Despite mounting public awareness, New Hampshire, like other states, struggles to contain its opioid epidemic. Part of the problem is a lack of real-time information about who’s using opioids, especially fentanyl, and how government policies can help them stop.
Lisa Marsch is among a group of researchers hoping to fill that information gap. Marsch is director of the Dartmouth Center for Technology and Behavioral Health, and with funding from the National Institute on Drug Abuse, she and her colleagues recently interviewed opioid users and first responders throughout New Hampshire, asking about how someone becomes addicted and how they can be helped.
Marsch spoke with NHPR’s Peter Biello about the new study.
When you went into this study, before your team began conducting interviews, what were the questions that you wanted answers to?
The goal of this study was really to understand the confluence of factors that are giving rise to the disproportionately high rate of fentanyl overdoses that we’re seeing in New Hampshire. New Hampshire has the highest rate of fentanyl overdoses per capita relative to any other state in the U.S. and has experienced a doubling of fentanyl deaths in the past couple years.
So the goal here was to conduct a rapid, epidemiological study in which we conducted systematic interviews and surveys with active fentanyl and heroin users as well as a number of first responders, emergency department personnel, fire personnel, police, and emergency medical services—to understand what’s happening in New Hampshire communities, to better inform community response to the crisis.
Let’s go through some of your findings. What surprised you about the stories you heard from users and first responders?
I think one issue that was quite surprising is that consumers are actively seeking out fentanyl. There was some misconceptions that they were seeking out heroin and accidentally getting fentanyl mixed in. Certainly that was the case for some consumers, especially early on in the fentanyl crisis, but there’s a significant market demand for fentanyl.
In fact, if you talk to folks in Southern New Hampshire, where this has been the main focus of the crisis, heroin they say is becoming a thing of the past, and the product is fentanyl.
One of the surprising things I saw in your study is that you quoted one person saying, “If you find a heroin dealer, pretty much, you’re finding fentanyl.”
Yes, indeed, and that’s increasingly the case. We saw a couple years ago there was a lot of heroin [and] fentanyl product combined, but now it’s heavily fentanyl product as the product of choice.
What did fentanyl and heroin users say about how they got started?
The majority of the respondents started using opioids with prescription opioids. Over 80 percent of our participants had their introduction to opioids with a prescription opioid, either used non-medically or many were prescribed opioids for pain management.
On average, we found that a couple of years after the prescription opioid use, these folks shifted to heroin use, then a couple of years after the introduction to heroin, we saw a transition to fentanyl.
So it’s an interesting trajectory from pills, to heroin, to fentanyl in most of our respondants.
Emergency responders in New Hampshire and elsewhere have been using Narcan, which counteracts overdoses. Your report found that users have a complicated relationship with Narcan, even though it occasionally saves their lives. Can you tell us a little bit about how users feel about Narcan?
Yeah, so Narcan is an effective overdose reversal medication, and it can save one’s life if they are overdosing. What we find, though, is that there is some tension often at the scene of an overdose, where some folks at the scene may be reluctant to call first responders because the overdose scene may be treated as a crime scene, despite the presence of Good Samaritan laws, and they’re worried that they may have personal consequences if they’re at the scene or have some drug paraphernalia on them.
Because while we say that you can call and get help, there’s still distrust of police.
Absolutely, that was a very consistent theme in our study.
One thing that surprised me about the interactions of first responders and those getting Narcan is that those who are brought back from near-death are very angry. They’re angry that they’ve been brought back.
Oh yes. Very angry and often very aggressive, so they want to rapidly exit the emergency department or wherever the overdose reversal has taken place, and can be aggressive toward the person who just saved their lives .
Last week, the CDC reported that opioid prescriptions have dropped nationwide, though the trend was not consistent. In some New Hampshire counties, for example, prescription rates actually went up. And, people you interviewed believed that slowing prescriptions would only force users to turn to heroin. So how can New Hampshire and other states make progress in controlling prescription opioids?
Opioid prescriptions have started to decrease, as you said, in some parts of the country, but fatalities from opioids are still increasing as we know. I think what’s really key is that we have to curb our prescribing rates of opioids to prevent new generations of users, of individuals who are creating more and ongoing market demand for opioids. We have to break that trajectory at the beginning, with our prescribing practices, while at the same time tackling what we see in the synthetic opioid crisis.