When he gets the call at sundown, Pastor James Sizemore of Fayetteville, North Carolina, grabs a package of syringes and heads out the door. Half of the needles will be used for shooting up heroin; the rest are filled with an overdose reversal medication.
Pulling up in a dark parking lot on the west side of town, Sizemore meets the representative of a heroin user group of about 10 people. The rest hang back, waiting for him to return with the needles. He hands the man a bag with syringes, sterile wipes and other items and collects used needles for safe disposal. Before the pastor leaves, he says a prayer for their safety.
For the past 10 years, encounters like this have been Sizemore’s life — running an underground, illegal syringe exchange for his community. He said he distributes about 1,000 to 2,000 needles each month. “I try to give them enough syringes to get through a week or two,” Sizemore said. “They call about every two weeks. So I load up my truck, drive into town and do the handoff.”
Along with the syringes, he also offers health checks and advice on how to safely quit heroin. “I do offer HIV and Hepatitis C testing, and referrals to drug treatment if they decide to,” Sizemore said.
The pastor said that he has a good relationship with treatment centers in the state, and that he's often able to get people in when they ask. The problem is that Fayetteville — a city of 400,000 people — doesn’t have a single residential drug treatment program within 60 miles.
“Fayetteville was actually kind of typical for all of North Carolina with the lack of treatment options available locally,” Sizemore said.
He said his syringe-exchange program fills the gap in state policies amid an explosion of heroin use in North Carolina and other parts of the southern United States. The epidemic is getting so bad it is actually putting general public health at risk, particularly through the spread of diseases including Hepatitis C and HIV, the pastor said.
That’s why the local police department has an informal arrangement with Sizemore to allow him to continue his work without fear of arrest, he said. Fayetteville's police department did not respond to Al Jazeera's request for comment.
Sizemore knows what can happen without harm reduction measures like providing clean needles — or similarly, condoms, which he has also distributed in Fayetteville. As a student of clinical pastoral education in Miami in the late 1990s, Sizemore was assigned to a hospital’s HIV ward during the peak of the AIDs crisis in the city.
“The total family destruction, and seeing people die from HIV and AIDS, it really stuck with me to the point where I realized if Jesus were here today that he would do everything he could to ensure that people lived,” Sizemore said. “Because Jesus was, in all intents and practice, a practitioner of harm reduction — spiritually and physically — to keep them alive and safe and secure in this world.”
But in North Carolina and across the southern United States, lawmakers have been slow to enact harm reduction policies and create more treatment centers for drug users, even as a tightening of laws on opioid painkillers has contributed to a rapid rise in heroin use.
“Once the state started to regulate pain medication, everyone switched over to heroin,” Sizemore said.
The heroin moving into North Carolina these days even looks like crushed pills, said Robert Childs, executive director of the North Carolina Harm Reduction Coalition. This familiar appearance has made it easier for people already addicted to pills to transition to heroin, Childs said. Rather than ingest the pills, some users snort crushed painkillers to get a more intense effect. And some people who get addicted to heroin begin by snorting it before moving on to inject the drug, which gives the person a stronger high.
Rates of prescription opioid overdose deaths had begun to fall in the state from around 2008. But by 2010, deaths caused by heroin overdoses had started to rise at an even faster rate, data from the North Carolina Harm Reduction Coalition showed.
Heroin deaths in North Carolina have increased by 402 percent during the period from 2010-2014, and the rate of Hepatitis C infection is up 700 percent in 10 years, the coalition said.
This rise in threats to public health, along with gaps in state policies, make programs like Sizemore's increasingly important, Childs said.
“We haven’t see an increase in support with social services with the rise of the problem of heroin use,” Childs said. He runs the South’s largest center for distributing naloxone, an overdose reversal medication, and has given out more than 20,000 naloxone administration kits in North Carolina since 2013. That was made possible by the passage the same year of the state’s Good Samaritan/Nalaxone Access law, which protects them from prosecution for possession of drug paraphernalia and liability to those distributing the medication, as well as overdose victims and the people who call for help on their behalf.
The group helped rescue 1,500 people in 2015, up from 189 in 2014, he said. That increase was “both because we’re getting better and the need is increasing,” Childs said.
The lack of harm reduction education given to the public is contributing to the problem, Childs said. “People don’t know enough about it. If they want to start or reduce use, there’s a lack of information on how to do that,” Childs said.
But that may be starting to change, said Corey Davis, deputy director at the Network for Public Health Law in Los Angeles. Davis said the south has seen a rapid spread of naloxone access and Good Samaritan laws, most of them been passed in the last year, he added. However, syringe exchange has not been made legal in any southern state.
But that doesn't necessarily tell the whole story, he added. Many Southern states, he said, have taken some actions to make it easier for injection drug users to access safe needles — by removing syringes from lists of illegal drug paraphernalia, for example, or exempting public health programs from those laws. South Carolina, for example, removed references to needles or syringes from its drug paraphernalia law, according to Public Health Law Reference, a health policy advocacy group.
In other cases, as in Fayetteville, sheriffs and police chiefs open the door for change informally. "I don't want it to work that way, but I do think there's more opportunity to do that in a place where the sheriffs and police chiefs say we won't bother you as long as you follow our unwritten rules," Davis said.
For Sizemore, it's only a matter of time. "It used to be some participants in the syringe exchange program would be arrested walking down the street for having a needle on them, just like sex workers would get arrested just for having condoms on them," he said. "So slowly, things are beginning to change — the legality is just a matter of time."