Phase II of a National Drug Early Warning System (NDEWS) HotSpot Rapid Epidemiological Study
Andrea Meier, MS, LADC, LCMHC, Sarah K. Moore, PhD, Elizabeth C. Saunders, MS,
Stephen A. Metcalf, MPhil, Bethany McLeman, BA, Samantha Auty, BS, and Lisa A. Marsch, PhD
The Phase II rapid epidemiological HotSpot study was conducted for NDEWS by the Center for Technology and Behavioral Health (CTBH) with the support of the Northeast Node of the National Drug Abuse Treatment Clinical Trials Network (CTN), both based at Dartmouth College.
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Rates of synthetic non-methadone opioid overdose in New Hampshire have increased by nearly 1,600% from 2010 to 2015. From 2014-2015, the latest data available for this report, the state saw an increase of 94.4%, rising from 12.4 to 24.1 opioid overdoses per 100,000 residents in that year alone. The escalation is predominately driven by increased rates of fentanyl use and overdose. In August 2016, the National Drug Early Warning System (NDEWS) and the Center for Technology and Behavioral Health (CTBH) at Dartmouth College, with funding from the National Institute on Drug Abuse (NIDA), partnered to conduct a Rapid HotSpot study on New Hampshire’s synthetic non-methadone opioid (fentanyl) overdose crisis in two phases. During Phase I, researchers met with a diverse array of New Hampshire stakeholders to produce a report about the fentanyl outbreak, highlighting available data and information learned. Results of the Phase I study indicated that real-time data from opioid consumers and first responders was imperative to more accurately inform policy (Phase II). This report presents results from Phase II.


Phase II of the NDEWS Rapid HotSpot study was conducted as an epidemiological investigation into the experiences and perspectives of opioid users, first responders and emergency department (R/ED) personnel surrounding the opioid overdose crisis in New Hampshire. Seventy-six opioid consumers, 18 first responders, and 18 emergency department personnel were recruited from six counties across New Hampshire. Recruitment was heavily targeted in Hillsborough County, which has seen particularly high rates of opioid overdoses. Each participant completed a semi-structured interview and a brief demographic survey. Interviews focused on questions that arose during the Phase I HotSpot study, including trajectory of opioid use, experiences with overdose, trafficking and formulation of fentanyl, fentanyl-seeking versus accidental ingestion, the value of harm reduction models, prevention strategies and treatment preferences. Interviews were transcribed and analyzed using content analysis to condense the transcripts into content-related categories and review these for themes.


For this NDEWS HotSpot report, we conducted initial analyses of 20 consumers and 12 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) were male, 90.% (18) were white, and all (20) were neither Hispanic nor Latino. Responders were, on average, 47.8 (sd 7.2) years of age, 83.3% (10) were male, 91.7% (11) were white, and all who reported ethnicity (11) were neither Hispanic nor Latino.


Analysis of consumer and R/ED personnel interviews resulted in 10 identified categories:

  • Trajectory of opioid use
  • Formulation of heroin/fentanyl
  • Fentanyl-seeking behavior
  • Trafficking and supply chain
  • Experiences with overdoses
  • Experiences with Narcan
  • Harm reduction
  • Experiences with treatment
  • Prevention
  • Laws and policies



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. Responders report limited knowledge of the formulation of heroin/fentanyl.

Fentanyl-seeking behavior

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.

Harm reduction

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 waitlists, 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:

o   Increasing access to medication assisted treatment, especially Suboxone,

o   Medically-assisted detoxification, and

o   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.



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, an 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 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)


Download: NDEWS HotSpot Report: Understanding Opioid Overdoses in New Hampshire (109 pages)

Smaller file sizes are divided below:

Table of Contents

Executive Summary __________________________________________ 1
Introduction ________________________________________________  6
Study Participants: Full Sample ________________________________ 11
Study Participants: Subsample ________________________________ 13
Survey Results: Opioid Consumers _____________________________ 15
Survey Results: Responder and ED personnel ____________________ 23
Interview Findings by Category ________________________________ 25
Interview Findings by Category: Trajectory of Opioid Use ____________ 26
Interview Findings by Category: Formulation of Heroin and Fentanyl ___ 29
Interview Findings by Category: Fentanyl-seeking Behavior __________ 33
Interview Findings by Category: Trafficking and Supply Chain _________37
Interview Findings by Category: Experiences with Overdoses _________ 41
Interview Findings by Category: Experiences with Narcan ____________ 57
Interview Findings by Category: Harm Reduction ___________________ 63
Interview Findings by Category: Experiences with Treatment __________ 66
Interview Findings by Category: Prevention ________________________ 76
Interview Findings by Category: Laws and Policies __________________ 79
Discussion: Uniqueness of New Hampshire ________________________ 83
Next Steps __________________________________________________ 89
References Cited _____________________________________________ 90
APPENDIX __________________________________________________ 92







Last modified
10/08/2018 - 11:35 am