#

New Hampshire became the latest state to have three residents die of overdoses from one of the most deadly opioid drugs in the world, adding to the growing list of communities nationwide trying to handle the crisis. Gov. Chris Sununu and public health officials announced last week that for the first time in the Granite State, the synthetic opioid carfentanil was found in the bloodstream of three people who died from overdoses in March.

Two of the deaths were in Manchester, and the third was in Meredith. The substance is so potent that it’s not intended for human consumption. It’s 100 times more potent than fentanyl and is commonly used to tranquilize elephants.

“Unfortunately, today is the first day that we’ve been able to confirm this,” Sununu said at a Tuesday press conference. “And worse yet, I think we all understand that it is likely not the last day that we talk about this issue.”

New Hampshire is the first New England state to have confirmed deaths from carfentanil and its effects are being felt by many key players in the opioid crisis, including public health officials, first responders, and treatment and recovery providers.

While these are the first confirmed cases in New Hampshire, the rise in carfentanil overdoses has been happening throughout the United States over the last few months. At least 96 heroin users overdosed in one devastating week in August in just one Ohio county, with several of the overdoses linked to carfentanil. In September, the Drug Enforcement Administration issued a nationwide warning about the powerful opioid.

Tom Pifer, forensic lab director for the N.H. State Police, said the drug was developed in the mid-1970s by a pharmaceutical company, but was never made public due to its high potency.

It takes just two milligrams of carfentanil to knock out a 2,000-pound African elephant. When veterinarians or zookeepers do that, they wear gloves and face masks to prevent exposure to the drug because a dose the size of a grain of salt could kill a person. A dose may even be lethal when absorbed through the skin or potentially through inhalation. That’s why the state asked law enforcement and first responders to stop field testing drugs. The problem is that users might not know they are even taking the drug since dealers have been cutting heroin with fentanyl or carfentanil to give it a boost and stretch their supply further.

“You cannot tell the difference between heroin and fentanyl and certainly not fentanyl and carfentanil,” Pifer told New Hampshire Public Radio. “You are literally rolling the dice with any sort of dosage unit you’re purchasing on the street.”

It’s not only incredibly powerful, but it’s also incredibly resistant to naloxone — also known as Narcan, the opioid antidote that can save someone’s life from a heroin overdose. A typical overdose requires one or two shots to work, but when a dosage is laced with carfentanil, it could require six or more shots to be effective — if it works at all.

Even though there is an abundant supply of Narcan in states battling the opioid crisis, an increase in carfentanil overdoses could deplete the antidote supply fairly quickly and drain money from states who need to purchase more. With drug overdose deaths rising, state crime labs could also see a backlog of cases to investigate. In New Hampshire, there are thousands of cases dating back from 2015 that have yet to be investigated.

A criticism in New Hampshire of government officials is that funding from the state and federal government to tackle the crisis has been slow to come out.

Congress signed the 21st Century Act in December, which would provide more funding to states for the opioid crisis. In April, U.S. Sen. Jeanne Shaheen, D-N.H., said $485 million in grants would soon be administered to states. It’s not clear exactly when that would happen.

New Hampshire is ranked as the second hardest hit state in the opioid crisis based on per capita deaths. Yet, it’s only supposed to receive $3 million out of the $485 million promised to states since the formula is based on total mortality. Shaheen is urging Trump’s administration to revise the funding formula for next year.

The other Democratic senator from New Hampshire, Maggie Hassan, and Shaheen wrote in a letter last week to U.S. Health and Human Services Secretary Tom Price that the formula should be re-tooled. Officials have indicated that they will review the formula and the two senators were optimistic after their meeting with New Jersey Gov. Chris Christie, who is heading President Donald Trump’s national opioid commission.

In March, Trump created The President’s Commission on Combating Drug Addiction and the Opioid Crisis with Christie at its helm to start fulfilling his campaign promise to end the opioid crisis.

Trump promised the people of New Hampshire that he would build a wall between the U.S.-Mexico border to curb the opioid crisis and stop the flow of drugs into the area.

“New Hampshire has a tremendous drug epidemic,” he said in October. “I am going to create borders. No drugs are coming in. We’re going to build a wall. You know what I’m talking about. You have confidence in me. Believe me, I will solve the problem. They will stop coming to New Hampshire. They will stop coming to our country.”

