When you hear the phrase "harm reduction," North Carolina isn't one of the first places that leaps to mind. But maybe it should be. After several years of laying the groundwork, North Carolina harm reductionists have successfully shepherded one bill through the legislature already this year, and another one just sailed through the House this week.

[image:1 align:right caption:true]Last month, Gov. Pat McCrory (R) signed into law Senate Bill 20, an omnibus harm reduction bill that includes a 911 Good Samaritan provision for reporting drug overdoses, a naloxone provision increasing access to the overdose-reversal drug, and an alcohol amnesty giving underage drinkers the same protection from prosecution for reporting alcohol overdoses as the Good Samaritan provision provides for drug overdoses.

And this week, the House overwhelmingly (111-2) passed House Bill 850, a partial syringe decriminalization/needle-stick prevention measure. Under that bill, which must still make it through the Senate, people carrying syringes and sharps, who are stopped by police and asked if they are carrying syringes or sharps would not face criminal charges if they admitted that they were.

Although North Carolina may be a purple state when it comes to presidential politics, it is also a deeply conservative Southern state, and nowhere more so than in its Republican-dominated state legislature. So, how did this happen?

The harm reduction successes in Raleigh didn't come out of nowhere. Instead, savvy activists at the North Carolina Harm Reduction Coalition (NCHRC) and allied groups, such as overdose prevention-emphasizing Project Lazarus have been working for several years to build a consensus for harm reduction reforms.

"We've been running a campaign since 2010," said NCHRC executive director Robert Childs. "For the first couple of years, we were just learning the advocacy and legislative ropes, and we learned really quickly that if you want to pass this kind of legislation, you have to have libertarian, conservative and Republican buy in. We did media marketing to all media -- liberal, moderate, and conservative -- and we also did a lot of talking on the conservative circuit, meeting with groups like the Young Republicans, American Future Foundation and the libertarian-leaning John Locke Foundation. A lot of key thinkers and legislators spend time with these groups and they are great places to explore harm reduction and drug policy with our conservative brothers and sisters," he explained.

"We really went out of our way to ensure that this wasn't seen as a traditional liberal issue, but one that effects everyone," Childs continued. "We really focused on creating politically neutral messages that everyone in the state can buy into, which wasn’t tough because this is a politically neutral issue, but it hasn't always been marketed as such."

The harm reductionists also took on -- or, perhaps more accurately, smartly played to the concerns of -- untraditional allies to harm reduction, law enforcement. If drug users want syringe decriminalization to avoid prosecution, police and sheriffs want syringe decriminalization to avoid getting stuck by dirty needles.

"The other angle we've been heavily focused on is law enforcement safety," Childs said. "We decided early on that we needed law enforcement participation, and we decided the way to that was to get them as involved as possible. It makes sense from a public health and public safety angle, as well as building positive relationships between syringe users and law enforcement. They often get left out the harm reduction conversation, but law enforcement need harm reduction, too, to remain safe on the job, too. From ideally wearing needle stick proof gloves, to taking their time on searches, officers need a harm reduction tool kit to stay disease exposure free and come home safe at the end of the day."

Two NCHRC staff members are retired law enforcement officers, one of whom has suffered a needle stick and one who is strongly committed to improving officer work safety conditions. This has helped build a bridge between law enforcement and harm reduction advocates.

"One out of three law enforcement personnel will get stuck during their career, with the danger of exposure to hepatitis B and C and a small chance of HIV exposure," Childs noted. "One of the ways we got law enforcement to become interested in our issue was officer safety, which is sometimes left out of the harm reduction conversation. We actually measured needle sticks and found they were a regular occurrence in departments across NC and then shared that information with law enforcement leadership across them the state.  We showed them that this is actually a big issue for officer safety, and we need to do something about it ASAP."

By the time HB 850 came for a vote Monday night, the work had paid off.

"The law enforcement lobbying groups came out in favor of the bill," said Childs. "Every former member of law enforcement who is currently serving as a legislator was a primary sponsor for the bill and voted in favor of it. It went really well."

Syringe decriminalization is even more important because North Carolina doesn't have any legal syringe exchange programs.

"We do currently have multiple underground syringe exchanges, including one of the nation's oldest programs in Asheville," he explained, "but there are no legal syringe exchange programs in the American South. They either operate illegally or with a law enforcement agreement in order to protect the health of the local law enforcement officers. But throughout the South, people are incarcerated for possessing needles. This leads to a lot of law enforcement needle sticks, since diabetics and syringe users are afraid to tell Southern law enforcement that they have syringes on them because they are afraid of the repercussions."

