New Hampshire plays a pivotal role in the primaries, but with the state battling record overdose deaths, an epidemic is moving into national spotlight again

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Kelly Riley’s voice instantly cracks as she remembers her son Richie.

It’s been eight years since he died, but the grief never leaves a mother who wished there was something more she could do. Like countless others, Richie was a victim of a heroin epidemic that has quickly accelerated into one of the biggest public health crises facing the United States.

“I get up in the morning,” Riley says. “But because of a lot of grief and tragedy, mornings are hard.”

She trails off while trying to keep her composure, but the tears begin to flow. Her son was only 24 years old when he died while trying to overcome the crippling disease of substance abuse.

Richie had gone to a treatment facility and was on the road to recovery, but he lacked basic services such as counseling and community support groups to keep him on track. Riley herself is in long-term recovery and did her best to juggle her own struggles with those of her son.

But in 2007, Richie overdosed – a young man and an entire future lost in a sea of harrowing statistics of an opioid crisis that only seems to grow with each passing year.

“I never in a million years thought this was going to be my life,” Riley says. “I worked, I had a big beautiful house, I was married. I lost all of that.”

Heroin-related overdose deaths increased 286% over the last decade, according to data from the Centers for Disease Control and Protection. In 2013, more than 37,000 Americans died of a drug overdose – most of them in relation to heroin or prescription painkillers. Dependency has also skyrocketed, with no demographic left untouched, due in large part to access to opioid painkillers.

Prescriptions for opioid painkillers, dubbed by some as “heroin in a capsule”, escalated to a staggering 207 million in 2013 from 76 million per year in 1991. Many whose addiction starts with addictive painkillers later turn to the streets in pursuit of heroin.

In New Hampshire, there were more recorded deaths from drugs in 2014 than traffic accidents, and they have come at an estimated price tag of $2bn annually in lost productivity, treatment and jail time.

Whether it’s prevention, treatment or recovery centers, all aspects along the continuum of heroin care are overcrowded and underfunded. State lawmakers have until recently neglected the urgency of the issue, and only now is substance abuse under a national spotlight.

With an election year looming and a primary process in which New Hampshire plays an early and pivotal role, 2016 presidential candidates have begun to take notice.

As Hillary Clinton recalled prior to rolling out her proposal to tackle substance abuse, the issue was never intended to be a focal point of her campaign. But the former secretary of state encountered the topic repeatedly in conversations with voters – be it related to heroin in New Hampshire or meth and prescription drug use in Iowa – during the early months of her campaign.

“I did not expect that I would hear about drug abuse and substance abuse and other such challenges everywhere I went,” Clinton said at an August forum that brought together stakeholders to address heroin use in particular.

Now, the saying goes in some circles that 2016 presidential contenders may as well skip the New Hampshire primary if they aren’t prepared to address the state’s substance abuse epidemic.

Outcry on the trail

Riley is seated at a table that sits inside the entrance of Hope for New Hampshire Recovery, a facility dedicated to providing peer based recovery support services nestled in a quiet corner of downtown Manchester.

Over a plate of banana bread and grapes, she shares memories with Holly Cekala, the director of recovery support services at Hope and Ken Daggett, a board member of the group, both of whom are also in long-term recovery.

“I went to 44 funerals last year,” Cekala says, of family members and friends who have lost a loved one to substance abuse disorders.

Daggett lost both his father and his sister. “I can’t teach anybody lived experience,” he says.

Former Florida governor Jeb Bush and New Jersey governor Chris Christie recently sat at the very same table. Both Republican candidates, in separate private meetings away from the media and their cameras, said they wanted to listen so that input from facilities such as Hope might help inform their solutions.

Hillary Clinton has taken a similar approach, using both private sit-downs and public meetings with substance abuse advocates to map out a way forward.

Candidates are hard-pressed to visit the early voting state, a critical battleground in both the primaries and general election, without encountering at least one drug-related question.

