By Amanda Dale, PhD
In September 2024, Hurricane Helene brought both immediate and long-term devastation to Western North Carolina. Over 100 storm-related deaths have been recorded, and over 375,000 households were displaced in the aftermath of the storm [1]. Additionally, millions of North Carolinians lost access to water and sewer services, electricity, telecommunications, and healthcare facilities like clinics and pharmacies. While these disruptions affected and continue to affect many, they have a unique impact on people who use drugs and people who take medications for opioid use disorder (MOUDs).
Natural disasters can produce a significant amount of stress and may lead to or amplify existing mental health conditions [2]. Houselessness, displacement, loss of community, and lack of clean water can also present barriers to engaging in harm reduction strategies around substance use. For instance, a study of people who used drugs in Puerto Rico before and after Hurricane Maria found that fewer people reported using a new needle to inject drugs after the storm compared to before the storm. Study participants were also 3 times as likely to report an overdose post-Maria relative to pre-Maria [3]. Additionally, MOUD use may be limited during and after natural disasters due to pharmacy closures, challenges to accessing and prescribing medications across state lines, hospital and clinic service limits, and disrupted communications with providers [4].
As Western North Carolina continues to recover from Hurricane Helene, prescription flexibilities and harm reduction-led relief efforts are supporting the health and wellbeing of people who use drugs and people who take MOUDs.
On September 25th, North Carolina Governor Roy Cooper declared a state of emergency (Executive Order No. 315) due to Hurricane Helene. This allowed the NC Board of Pharmacy to enact two administrative rules, 21 NCAC 46.1809 and 21 NCAC 46.1815; these rules apply to one-time emergency supplies of prescription medications that can be dispensed when the medication is essential to the maintenance of life or the continuation of therapy in a chronic condition. The rules allow a pharmacist to dispense a one-time 30- or 90-day supply of medication for an individual when they cannot obtain a refill authorization from the individual’s prescribing provider. Under these rules, an individual whose usual provider or pharmacy is unavailable due to a natural disaster can go to a different pharmacy and obtain an emergency refill of prescription medications.
Also, on September 25th, the NC Department of Insurance issued a bulletin reminding health insurance plans of their legal responsibilities under GS 58-2-228. Under this rule, insurers must allow and cover prescriptions that are otherwise being filled “too early” by people living in an area subject to an emergency declaration. Similarly, NC Medicaid pharmacy providers were approved to fill prescriptions early from September 26th through December 31st, allowing beneficiaries to have access to necessary medications.
In early October, the Drug Enforcement Administration (DEA) issued an exception letter clarifying that North Carolina’s administrative rules governing emergency prescription refills when medical services are interrupted may be used to create and dispense one-time 90-day emergency refills of Schedule III, Schedule IV, and Schedule V controlled substances, including buprenorphine (a Schedule III drug used in the treatment of opioid use disorder) [5]. Additionally, NC Medicaid enrolled pharmacy providers were approved to override prior authorization requirements for people impacted by the storm from September 26, 2024, until December 31, 2024. This allows people to access necessary medications and for pharmacy providers to be reimbursed.
On October 4th, the Administration for Strategic Preparedness and Response, an agency within the U.S. Department of Health and Human Services (DHHS), activated the Emergency Prescription Assistance Program (EPAP) in North Carolina. Through this program, uninsured residents can request a 30-day supply of certain prescription medications at any EPAP-participating pharmacy, which can be renewed every 30 days while the EPAP is active. This program also helps eligible residents receive vaccinations, medical supplies, and equipment that they may need.
Veronika Ethereal is a Haywood County-based regional community engagement and harm reduction services coordinator with the North Carolina Harm Reduction Coalition, an organization that encourages and motivates the implementation of harm reduction interventions, public health strategies, drug policy transformation, and criminal justice reform in North Carolina [6]. Harm reduction is framework for preventing disease and promoting health that “meets people where they are” rather than making judgments about where they should be. Accepting that not everyone is ready or able to stop risky or illegal behavior, harm reduction focuses on promoting evidence-based strategies for mitigating health risks associated with drug use. These strategies include access to sterile syringes, medications for opioid use disorder such as methadone and buprenorphine, and overdose prevention [7].
Veronika shared that they received policy and relief updates from their work, including those about prescription flexibilities. However, they said that the information was not widely known or relevant to people in the community who used harm reduction services. Thus, harm reduction workers led and joined local efforts to distribute food, clean water, and hygiene supplies. They also worked to communicate with community members about the presence of law enforcement, who had been seen making arrests during supply distribution activities. Veronika, themselves displaced by Helene, witnessed firsthand the devastation caused by the storm and the resiliency of community, even in the midst of uncertainty. “Everyone really pulled together to help one another… They were almost proud to run [federal response] off and take care of their own community.”
While policy can be leveraged to improve access to care for people with opioid use disorder and people who use drugs, it is often trusted community partners that communicate those policy flexibilities and provide direct services during times of crisis. Harm reduction workers are often deeply embedded in their communities and are reliable sources of information on health, safety, and community resources. It is important to recognize the key role of harm reduction in amplifying health policy efforts and in meeting the needs of communities impacted by natural disasters.
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