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It’s a well-known figure that New Hampshire has the second-highest per capita drug overdose deaths in the United States, right behind West Virginia. The state also has the highest rate of fentanyl-related overdose deaths per capita, leading researchers, health care providers, first responders, and lawmakers to wonder what about the Granite State makes it one of the most ravaged by the drug epidemic.

That was the subject of a forum at Dartmouth College last month, which included Dr. Nora Volkow, director of the National Institute on Drug Abuse (NIDA) at the National Institutes of Health; Lisa Marsch, director of the Dartmouth Center for Technology and Behavioral Health (CTBH); and U.S. Rep. Annie Kuster, D-N.H.

“Not only did we want to bring together a broad group of stakeholders about the crisis in our communities, but we also wanted to have a discussion about the response to the crisis,” Marsch told NH Journal. “Why New Hampshire? What’s going on in New Hampshire that’s distinct and giving rise to it?”

To find out why the rate of opioid overdoses increased by nearly 1,600 percent from 2010 to 2015, the New Hampshire Fentanyl “HotSpot” Study was funded by the NIDA. The rapid epidemiological study focuses on the increase of overdoses from fentanyl, a drug that is 50 to 100 times more potent than heroin and often is mixed with heroin. In Phase I of the study, researchers spoke with medical responders, law enforcement officers, state authorities, and policymakers.

The study was conducted by the CTBH, in collaboration with the National Drug Early Warning System, and funded by the NIDA.

Marsch said they quickly realized that they needed to speak with opioid users to better understand the trajectory of fentanyl use, the tracking of the drug, and fentanyl-seeking behavior in order to effectively inform policy and community response.

Phase II was then commissioned to do just that. March’s team interviewed 76 opioid users, 18 first responders, and 18 emergency department clinical staff from six counties in New Hampshire during October 2016 to March 2017. The results of the study are not publicly available yet, but Marsch presented key findings at the forum.

The report found that the recent increase in the availability of fentanyl is because it is less expensive and quicker to take effect than heroin. However, the high doesn’t last as long and requires users to use more often, increasing the risk of overdose.

About 90 percent of the drug users interviewed for the study indicated they actively sought out drugs that would cause overdoses.

“We want whatever is strongest and the cheapest. It’s sick,” one respondent said. “I now me using, when I hear of an overdose, I want it because I don’t want to buy bad stuff. I want the good stuff that’s going to almost kill me.”

Marsch said the study allowed researchers to analyze “a whole array of factors that set up the perfect storm” for New Hampshire to be one of the hardest hit states by the opioid crisis. She said the Granite State consistently rates in the top 10 states with the highest drug use rates and opioid prescribing by doctors exceeds national averages.

New Hampshire is also in close proximity to a supply chain for the fentanyl drug in Massachusetts.

According to the U.S. Drug Enforcement Administration’s 2014 National Drug Threat Assessment Summary, most heroin supplies in the New England region are brought in from New York along the vast interstate highway system, naming I-95 and I-93 as the major routes for New Hampshire’s heroin traffickin. The report also named Lawrence, Mass. as a main distribution center for northern New England states.

The New Hampshire “HotSpot” Study pointed to these other factors contributing to the heroin and fentanyl crisis in the Granite State:

• Treatment admission rates per capita are lower than both the national average and all other New England states
• N.H. has the lowest per capita spending on treatment in all of New England and it’s the 2nd lowest in the nation
• The state has the lowest rate of Suboxone, a medication used to treat opioid addiction, providers per capita in all of New England
• Public health funding per resident is lower than the national average and surrounding states
• N.H. is the only state in the Northeast with no needle exchange program (The legislature recently passed a bill legalizing the programs and Gov. Chris Sununu said he would sign it.)
• The state’s rural setting keeps people in tightly knit social networks and has limited access of “things to do.”

“The economic factors, the rural nature, the politics, lack of resources, and the close proximity to the source of these drugs has created a really bad scenario for the state,” Marsch said.

In order to curb the alarming trend of opioid overdose deaths in the Granite State, the researchers suggested the state increase public health resources for substance use prevention and treatment, expand prevention programs in elementary and middle schools, assist physicians with understanding opioid prescribing, and collaborate with Massachusetts on addressing the manufacturing and trafficking of fentanyl and other opioids.

At the forum, Kuster, who co-chairs the House Bipartisan Task Force to Combat the Heroin Epidemic, said she was confident that Granite Staters’ “certain blend of tenacity and creativity” will help find solutions to this epidemic. Officials point to the Safe Station program, which allows anyone who is struggling with drug addiction to go to fire stations in the state to connect with recovery resources, as a New Hampshire solution to the drug epidemic.

Yet, Kuster was worried that it would be difficult to get more funding and resources under President Donald Trump’s leadership.

“We cannot get this job done without Medicaid expansion. I’m concerned about cuts for mental health and behavioral health services,” she said. “If they’re [Republicans] going to walk the walk, as they have talked about opioid addiction, they’ve got to fund the programs that will bring the services to our communities.”

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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.

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It’s not often where there is a war of words between a governor and a mayor of neighboring state. Yet, that’s what happened last week between New Hampshire Gov. Chris Sununu and Mayor Daniel Rivera of Lawrence, Mass., when discussing who’s to blame for the Northeast’s growing opioid crisis.