While heroin supplies mostly come from Mexico, synthetic opioids, like fentanyl and carfentanil, are believed to originate in China. Even though it’s illegal there, secret labs in the country manufacture the drug before shipping it to the United States. People can order it online, and it’s shipped through the U.S. Postal Service before it makes its way into the local heroin supply.

It’s still not immediately clear how the drug made it into New Hampshire. It’s likely that either someone bought it online, or it was purchased in another state and then followed the traditional route of heroin and fentanyl into the Granite State, which is from major distribution centers like Philadelphia and New York and then through Massachusetts.

Follow Kyle on Twitter.

Sign up for NH Journal’s must-read morning political newsletter.

With about $59 million less to spend than expected, it’s natural that the House Finance Committee would trim a few items from Gov. Chris Sununu’s budget proposal. Yet, the cuts they’re making are concerning advocates who championed Sununu for including them in the first place.

On Wednesday, Republican budget writers in the House killed Sununu’s plan to spend $18 million over the biennium to expand full-day kindergarten programs. They also cut a $5 million college scholarship program.

“This is a short-sighted decision by a subcommittee of the Finance Committee,” said Mark Shriver, president of Save the Children Action Network, in a statement. “When he proposed his budget last month, Governor Sununu showed that he recognizes the importance of a full-day of kindergarten and understands the long-term economic benefits quality early learning programs can have for New Hampshire. The Republican majority in the House should stand with Governor Sununu and vote to put the full-day kindergarten funding request back into the budget.”

Full-day kindergarten isn’t the only proposal on the chopping block. The Alcohol Abuse Prevention and Treatment Fund was also cut this week.

The Alcohol Fund was created in 2000 by a bipartisan majority in the Legislature to be a funding mechanism that takes 5 percent of the gross profits from the sale of alcohol to support education, prevention, treatment, and recovery programs for alcohol and drugs. The funds would be allocated to the Governor’s Commission on Alcohol and Drug Abuse Prevention, Intervention, and Treatment to pay contracts for service providers in communities.

The fund has only been fully financed one time since its inception, which was in the 2003-2004 biennium. In his budget speech, Sununu proposed increasing the funds to 3.4 percent, double the 1.7 percent rate the previous budget had set.

“First, I propose we double the Alcohol Fund, increasing these important resources by more than $3 million and creating incentives to ensure that those funds are truly spent,” he said in his Thursday speech.

In several biennium budgets, the governor or Legislature would usually suspend the formula and allocate monies from the general fund to go to substance abuse prevention, treatment, and recovery.

Since there’s $59 million less in tax revenue coming in than expected when Sununu wrote his budget, Alcohol Fund advocates suspected that lawmakers would suspend the formula again. However, a more dramatic approach was taken by the House Finance Committee on Tuesday.

An amendment introduced by Rep. Neal Kurk, R-Weare, was added to the budget in House Bill 2 that would repeal the Alcohol Fund for good and it passed in a 6-4 vote on party lines.

“They’re trying to get to a number and they’re trying to come up with different avenues to do that, and some are very creative,” said Kate Frey, vice president of advocacy for New Futures, a nonprofit advocacy group that’s been one of the biggest proponents of the Alcohol Fund.

“New Futures has always been in favor of restoring the Alcohol Fund and using it as intended by the original statute to address problems for the substance abuse crisis,” she told NH Journal. “The fact that they are repealing the Alcohol Fund in its entirety is very unsettling.”

Advocates and some lawmakers like the fund because it’s non-lapsing and flexible, which is a creative and innovative solution to curb the opioid epidemic. The funds are non-restrictive, unlike some federal funds from grants that can’t be used to build brick-and-mortar recovery centers, for example.

New Hampshire is expected to receive $6 million, less than the $10 million previously anticipated by state officials, from the 21st Century Cures Act, bipartisan legislation approved by Congress and signed into law by former President Barack Obama in December, which gave $6.3 billion in funding to states hit hardest by the opioid crisis.

When Kurk introduced the amendment, advocates were also concerned because the language in the amendment appeared that he also repealed the authority of the Governor’s Commission to disperse the funds. The issue was cleared up on Wednesday, when that language was changed, giving the authority back to the Governor’s Commission to allocate funds, but still repealing the Alcohol Fund. The measure passed on a 5-4 vote on party lines, with Kurk absent.

