A day after Hurricane Helene ripped through western North Carolina in late September 2024, Toni Brewer had no power or water. The storm had strewn fallen trees across most roads, wiped out phone and internet communications, and put some neighborhoods near her Asheville home under water.
Brewer cleared 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 she arrived, she opened the center console of her car, where she kept medication, and discovered another crisis. She had only three days' worth of Suboxone, a brand of buprenorphine, a prescription drug that eases opioid cravings. Without it, she risked relapsing into a life she described as miserable.
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She recalled what it felt like to have those cravings and panicked.
"It's terrifying just to have that feeling again of, 'I need this, and I'll do whatever it takes to get this,'" said Brewer, who had been in recovery from opioid addiction for 18 months at the time. She needed a new prescription but knew communication lines 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 physicians working in addiction medicine published an American Journal of Public Health editorial that outlines strategies for getting medication to people in recovery during natural disasters.
As climate change threatens to cause an increased number of disasters in the U.S., the group of doctors urged state and federal governments to act soon or risk allowing more disasters to aggravate overdoses, relapses, and deaths caused by opioid use disorder, an ongoing epidemic that has killed more than 800,000 in the U.S. since 1999.
One study estimated that after Superstorm Sandy in 2012, 70% of New Yorkers who relied on recovery medications couldn't get enough of them. In the two years following Hurricane Maria's devastation in Puerto Rico in 2017, overdose reports increased, another study found. The Tubbs and Camp fires in Northern California caused substantial disruptions in patients' access to opioid addiction medications, a study published in 2022 found.
A combination of factors aggravates the opioid crisis in the U.S., the AJPH editorial authors noted. Mental health stressors, treatment disruptions, drug market volatility, and economic decline all create conditions in which climate-related disasters heighten the risk of overdose deaths.
"We make it so challenging for them to access treatment medications in the first place," said Elizabeth Cerceo, the climate health director at Rowan University's Cooper Medical School and a co-author of the editorial. "When people are displaced or unable to get to their usual clinics or pharmacies, those challenges just become insurmountable."
Their push comes as President Donald Trump has had a markedly different approach to substance use policy in the past year than in his first term. In 2017, Trump declared the nation's opioid crisis a national public health emergency and signed a law, 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 staffers last year at the Substance Abuse and Mental Health Services Administration and ending numerous grants to advance research on prevention efforts.
Disasters threaten treatment
The Substance Abuse and Mental Health Services Administration works with states to ensure that access to opioid use disorder medication isn't disrupted, Health and Human Services spokesperson Emily Hilliard said. States can approve emergency measures to allow people more flexibility to obtain their treatments, she added, which North Carolina did.
Cordelia Stearns, another co-author of the editorial, saw these access issues play out in the wake of Hurricane Helene.
Stearns, the chief medical officer at High Country Community Health in North Carolina's Blue Ridge Mountains, said the first calls to her clinics were for buprenorphine. She said people who needed the medication traveled over mountains and crossed rivers to get to her clinics.
"The things that my patients did to be able to access their bupe," Stearns said, "it was astonishing."
The authors of the editorial recommend that the federal government work with pharmacies to allow patients to take home more medication during emergencies. They suggest keeping a registry of patients with recovery medication prescriptions who can get treatment when evacuating across state lines.
And they propose factoring the need for such medications into disaster response plans, whether that means stocking rescue vehicles with buprenorphine, adding backup generators to opioid treatment clinics, or training volunteer responders.
People with substance use disorders already must often navigate strict, complex regulations to get the medications. For example, methadone can be obtained only through an in-person visit to federally controlled opioid treatment centers, many of which closed for days or weeks after Hurricane Helene.
Buprenorphine is controlled by the Drug Enforcement Administration's suspicious orders report system, which restricts supply when pharmacies order more than allowed under specified thresholds. The system is meant to catch potential overuse of recovery medication in a region.
Blake Fagan, a clinical director of substance use disorder initiatives at the Mountain Area Health Education Center in western North Carolina, said that system delayed medications numerous times in the aftermath of Helene. No exceptions were allowed, Fagan and his colleagues reported.
The agency did not respond to questions about the system.
Individual pharmacies also control who gets medication and who doesn't. When people try to get medication for opioid use disorder far from home, it can raise alarms.
"We realized there were some pharmacies that would just be like, 'I don't know this person. I will only give you three days' worth, and I'm sure they'll be back in Asheville soon,'" Fagan said. "They didn't want to fill a month's worth. And in our mind, we're sitting in the disaster, and we're like, 'They're not coming back in a month.'"
Risk of relapse
When Brewer made it to Franklin, she immediately logged in to the Mountain Area Health Education Center patient portal, dubious about whether she would be able to have her three-month Suboxone prescription refilled.
She didn't know that her doctors had left the area, too, to get a stable internet connection. They were trying to call and email patients to fill prescriptions.
Trying to be thorough, Brewer messaged several doctors. Two responded, and one filled her prescription.
But when she went to a local Walgreens, it was out of Suboxone. So Brewer took another trip, this time to Clayton, Georgia, where she was finally able to pick up a month's worth.
The medication that would have been mostly covered by North Carolina Medicaid if she'd stayed in-state was about $130, a high price for Brewer, who had temporarily lost her job when her workplace, a sober living facility, lost power and closed because of the storm.
Despite what little income she had at the time, Brewer said, she paid for her prescription. The thought of relapsing back to her previous life when her addiction was untreated scared her, she said.
"I would wake up every day, and the only thing on my mind was finding my next fix so I could go on about my day, or even just take care of things like feed myself, or bathe, and show up for my daughter," she said.
Brewer recalled feeling relief after getting her prescription refilled. Her panic washed away.
"Now I can worry about everything else," she recalled thinking as she drove home to Asheville.
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