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Unlocking Fentanyl's Grip on the Granite State

By Susan Green

Geisel School of Medicine researchers are on the forefrontof 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 powerful synthetic opioid.

The Dartmouth-based Northeast Node of the National Drug Abuse Treatment Clinical Trials Network, in a joint effort with a team of investigators from Dartmouth's Center for Technology and Behavioral Health (CTBH), took a closer look into what is driving New Hampshire's complex problem.

Their two-phase rapid epidemiological HotSpot Study included in-depth meetings with key stakeholders statewide—the Bureau of Drug and Alcohol Abuse, the Opioid Task Force, community coalitions, law enforcement, and fire departments.

They also delved into drug users' experiences and perspectives, along with those of first responders and emergency department personnel who treat overdose. Interviews spanned users in six New Hampshire counties with a specific focus on two 'hot spot' counties bordering Massachusetts: Hillsborough and Stratford—the epicenter of the crisis with a majority of fentanyl overdose deaths. Most of those interviewed said the principal suppliers of fentanyl in New England are based in the Massachusetts towns of Lawrence and Lowell.

This shared border gives Granite State users easy access to the readily available, highly potent drug. Fentanyl is a 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.

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. 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.

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 because of numerous obstacles.

The study also revealed a need to understand more about the tightly knit social networks in rural communities with economic disparity—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.

Given the study's overall findings, there is an opportunity for integrating new care models extending beyond hospital emergency departments reversing overdoses.

For example, Safe Station, launched in 2016 and heralded by users, is the Manchester Fire Department's novel response to 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 will pick up those seeking treatment from other fire station locations thereby removing obstacles to treatment.

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 own communities.

HotSpot's investigators have launched a systematic study to understand the characteristics responsible for Safe Station's success and to create guidelines to ensure its sustainability.

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Geisel School of Medicine at DartmouthDartmouth-Hitchcock Medical CenterWhite River Junction VAMCNorris Cotton Cancer CenterDartmouth College