Rep. Cindy Rosenwald, D-Nashua, who sits on the House Finance Committee, said the Governor’s Commission would receive $5.9 million in 2018 and $6.2 million in 2019 for alcohol and drug abuse education, prevention, treatment, and recovery, slightly less than what was allocated in the current biennium. If the elimination of the Alcohol Fund is passed, it would be up to the Legislature in each budget to allocate whatever they thought was an appropriate amount.

“Without the stability of that fund, it’s concerning to providers that are thinking about expanding their services here,” Rosenwald told NH Journal. “The flat funding for the next two years doesn’t expand access to treatment or recovery very much.”

When introducing the amendment in New Hampshire, Kurk said it was inappropriate for alcohol funds to go to the opioid crisis and that the issue the fund was originally created to solve, alcohol abuse, isn’t the main issue anymore — it’s opioids.

Advocates were quick to point out that the statute language when it was first written allowed funds to be used for alcohol and drug abuse programs. They also dismissed the idea that New Hampshire doesn’t have an alcohol problem anymore. According to a 2014 report, the Granite State’s per capita alcohol consumption is nearly twice the national average.

“I was very surprised at the elimination of the [Alcohol] Fund and I was surprised that they would suggest that somehow there is a disconnect between alcohol and our current opioid epidemic,” said Tym Rourke, chair of the Governor’s Commission, in an interview with NH Journal.

“The suggestion that New Hampshire only has an opioid problem is just false and somewhat disappointing that the Legislature would be picking one group of individuals who are suffering over another,” he added.

Previously, the Senate Finance Committee recommended passage of Senate Bill 196, which would put the Alcohol Fund at the 3.4 percent rate originally proposed by Sununu. The bill was laid on the table so lawmakers could go through the budget process before deciding on the fate of that bill.

Once the House Finance Committee signs off on the budget, it goes to the full House for a vote. The Senate will then get their turn to go line-by-line in the budget. At this point, Senate budget writers could have more money to play with since revenue estimates change throughout the year, so in theory, reinstating the Alcohol Fund and funding full-day kindergarten could see a new life. Advocates for those issues are hopeful the Senate would return them to the budget for Sununu to sign.

Follow Kyle on Twitter.

If John Carter had been involuntary committed after he overdosed on opioids, then he might still be alive. That’s what some members of his family said when they spoke in favor of a bill that would add opioid addiction to the state’s mental illness definition in order to expand the involuntary commitment criteria for admission to mental health institutions.

John, better known as Bubba, started his drug addiction at the young age of 13 years old by smoking marijuana. By 16 years old, he went to his first drug rehabilitation center. He went more than three times during a three-year period, unable to beat his addiction. At 18 years old, he started to use intravenous drugs, and two weeks before his fatal overdose, his family went to the police to get him committed. The police said their hands were tied and couldn’t do anything, his father Jack Carter told a Senate committee on Tuesday.

“We don’t have time to wait,” he said. “There’s no reason for more families to bury their kids. These are our children. Something has to get done. President [Donald] Trump called New Hampshire ground zero for the opioid crisis. It’s time to step up and do something for these families, for us, for the kids of our future.”

Senate Majority Leader Jeb Bradley introduced Senate Bill 220 in the the Senate Health and Human Services Committee. If enacted, it would expand the state’s mental illness definition to include those listed in the “Diagnostic and Statistical Manual of Mental Disorders,” which is published by the American Psychiatric Association and includes substance abuse and addiction as a mental disorder. The bill would also expand the involuntary commitment criteria for the state’s mental health services system.

In order to be committed, the bill states, “The person has ingested opioid substances such that the person’s behavior demonstrates that he or she lacks the capacity to care for his or her own welfare and that there is a likelihood of death, serious bodily injury or serious debilitation if admission is not ordered.”

Bradley said he understands that some people might oppose his bill on the grounds that treatment only works if the person is willing to seek it and that hospitals currently don’t have the space or funds to handle involuntary commitment.

“I know there are a couple of issues,” he said. “We are clearly a ‘live free or die’ state and we believe in individual responsibility,” he said. “But responsibility falls on [everyone] who sees someone who is addicted to substances, which is an illness, and needs help. And sometimes people don’t want to seek help and then it becomes our responsibility to help those people. We ought to be able to have this tool to help people who are reluctant to seek out help. I don’t think there is any disagreement about that even in our live free or die state.”