Responding to the outcry she heard on the campaign trail, Clinton detailed how she would take on the issue as president with a $10bn plan aimed at bringing substance abuse across America under control. The Democratic frontrunner said she would invest $7.5bn in funding toward new federal-state partnerships over the next decade, through which states putting forward a comprehensive plan to prevent and treat substance abuse disorders would be eligible for new grant money.

Clinton also threw her support behind medication-assisted treatment, a process supported by advocates for combating drug abuse, by proposing to eliminate federal regulations that currently prohibit nurse practitioners and physician assistants from prescribing medications that help treat opioid users by blocking or partially blocking the effects of the drug.

Clinton’s plan, which advocates in New Hampshire say is thus far the most comprehensive, would also seek to bolster treatment over incarceration.

Vermont senator Bernie Sanders, Clinton’s main Democratic rival, has pushed state governments to lower the cost of naloxone, the drug that can reverse the effects of heroin and is used to treat overdoses.

Expanding access to naloxone, also known by its brand name Narcan, is a top priority for many seeking substance use reforms. It is already a staple in emergency rooms, but advocates would like the antidote to be available to law enforcement, first responders and even members of communities more likely to witness an overdose.

“Many of the proposals that we’ve seen from candidates and in Congress expand access for law enforcement and first responders, which is a good thing,” said Grant Smith, the deputy director of national affairs at the Drug Policy Alliance. “We support facilitating or expanding naloxone in any possible way. But the first responders are often families and friends, and that’s especially true in rural areas where it’s too late by the time help arrives.”

Some retailers, such as CVS, are going at it alone. The drug store conglomerate announced this week that pharmacists in 12 states can now distribute naloxone without a prescription.

Not all of those vying for the nation’s highest office have outlined a plan – and, among those who have, the solutions vary in their scope. Some candidates have arrived in New Hampshire holding empathy in one hand and their record in the other.

Citing “personal experience of dealing with the challenges of drug addiction”, Jeb Bush made a rare reference to his daughter Noelle and her struggles with substance abuse as he sought to convey to those struck by the disease that he understood where they were coming from.

Jeb Bush alludes to daughter's drug problems in New Hampshire meeting Read more

“It’s not easy. It’s not just the loss of a life or the loss of potential of one person, which is phenomenal,” the Republican presidential candidate said at a town hall in Merrimack this month. “I can go into meetings and I know the people whose families have suffered because of this. It’s very easy to see, you can see it drained out of your face, you can just feel it.”

Bush spent much of the event, a gathering of community leaders that was focused on New Hampshire’s substance abuse crisis, listening and taking notes. He held up actions taken by his administration when he served as governor of Florida as a potential blueprint for state and national reforms.

As governor, Bush focused on reducing recidivism by dealing with low-level drug crimes through monitored treatment and testing as opposed to incarceration, tripled the number of drug courts in Florida, and established “prevention coalitions” in each county. He also supported laws aimed at reining in the drug market, ranging from legislation that made it a felony for physicians to fraudulently prescribe a muscle relaxant known as carisoprodol to a bill requiring that pharmacies operating over the internet obtain special permits.

Bush also launched a Prescription Drug Abuse Task Force, and his wife Columba remains a national advocate for substance abuse awareness. The issue, he said, must be dealt with “in a comprehensive way”, marking a departure from views he once held that prioritized “punishment over therapy” in the juvenile justice system.

But Bush’s tough-on-crime stance that favored significant jail time for drug offenders was central to Florida’s 1994 gubernatorial election, the same year then-President Bill Clinton signed into law the crime bill that is now regarded as the catalyst for mass incarceration.

Criminal justice reform, particularly as it relates to nonviolent drug offenders, is now a source of bipartisan consensus and may even see a comprehensive change at the federal level in the coming months.

‘The Ebola of northern New England’

Dean LeMire, a resident of Dover, was 19 years old when he began using prescription opiates. He stole them from a relative who had been overprescribed from chronic pain.

It was hardly LeMire’s first bout with substance abuse. As a teenager, he said what began with drinking developed into a cycle of drugs. Psychedelics, adderall, or anything introduced into his orbit.

