Geisel School of Medicine researchers are on the forefront of trying to solve 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) 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,” said 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, 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.

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.

Historically, New Hampshire has consistently been among the top 10 states in the U.S. for high overall rates of drug use. 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.

Meier said new models need to emphasize prevention as well as breaking the intergenerational cycle of abuse and addiction alongside treatment and overdose reversal.