Bradley expects the bill to be retained and worked on over the following months to discuss what the new law would cost the state and improve the language to better define what the process to be uncommitted would entail. Yet, it has bipartisan support with Democratic and Republican cosponsors.

From 2014 to 2015, New Hampshire saw a 31 percent increase in deaths from drug overdose, which is the second highest in the nation, according to the Centers for Disease Control and Prevention. The Office of the Chief Medical Examiner of New Hampshire estimates 470 deaths will be attributed to drug overdoses in 2016, but the number officially stands at 385, as 85 cases are still being investigated. The chief medical examiner predicts more than 450 people will die from an overdose in 2017.

As of 2011, 38 states had some form of an involuntary substance abuse treatment law that are separate from any kind of criminal issues, according to the Partnership for Drug-Free Kids.

From the other people who testified, the overall sentiment was general support for trying to combat the opioid crisis, but they also sought more information on the specifics of the bill.

“This is a very complex issue,” said Alexander de Nesnera, interim chief medical officer at New Hampshire Hospital. “When individuals go through detox, they are usually on many medications and it could complicate the medical detox process if they’re not monitored very carefully. When you look at developing a system for individuals to be involuntary hospitalized, we need to make sure the receiving facility is linked to a hospital directly, so they can receive treatment if there are severe complications of detox that occur.”

De Nesera also cautioned lawmakers on the possible consequences of the bill.

“By changing the definition of mental illness, you would greatly expand the number of people. Currently, there are 44 patients that are waiting admission to New Hampshire Hospital,” he said.”If we were to expand the definition of mental illness, the numbers in the queue would expand greatly. We only have 168 beds, and with that limited capacity, patients are in waiting rooms to get treatment. That’s not the answer.”

He encouraged legislators to think about investing in more outpatient programs and to have a conversation with the hospitals in the state about what would work for them.

New Hampshire is poised to receive some federal assistance from the 21st Century Cures Act, but not nearly as much as lawmakers expected. When President Barack Obama signed the act into law last year, New Hampshire officials anticipated getting $10 million over the next biennium. It turned out the state is only getting $6 million. State officials thought the money would be distributed based on per-capita overdose deaths, but that’s not what happened. New Hampshire has the second highest overdose deaths per capita in the country, yet California, who has a per-capita rate that is nearly two-thirds lower than New Hampshire, will receive the most money.

“I think our members of Congress across the country have started to recognize that the heroin epidemic is a serious problem and needs more resources,” Bradley said. “I’m surprised to see the way it’s been allocated in New Hampshire. Hopefully, that can be rectified. That being said, we also have to continue what we’ve been doing in the last budget and allocate more of our resources.”

Follow Kyle on Twitter.

As expected, it didn’t take long for Democrats in New Hampshire to point out what proposals they didn’t like in Gov. Chris Sununu’s budget speech last week.

“I am encouraged by statements of Governor Sununu in support of full-day kindergarten and funding for the developmentally disabled, but as we all know, the devil is in the details,” said House Democratic Leader Steve Shurtleff in a statement. “The Governor’s budget address made no mention of the successful NH Health Protection Program, leaving serious unanswered questions for the 50,000 Granite Staters who rely on the program for their health care coverage.”

But the more divisive statements came from the Senate Democratic Caucus and New Hampshire Democratic Party (NHDP). While they applauded Sununu for keeping several initiatives put in place by former Gov. Maggie Hassan, they criticized him for not fully funding the Alcohol Fund to combat the opioid crisis.

“And in the midst of a substance abuse crisis, we need to find out why Governor Sununu chose not to fully fund the Alcohol Fund, which supports our effort to combat this crisis,” said Senate Minority Leader Jeff Woodburn in a statement.

NHDP Chairman Ray Buckley echoed Woodburn’s sentiments saying he was “disheartened to see that the governor did not fully fund the state’s alcohol fund, which would provide key resources to combat this epidemic.”

The Alcohol Abuse Prevention and Treatment Fund was created in 2000 by the Legislature, and it’s a mechanism that takes 5 percent of the gross profits from the sale of alcohol to support education, prevention, treatment, and recovery programs for alcohol and drugs. The fund has only been fully financed one time since its inception, which was in the 2003-2004 biennium — the first year it began. In his budget speech, Sununu proposed increasing the funds to 3.4 percent, double the 1.7 percent rate the previous budget had set.