Legal syringe exchange has not had legislative success in North Carolina, Childs said, citing several Democratic-sponsored bills that never made it out of committee in the 2000s.

"A lot of legislators would like to support it, but view it as tough politically, so we are trying to do something a bit more progressive and a bit more conservative instead, which is to decriminalize syringe possession," he explained. "With syringe exchanges, there are limits. You have to be a member to reap the benefits. But with decriminalization, we can decriminalize syringes entirely, no matter the source, what it's being used for or where in the state you live.  So no matter if you have Addison’s disease, diabetes or are a injection drug user, you can carry syringes and do not have to be part of a government sponsored program to get benefits."

In addition to addressing law enforcement concerns, syringe decriminalization also goes with conservative values, Childs said.

"Decriminalization will decrease law enforcement needle sticks, but what really resonated with the legislature was its emphasis on less spending on costly diseases, greater reliance on the community members, personal accountability and responsibility," he said. "We stand in solidarity with our conservative allies on this issue by solving these public health and public order issues through deregulation."

With major military installations, such as the Army's Fort Bragg and the Marines' Camp Lejeune, veterans concerns are a major issue in the state. Legislators who may not be sympathetic to hard drug users are sympathetic to vets' concerns, and the NCHRC works hard to address those concerns and educate legislators about harm reduction needs of the armed services and veteran community.

"We have a high percentage of active service personnel and veterans, said Childs, "and what we see is a high percentage of them coming back with chronic pain, addiction and PTSD and self-medicating with substances. A large number of them are using opiates or opioids after they get out. This is also a vets' health issue -- they are disproportionately affected by addiction and chronic pain issues, as well as potentially acquiring medications illegally."

NCHRC has vets on its staff, including former Army Nurse Corps Officer Leilani Attilio, a registered nurse who also holds a master's degree in public health. Attilio played a key role in the passage of the Good Samaritan/naloxone/alcohol amnesty bill earlier this year, and she said there are real issues facing vets in the state.

"Because of the backlog in the VA system, there are a lot of vets who can't get the care they are entitled to, even things like substance abuse counseling," said Attilio. "One of my friends is a vet and was addicted to prescription meds. He sought help and was told to come back in six-seven weeks. Another vet I know who is injecting heroin was told six months. When people need rehab, they need it right then not six to seven weeks from now and definitely not in six months. Until we can get them in rehab, it's important that have harm reduction so they don't overdose or contract HIV or viral hepatitis from injecting drugs."

“Republican and Democratic Legislators can easily support harm reduction approaches if you make it relatable to them," said Attilio. "It's a matter of telling them that this is happening everywhere, showing them the prevalence in their districts. And it's also cost-saving legislation. We are reducing the number of vets who will be incarcerated for low-level, non-violent drug crimes, we are spending less money on hospital stays and autopsies. We are finally focusing on this as a public health issue and not criminalizing it."

As patterns of drug abuse shift, so must harm reductionists' responses. Another bill working its way through the state legislature would enact prescription monitoring in a bid to crack down on doctor-shopping. But Attilio warned that such measures could possibly push some pill users to heroin.

"They're trying to address supply, but there is research that shows that in states that crack down on pain pills, people are switching to heroin," she said. "We've had law enforcement here say the same thing: We're taking away the prescription meds, but something else is taking their place, and that's sometimes street drugs like heroin. Unless we link such measures to harm reduction, all we are accomplishing is a shift in addiction, not necessarily a reductionor elimination of the problem."

Passing the syringe decriminalization bill is one thing, but injection drug users will have to be aware of it to know they can avoid arrest by admitting they're carrying injection paraphernalia. Attilio said NCHRC had that angle well in hand.

"We're pretty well-organized," she said. "We have active and retired users in our networks who can disseminate the information across the state. We also do training in rehabs, at methadone clinics, in jails and prisons. We can get the word out in lots of places. We also have a plan to train law enforcement officers across the state if the law goes through, so they know the nuances of the law to protect their safety."

The American South can be a tough place to get drug reform legislation of any sort approved, let alone laws allowing drug users to carry syringes or -- God forbid! -- helping them to avoid dying from drug overdoses. But harm reductionists in North Carolina are showing that it can be done. That's a message that needs to be heard from Richmond to Little Rock, and beyond.