FAYETTEVILLE, N.C. ― Randolph Alcorn was almost in tears.
The 30-year-old had come from Louisiana for a contract job fixing power lines damaged by Hurricane Florence. After 16-hour days in the elements, he said he’d been soaking wet, from rain or sweat or both, from the day he arrived in North Carolina. But what really worried him was how far he was from the closest opioid addiction clinic that would treat him ― the Carolina Treatment Center of Fayetteville ― after a road collapse blew out the tires of his service truck. Without the methadone he takes twice a week, he worried about going into withdrawal ― or worse, relapsing and going back to opioids.
Getting to the clinic for the second time during his trip, amid road closures, the tire blowout and extended workdays, was also putting him in a tough position with his boss, who he said didn’t seem sympathetic about his treatment.
“I don’t even know if I’m going to have a job after this. I could have easily bought a whole bunch of dope and just left with that. I wouldn’t have had to worry about anything. But I promised my kids and my wife,” he said.
Alcorn was speaking over the phone with Louis Leake, clinic director of the Carolina Treatment Center. Leake leaned over his desk to speak into the cellphone.
“I’ll check back with you in an hour if you haven’t called me,” Leake said. “We’re gonna be here for you. Even if it means we have to come back here later, we’ll do that.”
Leake hadn’t anticipated that a patient from as far away as Louisiana would need his help during Hurricane Florence. But he was well aware that evacuations, flooding and blocked roads and bridges could put patients in addiction treatment in the potentially disastrous situation of being stranded without the medications they need, typically methadone or buprenorphine, to prevent withdrawal.
Inside the clinic, nearly every chair in the front waiting room was taken and the counseling room had been converted into a temporary overflow area. The back door opened and a delivery person wheeled a shipment of methadone and buprenorphine down the hall.
“I was worried about that [shipment arriving], with us having to medicate so many people,” Leake said. Meanwhile, nurses in the front of the clinic called out patient numbers and issued medication doses through windows.
Head nurse Kristen Morales, who had already been on a long stretch at the clinic when the storm hit, was working her 16th day straight this past Wednesday. Water was pouring into her home after the hurricane, and she’d stayed in a nearby hotel for six days to make sure she could get to the clinic to treat patients. She was tired, anxious about her home, and hadn’t slept much, but she was still reassuring patients that they had a plan in place and would be taken care of.
“We can do a lot of things, but we can’t do a lot of things without nurses,” Leake said. “Some of those nurses were without power, they sustained damage to their homes, but they showed up every day.”
Past storms have wreaked havoc for people with addiction. One recent study looked at how people who inject drugs fared when Superstorm Sandy hit New York City in 2012. Of those interviewed who were on opioid maintenance therapy, 70 percent couldn’t get sufficient doses of their medication in the week after the storm.
A different study on opioid treatment programs during Sandy found that half of patients and a third of staff had such profound transportation problems that they couldn’t get to the clinics even though they were open.
“Putting nurses up, that’s a terrific idea, provided that they have access to the facility and provided that patients can get there,” said Harlan Matusow, lead author on the latter study and project director at the National Development and Research Institutes.
In North Carolina, addiction is a big concern. The number of drug overdoses in the state increased 22 percent between 2016 and 2017, amounting to a death toll of 2,515, according to the U.S. Centers for Disease Control and Prevention’s provisional estimates. As the hurricane approached the coast, harm reduction groups and addiction treatment programs were readying their emergency plans and handing out naloxone, the overdose antidote.
In North Carolina, there are 70 opioid treatment programs that service 20,000 patients who receive daily medication. Georgia has a comparable number of treatment programs, and Virginia and South Carolina have far fewer. Tennessee has only 13.
“For the Southeastern United States, North Carolina has pretty good access,” said Zac Talbott, a certified advocate for medication-assisted patients with the National Alliance for Medication Assisted Recovery. “State authorities believe in the treatment.”