In each budget after that, the governor or Legislature transferred the revenue to the general fund and only appropriated a small amount to the Alcohol Fund, which means Republican Gov. Craig Benson and Democratic Govs. John Lynch and Maggie Hassan suspended funding during their terms.

In the most recent budget, for the 2016-2017 budget biennium, Hassan and the House proposed suspending the funding formula. Hassan proposed giving the fund $9.6 million over the two-year period, but the Republican-controlled House dropped that figure to $3.6 million. Senators proposed bringing the formula back and lowering the cap to 1.7 percent, which would give the fund $6.7 million.

If the fund was fully financed for the whole biennium, it would have received approximately $19 million, still nearly $10 million less than what Hassan suggested. After the Senate put forward its recommendation for the budget, the NHDP called their budget “unbalanced and partisan” with “irresponsible gimmicks.”

It’s interesting that the NHDP would criticize Sununu for not fully funding the Alcohol Fund, when previous Democratic governors did not fully fund it either.

“We haven’t had a Democratic governor who has fought as hard as Sununu is fighting for it [the Alcohol Fund] right now,” said former state Rep. Joe Hannon, R-Lee, who made his mark in the Legislature by focusing on the opioid crisis.

“No one has taken the leadership on this, and the battle will be in the House and Senate Finance Committees,” he told NH Journal. “I’m always happy when the governor speaks about how he is addressing substance abuse treatment. He gets it, and that’s something I haven’t seen in awhile from leadership in the state.”

New Futures, a nonprofit group looking to curb substance abuse in the state, is a fervent supporter of fully funding the Alcohol Fund at 5 percent. They believe the money from the non-lapsing, flexible fund could be used for creative and innovative solutions to stop the opioid epidemic.

“We are encouraged by the fact that Gov. Sununu has increased the funding for the Alcohol Fund by doubling the current amount,” said Linda Paquette, president and CEO of New Futures. “However, we anxiously await the release of House Bill 2 in order to clarify the support in the budget for addressing New Hampshire’s substance abuse epidemic.”

Paquette said she was “very curious” what Sununu meant when he talked about “incentives” with the Alcohol Fund.

“First, I propose we double the Alcohol Fund, increasing these important resources by more than $3 million and creating incentives to ensure that those funds are truly spent,” he said in his Thursday speech.

Pacquette said she is hopeful that the Alcohol Fund will be a priority for the Republican-controlled State House because the funds are “not restricted.” New Hampshire is expected to receive federal money from grants and the 21st Century Cures Act, legislation approved by Congress and former President Barack Obama in December 2016, which gives $6.3 billion in funding to circumvent the opioid crisis and enhance medical research and development.

“The Alcohol Fund can be used to fill gaps where grant money and federal funds are restricted for certain uses,” Paquette told NH Journal. “It can be used for supporting recovery housing and investing in early childcare as a substance abuse prevention strategy. He [Sununu] clearly has made the opioid crisis a priority of his administration.”

Sununu presented his budget to the House and Senate Finance Committee in a Tuesday joint committee meeting. The House Finance Committee will take a look at his budget first and put forward recommendations to the full House later in the spring. After passage in the House, the Senate Finance Committee will review that budget and put it up for a vote to the full Senate, before returning to the governor’s desk for his signature or veto.

“We’re going to double that fund and get the money where we can have a lot of impact,” he said in the meeting. “Not just in the high-density areas, but really all across the state. None of our communities have been immune to that.”

The Senate Finance Committee recommended passage of Senate Bill 196 on Tuesday, which was amended to increase the Alcohol Fund to the 3.4 percent rate proposed by Sununu. If the House changes the formula or suspends it in its budget recommendations, this bill could override it and fund it at the rate Sununu proposed.

“This is a sound proposal that I and a majority of the Senate Finance Committee supported today by recommending a bill to do just that,” said Senate Finance Chair Gary Daniels, R-Milford, in a statement. “We have established a number of initiatives that serve to stem substance abuse, including the heroin crisis, and I know we can do more with the funding Governor Sununu has proposed as part of his budget.”

Follow Kyle on Twitter.