New Hampshire, Long Grappling with Substance Abuse Issues, Struggles to Combat Opioid Addiction Picture in Ashley Hurteau s Office at Safe Harbor Recovery Center. Left is Hurteau s arrest photo taken in December 2015. On the right is a more recent one. By Myra Shah Ashley Hurteau was addicted to heroin in 2015, a dangerous obsession that had controlled her life for over a decade. She had already relinquished custody of her toddler son to her parents when she lost her husband to an overdose that year. But it wasn t until her arrest six months later that Hurteau started to turn her life around. Now Hurteau has joined a statewide effort to help people move into recovery. She has been sober for 15 months and thriving on the benefits of helping others.
I didn t start out to save anybody. I was holding on for dear life, said the 32-year-old volunteer and program coordinator at the nonprofit Save Harbor Recovery Center in Portsmouth. I m right where I m supposed to be. New Hampshire has the second highest rate of drug overdoses per capita in the country, according to the 2015 US Centers for Disease Control and Prevention numbers, with more than 470 people dying in 2016. Long troubled by high rates of alcohol and marijuana use, officials and advocates in this New England state with a population of 1.3 million are scrambling to combat the latest scourge to threaten their people, opiate abuse and overdoses. They are seeing some improvements. Our overdose death rates continue to rise, but last year they rose at a slower level than they had since the epidemic of opiate abuse began, said Timothy Rourke, the Director of Substance Use Disorders, Grantmaking and Strategic Initiatives at New Hampshire Charitable Foundation. We are seeing some early indices that give us some hope that we are moving in the right direction. Over the last two years, New Hampshire launched a mulit-pronged system that will tackle its substance abuse problem through trying to quell the surging number of deaths, reduce and track access to drugs and help those in recovery. Not enough time has passed to measure results, and there is much more work to be done, but some early indicators are showing that the state is making some progress. Here is a look at how the state is responding. Saving Lives During each of the past two years, more than 400 men and women in New Hampshire like Hurteau s husband died from drug overdose, and efforts to save lives took priority. In early 2015, the state provided training on the use of naloxone to police and fire department personnel, since they are often the first on the scene of potential overdoses. Naloxone, also known by the brand name Narcan, is a prescription drug that can reverse the effects of opioids and save a person from overdosing. That same year, the state also distributed nearly 5,000 naloxone kits to high-risk individuals or their friends and family. The New Hampshire Bureau of EMS reported that Narcan was used almost 3,000 times in 2015. Lawmakers also passed the Good Samaritan Law in 2015, a measure that provides immunity from prosecution for victims of an overdose or witnesses that call for help, in an effort to remove criminal prosecution as a reason for someone not seeking emergency help.
New Hampshire lies on Massachusetts s northern border. About 20 percent of the state s 1.3 million residents are under the age of 18, and the majority of the population, just over 93 percent, is white. With no sales tax and state run liquor stores, New Hampshire s per capita alcohol sales are the highest in the country. Residents are also using marijuana at higher rates than the rest of the country, and adolescent usage is among the highest in the nation, according to the New Hampshire s Bureau of Drug and Alcohol Services. Research shows that the younger a person is when they start using alcohol and drugs, the higher the risk is that they will later face substance use problems. There is also the risk that marijuana and alcohol use may lead to other drugs, including opiates. In New Hampshire, the misuse of prescription pain pills among young adults age 18 to 25 is among the highest in the country, according to the New Hampshire Department of Health and Human Services. Massachusetts is the entry point of illegal drugs into New England, according to the Drug Enforcement Administration (DEA). Its close proximity to New Hampshire allows easy movement of illegal prescription drugs, heroin and fentanyl into the state. Fentanyl, more potent than prescription pain pills or heroin, is now the main opiate in drug overdoses in New Hampshire, according to the state s Office of the Chief Medical Examiner. Kim Fallon, the chief forensic investigator at the office, sends out regular updates on drug overdose numbers to agencies and the media. At first she thought users did not know they were getting fentanyl, since it is often mixed with heroin or pressed into what looks like prescription pills. I thought if you got the word out that this is fentanyl, this is really deadly, that people would stay away from it, Fallon said. Since then I have heard that people will find out that someone has died from this, and that they want it because that is how good the drug is. While naloxone distribution and the Good Samaritan law may reduce overdose numbers, they will not stop or prevent opioid abuse. Other state measures are directed toward those efforts. Stopping the Addiction New England states have been hit particularly hard by opioids, and the number of pain pill prescriptions is linked to overdose numbers. The CDC reported that in 2012 the Northeast prescribed the most prescriptions per person for long-acting and high dose painkillers, and New Hampshire topped the list along with Maine. And since pain pill addiction can lead to heroin use, the prevention of prescription opioid misuse is crucial to the state s efforts to reduce abuse and overdoses. The National
