrying so much shame." She and Bryce assure them, "You deserve an unused syringe, you deserve wound care, you deserve a friendly ear and love and support, regardless of anything."

"And when they get that," Lasher says, "it may be the first time anybody's ever extended it to them."

There are encouraging signs in the region of growing acceptance of at least some harm reduction measures.

In Tennessee, legislation went into effect in July 2022 that allows health care providers and community groups to distribute naloxone under standing orders. The hope is that this will make naloxone much more accessible in rural communities.

But advocates argue Appalachian communities must be more proactive.

Syringe exchange efforts have been stymied in West Virginia by changes to local laws. HIV continues to spread throughout Kanawha County, even after a 2021 Centers for Disease Control investigation called it the most concerning HIV outbreak in the country, warning that the reported numbers could be just "the tip of the iceberg." Research indicates that the closure of syringe exchange programs will result in an increase in HIV infections.

As epidemiologist Robin Pollini put it, the "science is conclusive." And, she added, "What the science also tells us is that when you open these programs, it does not result in an increase in syringe litter or a rise in crime."

Judith Feinberg is "terrified that we won't have the humanity and the generosity of spirit and the political will to see that this is somebody's mother, somebody's brother, somebody's uncle, somebody's son and daughter."

On that day in Hot Springs, North Carolina, Nicole, 27, is Holler's last arrival. She's traveled over from Newport. Having gathered her supplies, she's sharing with Bryce her hopes of soon entering treatment.

"Three months ago," Nicole says, "this wasn't in my heart. You couldn't have made me stop if you wanted to. But it's on my heart so strong."

Nicole isn't sure where she’ll sleep tonight. Bryce urges her to be safe.

"It's good to see you," Bryce tells her. "Can I give you a hug before you go? Thanks for coming, dear."

Nicole knows where to find her.