HotSpot Study Shines New Light on the Granite State’s Opioid Crisis

Geisel School of Medicine researchers are on the forefront of trying to solve one of the nation’s toughest problems—the high and escalating rate of accidental opioid overdose deaths. New Hampshire leads the nation with the highest per capita deaths from overdoses of fentanyl, a synthetic opioid.

To identify and understand the confluence of factors giving rise to the disproportionally high overdose rates in the Granite State, the National Drug Early Warning System (NDEWS) funded by the National Institute of Drug Abuse (NIDA), reached out to the Dartmouth-based and NIDA-funded Northeast Node of the National Drug Abuse Treatment Clinical Trials Network (CTN) asking for a closer look into what is driving New Hampshire’s complex problem.

The Northeast Node of the CTN, in a joint effort with a team from Dartmouth’s Center for Technology and Behavioral Health (CTBH), recently completed Phases 1 and 2 of a rapid epidemiological HotSpot Study.

Andrea Meier, director of operations for the Northeast Node and lead investigator, says Phase 1 of the HotSpot study, so named because of New Hampshire’s status as an opioid hot spot, included intense meetings with key stakeholders statewide—the Bureau of Drug and Alcohol Abuse, the Opioid Task Force, with community coalitions, law enforcement, fire departments, and first responders.

Those initial conversations, which excluded opioid consumers, yielded only anecdotal speculation about the crises.

Consequently, the following six-month Phase 2 investigation delved into drug users experiences and perspectives, along with those of first responders and emergency department personnel who treat overdose. Interviews spanned six New Hampshire counties with a specific focus on two southern counties bordering Massachusetts: Hillsborough and Stratford—the epicenter of the crisis. A majority of fentanyl overdose deaths are occurring in Manchester and Nashua, cities in Hillsborough County.

According to the report, fentanyl is locally manufactured in, and distributed from, Massachusetts. “Most of those we interviewed said the principal suppliers of fentanyl in New England are based in Lawrence and Lowell,” says Lisa Marsch, PhD, a professor of psychiatry and of health policy and clinical practice at Geisel, and director of the CTBH.

Sharing a border with Massachusetts gives Granite State users easy access to the readily available, highly potent drug. Reportedly, dealers sell fentanyl at a higher price in New Hampshire than in their home state, so there is an economic advantage to targeting their northern neighbors—a bag of fentanyl-laced heroin sells for less than a six-pack of beer. And while the price for both fentanyl and heroin has dropped, the profit margin remains substantial.

Fentanyl is relatively new synthetic opioid similar to morphine, but faster acting and far more potent. According to the study’s respondents, it appeared on the New Hampshire scene a few years ago mixed with heroin. But fentanyl, because of its high potency and cheaper cost, has emerged from heroin’s shadow as the drug of choice, making heroin less desirable. Users report actively seeking drugs that cause overdose, and these often include fentanyl.

With heroin you have to transport the product, but if you can make fentanyl in your home, that makes preventing this escalation even more challenging.”

- Lisa Marsch, PhD

The evolution of clandestine mixing houses, which manufacture non-pharmaceutical grade fentanyl at home, complicates the problem further. The methodology for creating the drug isn’t terribly sophisticated and doesn’t require a detailed understanding of chemistry, but when a large quantity of fentanyl precursor is transformed into fentanyl it can be worth millions of dollars on the market.

“This is something a number of consumers talked about so it’s something else we need to understand,” Marsch says. “With heroin you have to transport the product, but if you can make fentanyl in your home, that makes preventing this escalation even more challenging.”

Historically, New Hampshire has consistently been among the top 10 states in the U.S. for high overall rates of drug use—rates of prescribing opioids exceeds national averages leading to risk of dependency. And with low spending on prevention and treatment programs there are limited resources available statewide to effectively mitigate the risk of addiction. Some users say they’ve given up on seeking treatment—it is not really an option because of too many obstacles.

“This is the baseline from which we started the study,” Marsch says. “Our recent history of prescribing includes not only long-acting, extended release opioid prescriptions at higher rates than the national average, but higher dose opioid prescriptions flooded the market thereby contributing to demand.”

When it comes to treatment, New Hampshire has the lowest per capita spending for drug treatment in New England and the second lowest in the nation. Only Texas spends less. Low rates of Suboxone® (a combination of buprenorphine and naloxone that effectively treats opioid addiction) prescribers per capita, an absence of needle exchange programs, significant barriers to accessing Narcan® (an overdose reversal drug), and, according to some respondents, the state’s rural setting, all contribute to the escalating problem.

“We also need to understand more about the tightly knit social networks in rural communities with economic disparity—decades ago they were booming and now the jobs are gone,” Marsch notes. “The economic context of this along with the rural social network may function to propagate patterns of use.”

A similar pattern has been observed in West Virginia, the only state with more opioid overdose deaths than New Hampshire. With further investigation, the intersection of rural economic degradation, coupled with the HotSpot findings, may be key factors to unlocking fentanyl’s grip on the Granite State.

Given the study’s findings, there is a tremendous opportunity for integrating care models that extend beyond hospital emergency departments reversing overdoses—some users are taken to hospital emergency departments multiple times a day from overdosing. Meier says new models need to emphasize prevention as well as breaking the intergenerational cycle of abuse and addiction alongside treatment and overdose reversal.

Safe Station, which launched in 2016, is the Manchester Fire Department’s novel response to the increasing availability of fentanyl and carfentanil, an opioid far stronger than fentanyl, responsible for the surging overdose death rate in the city.

Created as a connection to recovery, the 24-hour program welcomes opioid users seeking help at any one of Manchester’s 10 fire stations. Fire department personnel quickly assess each walk-in’s vital signs to determine the level of medical attention needed—those who have overdosed are immediately given naloxone and transported to a local emergency department if necessary. At the Central Station, those seeking treatment are escorted directly to Serenity Place, a drug and alcohol rehab facility co-located to the fire station. Certified counselors from Serenity Place will pick-up those seeking treatment from the fire station’s other locations.

In the Safe Station model, complex obstacles to treatment are removed—individuals have access to non-stigmatizing locations with professional personnel who are able to link them to the resources they need.

Since its inception nearly 16-months ago, the innovative program has helped more than 2000 people ranging from 18 – 70 years old, and not just local residents. People from states as far away as Oregon and Florida have traveled to Manchester to participate in the program. And fire departments from New York City to Los Angeles are interested in learning how to emulate this model in their communities.

We still have a lot to do. But for our country, the biggest challenge is wedding initiatives to tackle the opioid crisis to science, if we don’t we are wasting resources.”

- Lisa Marsch, PhD

Meier says consumers in the HotSpot study were clear about the value of Safe Station, which has resulted in a NIDA-funded Safe Station study launching this month. “Our goal with this systematic study is to reveal and understand the characteristics of Safe Station that are key to its success, to create guidelines so others can replicate a successful model—and to make sure Safe Station is sustainable.”

Both Marsch and Meier agree that solving this problem is part of a larger national conversation, but Marsch is delighted these projects are taking place in New Hampshire. “There is such a need here to take what we’ve learned from the research and work with our community partners to create sustainable models,” she says. “We still have a lot to do. But for our country, the biggest challenge is wedding initiatives to tackle the opioid crisis to science, if we don’t we are wasting resources.”

The NH Hotspot study was funded by the National Institute on Drug Abuse (NIDA) through its National Drug Early Warning System (NDEWS) to the Center for Technology and Behavioral Health (CTBH). Grant #U01DA038360-Z0717001; PI: Marsch. The Safe Station study is also funded by NIDA to CTBH. Grant # 3P30DA029926-07S1; PI: Marsch.