Institute on Drug Abuse found that 80 percent of heroin users abused prescription pain medication first. In November 2016, New Hampshire Board of Medicine adopted opioid prescribing rules, replacing the emergency rules that went into effect in May of that same year. The rules established standards for providers prescribing opioids for use outside of a hospital setting. The rules also limited emergency departments and urgent care centers from prescribing opioids for a period longer than seven days in most circumstances. Providers are now responsible for discussing risks with patients, and using an opioid checklist. Prescribers must now complete a three-hour opioid prescribing course every two years. And, a law passed to require providers to check the prescription drug monitoring program twice a year when prescribing opioids for chronic pain. The CDC has recommended the use of a drug monitoring program for years. The program can alert providers to patients who may have multiple prescriptions or who doctor shop, going from doctor to doctor to obtain additional prescriptions. The program also provides background information on patients that can assist a provider with assessing the risk for prescription misuse, in an effort to prevent it. After Florida implemented the system in 2010 along with stricter prescribing laws, the state saw a 50 percent reduction in opioid overdoses by 2012, according to the CDC. Michelle Ricco Jonas, the program manager for New Hampshire s prescription drug monitoring program, said that she hopes to collect data to better understand high-risk trends, and to identify where money can be used for prevention, treatment, and recovery. She said the state is struggling to implement the program, one of the last to do so in the United States. The 49 th state to establish a drug-monitoring program, New Hampshire did not put a system into place until October 2014, and at that time, it was voluntary. It only became required in January of this year. Ricco Jonas said that up until recently she was the only employee. She now has an assistant, and said they were fortunate to receive a stipend to hire a part-time person for analytics. She hopes this person will also help secure a grant to allow more focus on analyzing the data. New Hampshire sort of got catapulted, Ricco Jonas said. A lot of other states got to go through their growing pains and grow at a slower pace. Access to Treatment New Hampshire s access to substance abuse treatment is the second lowest nationally, according to Substance Abuse and Mental Health Services Administration (SAMHSA). Only six percent of the people who need treatment, receive it and those who enter treatment pay for more than 50 percent of it out-of-pocket versus 17 percent nationally,
according to a report by New Futures, a nonprofit that works to reduce and prevent drug and alcohol abuse in the state. During the last few years, the state has worked to improve access to care, and remove barriers like pre-authorizations and insurance denials. A statewide hotline, online treatment locator, and regional access points have aimed at improving access for someone ready for help. With the implementation of the Affordable Care Act in 2014, New Hampshire expanded coverage of the state s Medicaid program. This provided 50,000 people with coverage, and 7,500 of those accessed substance abuse treatment, which the ACA required. The state expanded the coverage temporarily while federal money covered it. In 2016, the state decided to continue the coverage, based mostly on the opioid crisis it faced. That year, the state also received a Medicaid waiver in the amount of $150 million over five years earmarked to overhaul how behavioral health is delivered. Even with state Medicaid, accessing treatment continues to be challenging, according to Hurteau. If somebody has Medicaid, there are only so many facilities that take that, and those waitlists are pretty substantial, she said. You re looking at a four to six weeks waitlist. It comes down to does that person make it out alive in those four to six weeks. The state passed a bill in 2016 that allowed immediate access to treatment in crisis situations, and in some cases, allows a provider to override the need for insurance preauthorization. We are building this infrastructure in the midst of a crisis, said James Vara, the governor s adviser on addiction and behavioral health. Which is never the way you want to do it, but it is the place we are in. What s Next? When the opioid epidemic arrived in 2012, New Hampshire s substance abuse resources already lagged behind the state s needs. Those who needed treatment faced barriers to accessing it, and the state provided little funding to support improvements. The foundation for the opioid epidemic started many years before the state called it a crisis. In the 1990s, pain experts began to focus on the management of chronic or longlasting pain, described in a study as pain that last for three months or longer. Chronic pain is often a result of tissue injury or nerve damage or dysfunction, and opioids began to be the drug used to treat it. Before this, prescription opioids were primarily used to treat pain related to cancer, end-of-life care, and acute pain.
