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People with anxiety and depression are disproportionately prescribed painkillers. That’s what new research from the Dartmouth-Hitchcock Medical Center suggests, adding a complex layer to the opioid epidemic ravaging the United States and encouraging calls from New Hampshire’s congressional delegation to not move forward with the repeal of the Affordable Care Act.

The findings, which appear in the July issue of the Journal of the American Board of Family Medicine, show that nearly 19 percent of the 38.6 million American adults with mental health disorders use prescription opioids compared to only 5 percent of those without a disorder. Adults with depression and anxiety receive 51 percent of the 115 million opioid prescriptions distributed each year in the U.S., the study found.

“Because of the vulnerable nature of patients with mental illness, such as their susceptibility for opioid dependency and abuse, this finding warrants urgent attention to determine if the risks associated with such prescribing are balanced with therapeutic benefits,” said Brian Sites, an anesthesiologist at Dartmouth-Hitchcock and one of the co-authors of the study.

Image Credit: Dartmouth-Hitchcock

Opioid prescribing in the U.S. quadrupled between 1999 and 2015, and during that time more than 183,000 people died from overdoses related to prescription opioids, according to the Centers for Disease Control and Prevention.

Sites also notes that because pain is subjective, “the presence of mental illness may influence the complex dynamic between patient, provider, and health system that results in the decision to write an opioid prescription.”

The study does not give a specific reason why people with mental disorders are more frequently prescribed opiates. The study encourages more research on this population to understand opiate addiction.

Those patients may have some form of physical pain, but their mental condition may cause them to feel that pain more acutely or be less able to cope with it, leading to increased requests for something to dull the pain. As a result, doctors trying to be empathetic to their patients’ complaints may tend to overprescribe opioid painkillers, Stiles said.

Research also shows that patients are more likely to take opioids when there aren’t specialists nearby. A study published earlier this year found that the number of seniors in rural America who take at least three prescribed psychotropic drugs ― including opioids and antidepressants ― tripled over a nine-year period. The study found that many of these prescriptions were given without a proper diagnosis.

Being able to identify a subset of the population that could be more likely to use opioids could help providers and policymakers address opioid use. It “suggests that there may be additional patient- and provider-related factors specific to those with mental illness that increase the likelihood of receiving prescription opioids,” the authors wrote.

U.S. Rep. Annie Kuster, D-N.H., was present for a press conference about the study on Monday. She said repealing Obamacare could be disastrous for New Hampshire’s opioid epidemic.

“This is critically important in New Hampshire, as we have gone from second in the nation in deaths from the opioid crisis and heroin to first for fentanyl,” she said. “That’s not what we want to be known as first in the nation for.”

The U.S. Congress is currently in a heated healthcare battle. The Senate is working on legislation to repeal the healthcare law, but a vote on the bill has been delayed due to opposition from Republicans. New Hampshire Democratic Sens. Jeanne Shaheen and Maggie Hassan have both stated their opposition to the healthcare overhaul and have sent many press releases condemning “Trumpcare.”

“This new study is yet another reminder that, to combat the devastating opioid crisis, we must make mental health treatment affordable and accessible,” Shaheen said in a statement.

Hassan said she opposes proposed cuts to Medicaid that would affect coverage of mental health and substance abuse services.

“As we work to combat the horrific substance misuse crisis that is devastating our communities and taking a major toll on our economy in New Hampshire, this study highlights how dangerous Trumpcare, which includes massive cuts to Medicaid, would be for our state,” Hassan said in a statement. “We need a comprehensive, holistic approach to combating this epidemic that addresses the underlying causes of addiction, including mental health issues.”

To address the overprescription problem within the mental health community, Sites has suggested physicians need more access to alternative medicine besides opioids, including acupuncture, massage therapy, physical therapy, and non-opioid pharmaceuticals.

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Gov. Chris Sununu signed his second bill since becoming governor on Monday. House Bill 103 requires school districts to provide at least two weeks notice to parents and guardians of course material involving discussion of human sexuality or sex education, and to make course curriculum materials available to parents on request.

“This bipartisan legislation is consistent with my longtime support for measures that further empower parents’ involvement in their child’s education,” Sununu said in a statement. “It is important to let parents know what students are learning and this bill encourages clear and open lines of communication regarding curriculum content in this important area.”

Third time’s a charm for Rep. Victoria Sullivan, R-Manchester, who put forward the same legislation for the past three years. Former Democratic Gov. Maggie Hassan previously vetoed it.

Sullivan put the bill forward due to a personal experience she had with her 8-year-old son who was shown what she thought was an inappropriate video in class. She wasn’t notified before that the video would be displayed for her child.

“Parents and parent groups throughout the state worked hard to make their voices heard,” Sullivan said in a statement. “Today, I am happy to say, the little guys won. It is a good day for parental rights in New Hampshire. More importantly, it is a good day for New Hampshire’s public school children. I am grateful to the Governor for signing this important piece of legislation into law.”

Supporters say the law gives parents the power to approve of the material their children are being taught at school. Opponents, including the New Hampshire School Boards Association, the New Hampshire School Administrators Association, and the American Civil Liberties Union, say it will create challenges when it comes to teachers leading class discussion in sex education.

“This bill jeopardizes Granite State students’ ability to get the critical information they need to make healthy lifelong choices,” said Kayla Montgomery, director of advocacy and organizing at Planned Parenthood of Northern New England. “We are disappointed Governor Sununu who did not listen to the thousands of constituents and experts both in education, public health, and local school administration who opposed this bill.”

The legislation amends existing law, which allows parents or legal guardians to opt their child out of material they find objectionable. Now, schools must give advance parental notice of curriculum materials.

Currently, 22 states and the District of Columbia require school districts to allow parental involvement in sexual education programs. Four states — Arizona, Nevada, Utah, and now New Hampshire — require parental consent before a child can receive instruction.

New Hampshire is ranked as one of the best states for teaching sexual education in schools, according to data from the Centers for Disease Control and Prevention (CDC). The CDC surveyed schools to ask if health instruction included 16 “critical” sexual education topics, which includes “how to create and sustain healthy and respectful relationships,” “how to obtain condoms,” and the “importance of limiting the number of sexual partners.”

New Hampshire, New Jersey, and New York were the only states to teach all 16 topics in at least 75 percent of schools.

The New Hampshire Democratic Party quickly criticized the governor for signing a bill that makes “it harder for schools to teach sex-ed.”

Instead of passing/signing any economic bills (still at ZERO), Sununu decided to make it harder for schools to teach sex-ed #nhpolitics https://t.co/psJada9UFx

— NH Democratic Party (@NHDems) April 17, 2017

The first bill Sununu signed as governor repealed required permits for concealed carry firearms. Right-to-work legislation failed to make it to his desk, which he would have likely signed, after the measure failed to pass in the House.

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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.”

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