HotSpot Phase II Initial Report Released
July 1, 2017
The Northeast Node, alongside partners at our parent institution from the Dartmouth Center for Technology and Behavioral Health (CTBH), have released the initial findings from our Phase II HotSpot study, Understanding Opioid Overdoses in New Hampshire.
In collaboration with the National Drug Early Warning System (NDEWS), CTBH, with infrastructure provided by the Northeast Node, conducted the Phase II study to understand fentanyl use and opioid overdoses in New Hampshire (you can read more about the specifics of the study here).
Below is a summary of the initial data analyzed for the NDEWS HotSpot Report:
For the NDEWS HotSpot Report, the research team conducted initial analyses of 20 consumers and 12 first responder and emergency department (R/ED) personnel (3 Emergency Department, 3 Emergency Medical Services, 3 Fire, 3 Police).
Consumers were, on average: 34.1 (sd 7.5) years of age, 55% (11) male, 90.% (18) white, and all (20) neither Hispanic nor Latino.
R/ED personnel were, on average: 47.8 (sd 7.2) years of age, 83.3% (10) male, 91.7% (11) white, and all who reported ethnicity (11) were neither Hispanic nor Latino.
The following categories were identified from the 32 initial interviews analyzed for this report:
Trajectory of opioid use
The initial results suggest that consumers’ path to opioid use was typically associated with:
- Early recreational substance use,
- Severe injuries warranting a prescription opioid, sometimes followed by an abrupt taper,
- Intergenerational substance use among nuclear family members, and/or
- Self-medication of mental health conditions.
Formulation of Heroin and Fentanyl
Consumers report being able to distinguish between fentanyl and heroin by the substance’s color, taste, subjective effect, and cost. R/ED personnel report limited knowledge of the formulation of heroin/fentanyl.
Most consumers report seeking drugs that are known to have caused an overdose, but typically do not specifically seek fentanyl alone. The majority of consumers report being neutral or averse to using fentanyl but if they hear that it is present in a batch that caused an overdose, they report seeking that batch. R/ED personnel have mixed reports of this behavior among consumers.
Trafficking and supply chain
Consumers and R/ED personnel both report fentanyl hit the supply chain in New Hampshire in 2014-2015. Consumers and R/ED personnel report fentanyl is locally manufactured in, and distributed from, Massachusetts, as there is a potential profit from selling in New Hampshire versus Massachusetts. Demand in the state is driven by lower cost, higher potency, and easier availability. Many believe fentanyl originates in China or Mexico.
Experiences with overdoses
Almost two-thirds of consumers had experienced an overdose. Both consumers and R/ED personnel agreed that fentanyl is the primary cause of overdose in New Hampshire, largely due to its potency and inconsistency in fentanyl/heroin mixes. Both groups unanimously reported that overdoses in the state occur across all demographics.
Experiences with Narcan
Neither consumers nor R/ED personnel had observed any side effects from naloxone (Narcan) administrations, aside from its intended effect of precipitated withdrawal during overdose reversal. Despite this, consumers reported many barriers to obtaining Narcan including high cost, fear of police, fear of stigmatization, lack of knowledge, and fear of withdrawal after administration. No unanticipated side effects were observed.
R/ED personnel and consumers both endorsed the need for needle exchange programs in New Hampshire, in addition to increasing the availability of medication-assisted treatment, medically assisted detoxification, and other treatment services.
Experiences with treatment
Both consumers and R/ED personnel agreed that consumers cannot stop using opioids without help. Available services are lacking in New Hampshire and include lengthy wait lists, trouble navigating the system, and funding (both for consumers to afford care and for programs to provide it). Referral rates after overdose treatment are low due to staffing shortages. Recommendations for improvement include:
- Increasing access to medication assisted treatment, especially buprenorphine (Suboxone),
- Medically-assisted detoxification, and
- More counseling options.
Participants reported that additional prevention efforts are necessary and suggested early education about opioids (before middle school), dismantling the stigma around substance use, prudent prescribing of opioid analgesics, and more education for patients regarding pain and opioids. R/ED personnel expressed the need to mobilize communities to fight this epidemic.
Laws and policies
Consumers are not well informed about state laws and policies regarding opioid use. There is frustration and mistrust towards police and the justice system due to encounters with the criminal justice system, lack of treatment availability in jail and mistrust of the Good Samaritan Law (allowing consumers to report an overdose and be immune from prosecution at that event). Consumers and R/ED personnel reported that new prescribing crackdowns may reduce opioid prescribing but would likely mean an increase in heroin use. Prescription Drug Monitoring Programs were viewed as useful but burdensome by ED staff.
WHAT MAKES NEW HAMPSHIRE UNIQUE?
New Hampshire has significantly higher rates of prescribing of long-acting/extended release opioids as well as concurrent prescribing of high-dose opioids and benzodiazepines than the national average. The shortage of treatment funding and availability, lower rates of Suboxone prescribers per capita, the absence of a needle exchange program, barriers to accessing Narcan, and the proximity of interstate access to the supply chain were identified as making New Hampshire’s opioid problem unique from other states. Some consumers and R/ED personnel also identified the rural setting of New Hampshire as a contributing factor, i.e., “Live Free or Die.”
Based on data from this study, preliminary considerations for New Hampshire’s approach to tackling the opioid overdose crisis include:
- Increase public health funds targeting substance use;
- Expand prevention programs in elementary and middle schools;
- Strengthen treatment to include broader availability, non-prohibitive cost, and inclusion of medication-assisted options and holistic approaches;
- Incentivize physicians to become buprenorphine-waivered providers;
- Assist physicians with prudent prescribing of opioids, educating patients, and alternatives to pain management;
- Support first responder and emergency department personnel with vicarious trauma associated with responding to overdoses;
- Initiate needle exchange programs;
- Collaborate with Massachusetts on addressing the manufacturing and trafficking of fentanyl and other opioids; and
- Launch programming to dispel stigma and fear:
- Educate consumers (e.g., Narcan and Good Samaritan Law)
- Educate physicians and pharmacists (e.g., chronic disease management and value of Narcan)
- Educate law enforcement (e.g., alternative approaches to punitive measures)
- Educate the public (e.g., opioid crisis is not isolated to one demographic/area and breaking the intergenerational cycle of addiction)
Further analyses of the study data are underway by the Dartmouth research team.