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One day after Hurricane Helene devastated western North Carolina in late September 2024, Toni Brewer was without power or water. The storm had scattered fallen trees across most roads, knocked out phone and Internet communications and left some neighborhoods under water near his home in Asheville.
Brewer cleaned out the food in her refrigerator, grabbed some clothes and drove more than an hour southwest with her partner to Franklin to stay with relatives.
When he arrived, he opened the center console of his car, where he kept his medications, and discovered another crisis. He only took three days' worth of Suboxone, a brand of buprenorphine, a prescription medication that relieves opioid cravings. Without it, he risked relapsing into a life he described as miserable.
He remembered what it felt like to have those cravings and panicked.
“It's scary to have that feeling again of, 'I need this and I'll do whatever it takes to get it,'” said Brewer, who at the time had been recovering from an opioid addiction for 18 months. She needed a new prescription, but knew the lines of communication at her doctor's office were down.
Now, a group of doctors is using the example of Hurricane Helene to urge federal lawmakers to help improve access to substance use medications in severe weather emergencies. Four doctors working in addiction medicine published an editorial in the American Journal of Public Health outlining strategies for getting medications to people in recovery during natural disasters.
As climate change threatens to cause more disasters in the US, the group of doctors urged state and federal governments to act soon or risk allowing more disasters to exacerbate overdoses, relapses and deaths caused by opioid use disorder, an ongoing epidemic that has killed more than 800,000 people in the US since 1999.
One study estimated that after Superstorm Sandy in 2012, 70% of New Yorkers who relied on recovery medications were unable to obtain enough medications. In the two years following Hurricane Maria's devastation in Puerto Rico in 2017, reports of overdoses increased, according to another study. The Tubbs and Camp fires in Northern California caused substantial disruptions to patients' access to opioid addiction medications, according to a study published in 2022.
A combination of factors exacerbates the opioid crisis in the US, AJPH editorial authors noted. Mental health stressors, treatment disruptions, drug market volatility, and economic decline create conditions in which climate-related disasters increase the risk of overdose deaths.
“First of all, we make it very difficult for them to access treatment medications,” said Elizabeth Cerceo, director of climate health at Rowan University Cooper School of Medicine and co-author of the editorial. “When people are displaced or can't get to their regular clinics or pharmacies, those challenges become insurmountable.”
Their push comes as President Donald Trump has taken a markedly different approach to substance use policy over the past year than during his first term. In 2017, Trump declared the country's opioid crisis a national public health emergency, and in 2018, he signed legislation, known as the SUPPORT Act, to expand access to treatments.
But his administration has also reduced federal resources for mental health and substance use services, cutting staff last year at the Substance Abuse and Mental Health Services Administration and ending numerous grants to advance research into prevention efforts.
Disasters threaten treatment
SAMHSA works with states to ensure access to medications for opioid use disorder is not disrupted, Health and Human Services spokesperson Emily Hilliard said. States can pass emergency measures to allow people more flexibility in getting their treatments, he added, which North Carolina did.
Cordelia Stearns, another co-author of the editorial, watched these access issues unfold in the wake of Hurricane Helene.
Stearns, medical director at High Country Community Health in North Carolina's Blue Ridge Mountains, said the first calls to her clinics were for buprenorphine. He said people who needed the medicine traveled through mountains and crossed rivers to reach his clinics.
“The things my patients did to be able to access their bupe,” Stearns said, “were amazing.”
The editorial's authors recommend that the federal government work with pharmacies to allow patients to take home more medications during emergencies. They suggest keeping a registry of patients with prescriptions for recovery medications who can receive treatment when evacuated across state lines.
And they propose factoring the need for such drugs into disaster response plans, whether that means supplying buprenorphine to rescue vehicles, adding backup generators to opioid treatment clinics or training volunteer first responders.
People with substance use disorders often already must navigate strict and complex regulations to obtain medications. For example, methadone can only be obtained through an in-person visit to federally controlled opioid treatment centers, many of which closed for days or weeks after Hurricane Helene.
Buprenorphine is monitored by the DEA's suspicious order reporting system, which restricts supply when pharmacies order more than is allowed under specific thresholds. The system is intended to detect possible overuse of recovery medications in a region.
Blake Fagan, clinical director of substance use disorder initiatives at the Mountain Area Health Education Center in western North Carolina, said the system delayed medications numerous times after Helene. No exceptions were allowed, Fagan and his colleagues reported.
The agency did not answer questions about the system.
Individual pharmacies also control who receives medications and who does not. When people try to get medication for opioid use disorder away from home, it can raise alarm bells.
“We realized there were some pharmacies that just said, 'I don't know this person. I'll only give you three days and I'm sure they'll be back in Asheville soon,'” Fagan said. “They didn't want to cover a month's worth. And in our minds, we're sitting in the mess and thinking, 'They're not coming back for a month.'”
Risk of relapse
When Brewer arrived in Franklin, she immediately logged into the Mountain Area Health Education Center's patient portal, wondering if she could renew her three-month Suboxone prescription.
He didn't know that his doctors had also left the area to get a stable internet connection. They were trying to call and email patients to get prescriptions filled.
Trying to be thorough, Brewer sent messages to several doctors. Two responded and one filled his prescription.
But when he went to a local Walgreens, they were out of Suboxone. So Brewer made another trip, this time to Clayton, Georgia, where he was finally able to get a month's worth.
The medication that would have been mostly covered by North Carolina Medicaid if he had stayed in the state was about $130, a high price for Brewer, who had temporarily lost his job when his workplace, a sober living center, lost power and closed due to the storm.
Despite the little income he had at the time, Brewer said, he paid for his prescription. The thought of slipping back into her old life without treating her addiction scared her, she said.
“I would wake up every day and the only thing on my mind was finding the next solution so I could continue with my day, or even just take care of things like feeding myself, bathing myself, and showing up to see my daughter,” she said.
Brewer recalled feeling relief after getting his prescription refilled. His panic disappeared.
“Now I can worry about everything else,” he recalled thinking as he drove home to Asheville.