LeMire grew up in a middle class household in Exeter, New Hampshire, was popular among his teachers and was involved in numerous school activities. Even as his struggles continued, he attended college at the University of New Hampshire and graduated. LeMire was even arrested at age 19 for a DUI, but that did little to change his inclination toward substance abuse.

As the years passed, he fell further into his disorder – a feeling LeMire described as a “crushing weight” that left him sobbing alone in his room and feeling as though his dreams had slipped away.

“I did everything I could to get whatever drugs I needed just to not be sick,” he recounted in an interview. “It was a horrible existence, it was incredibly lonely. I was no longer partying with or near friends. I was all alone.”

“I felt like the only meaningful relationship I had was with my heroin dealer.”

LeMire said he began shooting heroin when he was 25 years old, a point at which he became suicidal. A year later, he sought treatment.

With the help of his mother, LeMire entered a state-funded treatment center. With intensive counseling and peer-to-peer support, he was eventually able to turn the ship around and is now three years sober.

But having worked at a men’s sober house for a year and a half, and more recently through a new job in public health focused on community-level action against the substance misuse issues in his state, the environment LeMire sees today has grown exceedingly worse.

Facebook Twitter Pinterest Dean LeMire with daughter Audrey last year. Photograph: Courtesy of Dean LeMire

LeMire would have to drive more than an hour, to just outside of Boston, in order to obtain heroin, he said of his experience in 2012. “Now I can walk outside my door, walk 20 steps and within minutes get heroin.”

The strength of the heroin being sold on the streets today is also greater than it was just three years ago, he added.

But as most within the substance abuse community note, the support simply isn’t there for what the state’s chief medical examiner described as “the Ebola of northern New England”.

Suzanne Thistle is visibly frustrated, sitting in her office in Lebanon, New Hampshire, and trying to contend with a growing waitlist of people in need of treatment. She is the executive director of Headrest, a nonprofit that provides addiction and crisis support services.

There are 30 individuals on her waitlist or, as Thistle puts it, 30 people struggling with substance abuse who are simply in need of a bed.

“They go on the waitlist because no place in the state has a bed, and we don’t have a bed, because we’re full,” she said. “That’s the hardest part of our job – to know that we can’t put them where they belong.”

For context, Thistle notes that there used to be 640 beds in New Hampshire for treatment. Today, there are 60.

For those on the treatment side, insurance companies are a big part of the problem.

Although a federal law in 2008 required insurers to treat drug and alcohol dependency as equal to other medical conditions in terms of cost sharing and care, that parity is often called into question. Treatment centers such as Headrest routinely find themselves wrestling with insurance companies to cover longer stays, or sometimes just additional days, for patients.

“Insurance has had a significant role in the breakdown of treatment availability,” said Sandi Coyle, ‎the Recovery Community Engagement Director at New Futures, a nonprofit that works to prevent and reduce alcohol and drug problems in New Hampshire. “Private insurance carriers used to offer a lot more coverage for substance use treatment.”

A ‘pro-life’ issue

On a warm September evening in Rye, an hour outside Boston, New Jersey governor Chris Christie was pitching his candidacy to a few dozen voters at the home of former Massachusetts senator Scott Brown. As the boisterous governor fielded questions in a casual backyard setting, one woman raised the substance issue bluntly: “We have a big drug problem here in New Hampshire. How are you going to take care of this?” she asked.

We need to be pro-life for the 16-year-old drug addict on the floor of the county lockup Chris Christie, New Jersey governor

For Christie, who has placed his emphasis on New Hampshire while facing an uphill battle for the Republican nomination, heroin has been a key tenet of his campaign and was the subject of his first two television ads. His response boiled down to “being pro-life.”

The governor, who has done five events in New Hampshire around substance abuse, wasn’t talking about abortion.

The sanctity of life, Christie said, had to do with protecting not only the unborn but also the livelihood of individuals once they leave the womb and face real-world challenges.

“We need to be pro-life for the 16-year-old drug addict on the floor of the county lockup,” he said. “If we’re really going to be the pro-life party, we should be pro-life for the whole life and that means giving people a chance to reclaim their lives.”