“It’s coming from Lawrence,” Sununu said Wednesday at the Greater Manchester Chamber of Commerce breakfast. “Eighty-five percent of the fentanyl in this state is coming straight out of Lawrence, Massachusetts.”

He also pointed to Lawrence again in an interview later that day with Boston Herald Radio, saying the city’s status as a “sanctuary city” is causing problems for New Hampshire.

Sununu said he had a meeting with other New England governors when they met in Washington D.C. for the National Governors Association annual winter meetings.

“I sat down with [Massachusetts Gov.] Charlie Baker and all the governors from the New England regions and said we’re going to cross borders, you better get ready,” Sununu said. “I’m working with the DEA [Drug Enforcement Administration] in Bedford, working with the DEA in Boston, our state police, their state police.”

Sununu then vowed that “we’re going in.”

“We’re going to get tough on these guys, and I want to scare every dealer that wants to come across that border,” he said. “We’re not giving dealers nine months on parole and probation anymore. We’re putting them away for the five, 10 and 15 years that they deserve.”

Sununu’s “tough on drugs” rhetoric makes sense — albeit an interesting political move to pick a battle with a town in another state. He’s the first Republican governor in 12 years and the opioid crisis is still rampant in New Hampshire. He campaigned on the epidemic being the number one priority the state faces and depending on what he does to curb the crisis in his two-year term, could be a factor in his 2018 reelection campaign.

Despite several media reports about the subsequent back-and-forth between Sununu and Rivera, there is some legitimacy in Sununu’s claim about Lawrence being a hot bed of activity for heroin and fentanyl.

Most of the heroin coming to New England originates in Colombia and travels through Mexico, according to a 2013 report from The New York Times. Despite an increase in the number of seizures along the southern U.S. border, enough is still getting through to major distribution centers, including Philadelphia and New York, which then makes its way into northern New England, “often through Lowell, Lawerence, and Holyoke, Mass.”

According to the U.S. Drug Enforcement Administration’s 2014 National Drug Threat Assessment Summary, most heroin supplies in the New England region are brought in from New York along the vast interstate highway system, naming I-95 and I-93 as the major routes for New Hampshire’s heroin trafficking routes. The report also named Lawrence as a main distribution center for northern New England states.

“Massachusetts also serves as a staging area or interim transportation point for heroin being transported north,” the report states. “Lawrence and Lowell, north of Boston, are distribution centers for northern New England and Canada. Maine, New Hampshire, and Vermont are supplied with heroin chiefly by drug groups in northeastern Massachusetts, particularly in Lawrence and Lowell.”

Western Massachusetts is one of the staging areas for distribution in Vermont, Maine, and New Hampshire because drug dealers from those states who want the product have to drive to Massachusetts to get it because drug penalties in Vermont, Maine, and New Hampshire are stricter in the three northern New England states.

Because Lawrence sits on the I-93 highway, police have said many drug deals occur at fast-food restaurants off the highway exits.

It is so widely known that Lawrence is a main distributor for the opioid crisis, that even Massachusetts Attorney General Maura Healey said it to the Times in 2016.

“Massachusetts is the epicenter for the heroin/fentanyl trade,” she said. “From Lawrence, it’s being trafficked and sold all over the New England states.”

For example, undercover detectives followed a car on a heroin buying mission from Manchester to Lawrence and back on Sept. 15, 2015, which resulted in one arrest.

Still, despite these reports and former statements that show Lawrence is a main distributor of heroin and fentanyl for New England, Rivera took offense that Sununu called out his city.

“Just like the President is finding out that health care is complicated, I think that the governor is going to find out that this is a complicated issue,” Rivera said in a hastily scheduled press conference on Thursday. “I’m not sure that he meant to threaten the sovereignty of the Commonwealth of Massachusetts, but he did.”

One of the major problems Rivera had was with Sununu’s claim that 85 percent of the fentanyl entering New Hampshire came from Lawrence.

“I would ask you guys to ask him where he got that number from,” he charged reporters. “I don’t know if it’s a true number. I think the problem is if you think like ‘oh you snuff out what’s happening in Lawrence, it will all go away.’ I know he’s only been on the job 60 days, but the reality is it’s like water, it will find another place to go.”

Rivera and Sununu eventually spoke on Thursday afternoon, and Sununu released a statement after the call.

“The Mayor and his local law enforcement personnel have been doing a good job on this issue, but we must recognize this is a cross-border problem that requires cross-border solutions,” Sununu said. “It has no geographic boundaries and it remains incumbent upon all of us to come together and work collaboratively across our borders along with federal, state and local law enforcement.”

Sununu’s office has not offered any evidence of his “85-percent” claim, but regardless, Lawrence’s role in the opioid crisis cannot be disputed.

Baker, the Massachusetts governor, weighed in on the controversy, and said, “I do view this as a problem that affects us all and I think singling out a single community or a single state is not accurate.”

New Hampshire Senate Democratic Leader Jeff Woodburn offered his two cents.

“Instead of antagonizing key regional partners in our collective fight to combat the devastating effects of the opioid crisis, Governor Sununu should be fighting for our state’s successful Medicaid expansion program which has helped over 100,000 Granite Staters gain access to mental health and substance abuse treatment,” he said in a statement. “New Hampshire needs steady and serious leadership from the Governor’s office that focuses on a holistic approach to solving this public health crisis, not reckless, cavalier comments.”

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