The medications are highly regulated, but the state loosened the rules temporarily during the hurricane, approving between four and six days of take-home medication for patients in high-risk areas of the state, like Fayetteville, and urging opioid treatment program directors to offer patients take-home doses to keep them off the roads.
The state also approved “guest dosing,” meaning patients could get treatment at another licensed treatment program in the central registry if they had to evacuate or if their clinic closed.
These plans were tested in the face of massive rainfall and widespread inland flooding. Fayetteville Treatment Center, along with everyone within a mile of the surging Cape Fear River, was ordered to evacuate on Sept. 16. It had given patients between three and six days of take-home medicine before the storm hit, but with the mandatory evacuation order, those patients who’d received only three take-home doses were facing a potential gap in treatment come Monday morning.
“This is for our staff and patients’ safety due to the mayor’s mandatory evacuation order,” said Jessica Matthews, the regional vice president for Colonial Management Group, which includes Fayetteville Treatment Center.
It was in part because of potential clinic closures like this that Carolina Treatment Center, which was outside of the evacuation zone, was determined to keep its doors open during the storm.
With Fayetteville closed, the majority of its patients turned to nearby Carolina. Between the two clinics, Carolina was servicing more than 900 patients.
The two clinics have an agreement to cover each other in times of emergency. “If anything would prevent us from opening, they would accommodate our patients,” Leake said. But, he added, “We’ve never closed a single day in 20 years.”
‘As Devastating As A Hurricane’
Shaun Lewis, 40, was one of the Fayetteville patients who got four take-home doses of methadone. Sunday night he was starting to worry that the clinic might be closed and was relieved when he called on Monday and found out that he could get treatment at Carolina.
Lewis was far enough from the river that his home was spared, but Lumberton, where he lives, saw serious flooding when a makeshift levee broke on Sunday, causing water to pour into low-income neighborhoods. He had to take back roads to get to the clinic because of road blockages and flooding.
“We’re waiting to see what the river does,” he said. “If it floods back out, we’re probably going to be in the water.” Still, treatment was a primary concern.
“I was worried about withdrawal. It wouldn’t matter if it took me all day, I still gotta get my medication.”
In addition to painful symptoms like vomiting, diarrhea, shakiness and anxiety, the ultimate fear of withdrawal is that it will lead to relapse. Stress can also trigger the urge to use drugs during recovery.
“Hurricane Matthew was around the time that I started using a lot more,” said Brandon, a patient at Carolina, who preferred to go by his first name. He was referring to the storm that swept through North Carolina in 2016, causing widespread flooding in the eastern part of the state.
Brandon was at a hurricane shelter this time around when his take-home methadone doses ran out. Because of his experience in Matthew, he was particularly anxious about getting to the clinic during Florence.
“I thought it was ironic that I was coming into this situation again because of a hurricane,” he said.
Florence’s floodwaters got just inside the doors of his home and water leaked through his roof, but it was a far less harrowing experience than Matthew, when “I tried to get drugs right before the hurricane,” he said. “Because of that, I ended up stranded.”
This time around, continuous treatment was paramount.
“Treatment was one of the most important things I considered when getting ready for the hurricane,” he said. “I felt like the possibility of me relapsing ― my drug use could be as devastating as a hurricane might be. As far as what goes on in my life. I actually take both of them equally seriously.”
Terri Cooper, age 31, was among the patients who got four take-home methadone doses and was sent to Carolina to get medication while Fayetteville was closed. She said she waited outside for treatment for nearly two hours Monday before she got into the building.
“It was busy, but thank God I could come here,” she said. If the clinic hadn’t been open, she too would have faced an impossible choice. “I guess I would have got some damn drugs, to be honest. If I didn’t feel good. That’s the truth.”
While patients seemed unfazed, Talbott, the patient advocate, worried that the situation could have easily ended differently without providers going above and beyond in an emergency.
“I’ll always wonder, how many patients did CTC save?”