Christie pointed to his own record in New Jersey as a model, where heroin and opioid use has resulted in more than 5,000 deaths over the past 10 years. As governor, he has signed legislation requiring the submission of performance reports by substance abuse centers, extending legal protection to emergency responders and needle-exchange program employees who administer naloxone, and expanding mandatory drug court access across New Jersey for first-time, nonviolent drug offenders.

At the meet-and-greet in Rye, Christie emphasized the financial toll for those inclined to be “a cold accountant:” The annual cost to New Jersey of keeping an individual in prison was $49,000, as opposed to $24,000 a year to place a person in an inpatient drug rehab center.

Among the myriad proposals are rare areas of bipartisan consensus, rendering substance abuse one of the only issues to rise to the top of the political discourse that is not sharply divided along party lines.

Coyle, for example, said that Bush’s proposals were “notable and positive”, while Christie had shown leadership in this realm. Clinton, she said, struck her as someone who would take the issue seriously and “have the ability to make change happen”.

‘One-issue voters’

Not all candidates have laid out policies to combat substance abuse, but almost anyone asked would acknowledge the urgency of the issue.

During a campaign stop last month in Keene, Florida senator Marco Rubio said heroin use was not only an epidemic local to New Hampshire but one that extended nationwide.

Asked by the Guardian how he would address the issue as president, Rubio said the federal government was limited in what it could do but that his administration would “work very closely” to assist states and localities in their efforts.

“Drug addiction needs to be treated as a disease – it’s not a crime, it’s a disease. People suffer from this addiction,” Rubio said, adding that prescription opioids were of particular concern.

“Many of the people that are addicted to opiates became addicted using prescription medication that was given to them by a doctor … and then when that supply was cut off, because of changes in the law or their doctor, they migrated to street heroin which is incredibly dangerous.”

As potential proposals, Rubio said the Food and Drug Administration should partner with pharmaceutical companies to produce non-opiate painkillers as an alternative, and the government should lead a “more concise and robust effort” to crack down on the illegal trafficking of drugs across US borders.

Other presidential hopefuls have carved out ambitious targets, such as Martin O’Malley, a Democrat whose plan aims to reduce deaths from drug overdoses by 25% by 2020.

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Drawing on his experience as the former governor of Maryland and mayor of Baltimore, O’Malley said his administration would create a national dashboard to steer $12bn in federal investments and partnerships over the next decade, work to strengthen drug monitoring programs and establish mandatory training on pain prescribing for physicians.

“We now lose more of our children, parents, classmates and neighbors to overdose than we do to traffic accidents, suicide or homicide,” O’Malley wrote in an op-ed last week. “As a nation, we need leaders with the experience – and the political will – to save countless families from this quiet tragedy.”

What’s clear among substance abuse advocates is that there is neither a one-size-fits-all approach, nor one plan that will satisfy everyone involved in the fight.

Cekala said she’s seen most of the proposals but remains concerned that a disproportionate focus is being placed solely on treatment, which then overlooks the role of the peer support model in ensuring an individual stays in long-term recovery.

“To keep the integrity of a peer movement, it has to be separate from treatment. It cannot just be consumed by treatment,” she said. “The integral pieces will go away, the valuable data goes away, the outcomes will go away.”

“We already know that treatment without continuum of recovery support does not show effectiveness. The candidate that will probably win my vote, quite frankly, is the one who understands the need to reinvest in communities and the recovery community being one of them.”

Despite her grievances, Cekala, like other advocates, feels that a years-long battle for momentum is finally on her side.

“It means we’re here. We’re coming out of the dark shadows of the stigma,” she said.

And if that means there’s potential for substance abuse to be politicized on the national stage, so be it.

LeMire said he welcomes the politicization if that’s what it takes to usher in change. At this point, he said, he’s a “one-issue voter”.

“Any candidate who is running and doesn’t have a platform for how to deal with the opiate crisis in this whole country, they are completely out of touch,” LeMire said. “It is becoming one of the biggest financial crises in our country and we’re losing an entire generation of people to opiate misuse.

“This is the biggest public health issue of our generation.”