According to data from the Drug Enforcement Administration, Dartmouth-Hitchcock Pharmacy in Lebanon distributed 5,146,260 opioid pills between 2006 to 2014, making it the pharmacy which dispensed the most opioids in Grafton County. While the number of pills is not irregular considering the size of the population the pharmacy serves, the data illustrates the opioid epidemic in the Upper Valley and New Hampshire, which is changing with a rise in fentanyl use despite the best efforts of local organizations to combat the problem.
Until recently, New Hampshire has been the state with the second-most opioid overdose deaths in the nation behind West Virginia, according to Gov. Chris Sununu’s advisor on addiction and behavioral health David Mara. In 2019, New Hampshire fell to third, with Ohio now occupying second place.
A report released by Sununu’s office found that there were 295 confirmed opioid deaths in the state of New Hampshire in 2019. According to Mara, the landscape surrounding opioids in New Hampshire has changed drastically since 2012 due to state and local policies, community-based initiatives and nonprofits.
“Back in 2012, we started seeing in New Hampshire a lot of pills, and we started seeing property crimes going up, particularly burglaries,” Mara said. “When we dug into it, what we found was that people were stealing a lot of pills. People were taking drugs from medicine cabinets.”
Mara said that, while many people first try opioids as a prescription, once opioids became more regulated, those same individuals began to turn toward illicit opioids like heroin and illegally manufactured fentanyl.
According to Mara, most of the heroin and fentanyl entering the Upper Valley comes in through Manchester via drug routes from Mexico.
“The Mexicans, they saw a marketing opportunity, and they started flooding the market with cheap, potent heroin,” Mara said.
Illegally manufactured fentanyl is stronger than heroin and cheap to make and obtain. The availability and popularity of heroin caused a shift in the market; according to the same report from Sununu’s office, there were no purely heroin related deaths in 2019, with all but 22 of the 295 opioid related deaths in 2019 being attributable to fentanyl.
“By 2015, it was all fentanyl, and that was a marketing decision made by the Mexican cartels, because [fentanyl] is a lot more potent, and they can use the same smuggling routes,” Mara added.
According to director of the Dartmouth Center for Technology and Behavioral Health Lisa Marsch, Grafton County is not as affected as many other counties in New Hampshire. The counties most affected are closer to the Massachusetts border and Manchester, so the center has yet to do research on Grafton County specifically.
“While it is the case that rural communities were, early on, hit the hardest, there historically has been a higher density of substance problems in certain communities that have less resources,” Marsch said.
Former member of the Addiction Policy Forum Kimberly Lohman Clapp said that the best ways to mitigate addiction to opioids or any addictive substances are by reducing trauma in a child’s life, delaying onset of the first use of any addictive substance and providing ample positive social experiences for kids like sports, clubs and a sense of belonging. She added that it is critical to teach children and adults that addiction is preventable and treatable, and that it is a brain disease.
In her research, Clapp has found that most of the illegally manufactured opioids in the Upper Valley are coming in from Mexico and China. She noted the important distinction between the prescription fentanyl — which is tightly controlled by hospitals to manage pain during surgery — and the fentanyl that accounts for most opioids death statewide.
“The fentanyl making its way into street drugs is an illegally produced synthetic drug that is cheaper to produce than heroin, and 50 times more potent,” Clapp said. “This fentanyl is also 100 times more powerful than morphine. Oftentimes, the person using cocaine or heroin is unaware that the drug is cut with fentanyl.”
Senior director of state chapters at APF Doug Griffin echoed many of Clapp’s sentiments, and he added that much of the fentanyl coming in from China is available for purchase online and is delivered through U.S. Mail. Additionally, Griffin stated that much of the fentanyl entering the Upper Valley comes from towns in Massachusetts like Lawrence and Lowell. He also said why the Upper Valley and New Hampshire, like many rural communities, are more vulnerable to the opioid epidemic because of their isolation.
“The Upper Valley suffers from a lack of resources, [and] the sparse population allows isolation by those using drugs,” Griffin said.
In the decades since the opioid crisis began, many individuals and organizations around the state have done work to mitigate harm. For example, the Dartmouth-Hitchock Medical Center’s HIV/HCV Resource Center runs three syringe service programs and offers fixed site programs in White River Junction and Springfield.
Advanced practice addiction nurse at DHMC Daisy Goodman runs a program that helps pregnant mothers deal with addiction throughout their pregnancy. According to Goodman, DHMC provides “wraparound services” so that these mothers may have their psychiatric needs met, as women with substance use disorders oftentimes also have co-occurring psychiatric needs. Goodman’s program provides childcare services while mothers are in treatment and helps mothers apply for subsidized housing.
According to Dr. Charles Brackett, a general internal medicine doctor at DHMC, another significant program is the New Hampshire Doorway program. The Doorway program helps people struggling with opioid use disorder access clean needles and also offers recovery services
According to Brackett, the program has expanded so that individuals are never more than eight miles from a Doorway.
Although opioid deaths in New Hampshire are currently trending downward, Goodman said she feels that there is much more work left to be done locally, and looks forward to the expansion of addiction disorder support programs.
“We need ethics as a society and as a community, as the Upper Valley,” Goodman said. “But think about this really as a community issue. It’s not about suicide. We, as a community, need to wrap our arms around families and say, ‘What happened to you? What do you need? How can we help to develop the services that are needed right here in the Upper Valley for our families?’”
Correction appended (March 5, 2020): This article originally stated the DHMC offers a needle exchange service called Project 439 in Lebanon, but Project 439 is no longer active. This article also referred to a “recovery clinic” known as “Recover.” However, syringe service programs are not recovery clinics. The online version of this article has been updated to more accurately reflect the state of services offered.