The number of prescriptions for oxycodone and hydrocodone, the name brands of the leading prescribed painkillers, increased every year in the 90s. We know now, that deaths by opioid poisoning were increasing right along with the rising number of prescriptions. According to the CDC, numbers for opioid prescriptions have almost quadrupled, while overdoses from opioids have more than quadrupled in the United States since 1999. Though substance abuse has been a problem for New Hampshire for many years, the number of opioid deaths in the state, more than one a day, has finally helped push more legislation and initiatives forward over the last couple of years, and has started what Rourke calls a genuine and real conversation about addiction. I have been working the addiction field since no one was talking about this issue, he said. To have everybody from a new person in the House of Representatives to our current governor speaking loudly and publicly about doing great work in this arena is somewhat unprecedented. Hurteau s path to recovery in December of 2015 started in the state s drug court program. It was not her first time through the program, but she said that this time was different. A relapse alone is no longer punished, but is now treated as a health condition. She said the treatment plan is reviewed, and adjustments are made based on the needs of the individual. Her position at Safe Harbor Recovery Center recently took her back to prison. This time she visited to connect with inmates as part of her outreach work. I went to talk to them about Safe Harbor for when they get out, Hurteau said. To let them know we exist, so that they can have a safe place to go, instead of having society smack them in the face. Had I had a place to go where the main purpose was to serve people like myself, maybe things would be different, she said.
Sources: Michelle Ricco Jonas, Program Manager of the Prescription Drug Monitoring Program Michelle.RiccoJonas@nh.gov, 603-271-6980 Timothy Rourke, Director, Substance Use Disorders, NH Charitable Foundation tr@nhcf.org, 603-225-6641 Ext. 1295 Kim Fallon, Chief Forensic Investigator, Office of Chief Medical Examiner kim.fallon@doj.nh.gov, (603) 271-1235 x4 James Vara, Governor s adviser on Addiction and Behavioral Health James.Vara@nh.gov, 603-856-3854. Ashley Hurteau, Volunteer and Program Coordinator, Safe Harbor Recovery Center AHurteau@granitepathways.org, (603) 715-6834 Cassandra Thomas, Recoveree, Safe Harbor Recovery Center CDC Drug Overdose Numbers https://www.cdc.gov/drugoverdose/data/statedeaths.html Opioid Pain Pill Prescribing https://www.cdc.gov/vitalsigns/opioid-prescribing/ National Institute on Drug Abuse https://www.drugabuse.gov/publications/drugfacts/heroin#references New Hampshire Medical Society https://www.nhms.org/resources/opioid New Futures- Substance Misuse Report: http://www.newfutures.org/sites/default/files/pages/attachments/the%20corrosive%20effects%20of%20 Alcohol%20and%20Drug%20Misuse%20on%20NH s%20workforce%20and%20econo my_1.pdf New Futures: Medicaid Access http://www.newfutures.org/sites/default/files/pages/attachments/initiative%20%232 %20-%20SUPPORT%20PERMANENT%20MEDICAID%20EXPANSION.pdf Access NH Medicaid Expansion https://www.healthinsurance.org/new-hampshire-medicaid/ Alcohol Consumption: https://pubs.niaaa.nih.gov/publications/surveillance98/tab3-3_12.htm
CDC, Youth Behavioral Risk Surveillance System, 2013 https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5308a3.htm American Health Rankings, NH: http://www.americashealthrankings.org/explore/2016- annual-report/measure/drugdeaths/state/nh - drug deaths, alcohol abuse and public health funding Substance Abuse terms: https://www.dhhs.nh.gov/dcbcs/bdas/documents/issue-brieftreatment.pdf CDC importance of PDMP and prescribing laws: https://www.cdc.gov/psr/2013/prescriptiondrug/2013/nh-pdo.pdf New Hampshire drug and Alcohol use compared to national numbers https://www.dhhs.nh.gov/dcbcs/bdas/documents/nhseow121511.pdf Early use, greater risk for addiction https://www.samhsa.gov/data/sites/default/files/webfiles_teds_sr142_ageatinit_07-10-14/teds-sr142-ageatinit-2014.pdf Narcan Use https://www.nh.gov/safety/divisions/fstems/ems/documents/narcanuse_2012to5 _2016.pdf Young Adult Prescription Pain Pill use: https://nhshp.wildapricot.org/resources/documents/opioid%20crisis%20factsh eet_final.pdf DEA 2016 National Drug Threat Assessment Summary https://www.dea.gov/resource-center/2016%20ndta%20summary.pdf