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New Hampshire info

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New Hampshire is starting 2017 with stepped-up efforts to manage its oft-described opioid epidemic. Though the most recent regulations are directed at individual prescribers, and do not apply to the administration of opioids to patients in a health care setting, now is the time for New Hampshire hospitals, ambulatory surgical centers, urgent care facilities, and other health care facilities to revisit their protocols, record-keeping practices, and informed consent agreements relating to opioid prescribing.

In recent weeks the New Hampshire Board of Medicine and the Board of Nursing have each finalized and adopted, with minor amendments, emergency opioid prescribing rules that had been issued during 2016. Both sets of rules were effective January 1, 2017.

The final regulations follow on the heels of clinical guidelines and standards for managing chronic, non-cancer pain with opioids that have been published by the Centers for Disease Control and Prevention and various national professional societies, by establishing a legal framework of safe opioid prescribing practices for New Hampshire physicians and advanced practice registered nurses (APRNs). The regulations also provide 3 exemptions from the general requirement to query the Controlled Drug Prescription Health and Safety Program (the State's prescription drug monitoring program or "PDMP").

The final regulations set forth a laundry list of requirements that New Hampshire APRNs and physicians must meet before they may prescribe (or continue to prescribe) opioids to treat non-cancer and non-terminal pain (acute and chronic). Specifically, licensees must, among other things and with certain limited exceptions, query the PDMP, conduct and document a history and physical exam, conduct and document a risk assessment (the evidence-based screening tool Screener and Opioid Assessment for Patients with Pain (SOAPP) is suggested but not required), prescribe the lowest effective dose for a limited duration, document a pain treatment plan, create and document a written treatment agreement with the patient, and utilize a written informed consent that explains risks associated with opioids, including addiction, overdose and death, physical dependence, physical side effects, hyperalgesia, tolerance, and crime victimization. The rules also specify the information that must be provided to patients prior to prescribing opioids for either acute or chronic pain. In an emergency department, urgent care setting, or walk-in clinic, opioid prescriptions cannot exceed 7 days (or such fewer days as may be medically necessary to treat the patient's medical condition). Clinical coverage must be made available 24 hours per day, 7 days per week for the management of patients treated with opioids for chronic pain.

The goal of these final regulations is to encourage licensees to assure that opioids are prescribed to New Hampshire patients only in limited and clinically appropriate circumstances, and that sufficient information, tools, and support are made available to patients to prevent overuse, addiction, and overdose. Practitioners who historically have been adverse or resistant to treating pain with opioids due to the potential for patient overuse or addiction, or concerns for personal liability, can now rely upon the rules as a legal framework and best practice for safe prescribing practices. The adoption of these final rules should serve as a reminder to New Hampshire health care facilities that all of its prescribing practitioners play a vital role in combatting opioid abuse in New Hampshire, which has been characterized by federal Drug Enforcement Agency officials as "ground zero" in the opioid epidemic.

New Hampshire, opioid, regulation

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New Hampshire Finalizes Opioid Prescribing Rules | Health Care Law Today

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Tags: New Hampshire is starting 2017 with stepped-up efforts to manage its oft-described opioid epidemic. Though the most recent regulations are directed at individual prescribers, and do not apply to the administration of opioids to patients in a health care setting, now is the time for New Hampshire hospitals, ambulatory surgical centers, urgent care facilities, and other health care facilities to revisit their protocols, record-keeping practices, and informed consent agreements relating to opioid prescribing.

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General drug info

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Certain people are at risk for substance abuse and for developing addiction disorders. Their vulnerability might originate from a variety of factors, including their genetic endowment, family background, psychological factors, and social norms. Overall, these factors make the person value drug use highly, even though the decision might be against their long-term interests. Please note that a risk factor for one person may not be for another. Most people at risk for drug abuse do not become addicted.
1. Genetic vulnerability
Individuals' preferences to engage in one behavior versus another are shaped by their genetic endowment in interaction with their past experiences. The interactions between genetics and social environment may explain why some people become addicted and some do not (Kreek et al., 2005). For example, due to genetic vulnerability, children of alcoholics are at higher risk for future alcohol problems, and many of these children show high levels of impulsivity.
2. Cultural attitudes
The value that a person attaches to using drugs is strongly influenced by the community in which the person lives (Wilson, 2005). For example, students drink more on campuses that have a strong drinking culture, few alcohol-control policies on campus and easier access to alcohol through special promotions and low pricing by local stores and bars (Sher and Rutledge, 2007). Social norms help to define the circumstances in which it is appropriate to drink and how much alcohol should be consumed.
3. Financial incentives
Evidence shows that people will stop using when the costs become too high (Dalrymple, 2006). Many of the states that have the lowest smoking rates are those that have been the most aggressive about indoor smoking laws and about state taxes that drive up the cost of cigarettes. In general, when cigarette's price increases people smoke less. Increases in taxes on alcohol lead to reductions in alcohol consumption generally and reductions specifically in binge and other kinds of excessive drinking.
4. Personality
Impulsivity is a personality trait that has often been identified as a risk factor for alcohol and other substance misuse (MacKillop, 2016). Addicted individuals assign lower values to delayed rewards than to immediate ones. The excessive preference for the immediate rewards despite longer-term consequences leads to problems with addiction.
5. Self-medication
The self-medication theory of addiction suggests that suffering is at the heart of addictive disorders (Khantzian, 2012). That is, individuals with deficits in emotion-regulation skills (i.e., skills relevant for modifying emotional reactions and tolerance for negative emotions) use drugs in an attempt to manage negative or distressing affective states. Alcohol is frequently used as a way of coping with social anxiety. The drinking removes, at least temporarily, the stress of anxiety. Mate (2010) suggests that addictive behaviors ultimately driven by our unwillingness to allow ourselves to really feel and experience pain, frustration, fear, and all the negative emotions that are part of being human. Instead, we choose the chemical shortcut to avoid those emotions and become trapped there.
6. The lonely addict
Addicts commonly lack enough positive human contacts to sustain happiness, and they resort to drug intake partly as self-medication (Panksepp, 2012). The feeling of isolation is a major source of unhappiness. The subjective experience of loneliness is painful. That is why we turn to ice cream or other fatty foods when we are sitting at home feeling all alone in the world. Problems in self-regulation specifically attributed to loneliness have manifested in alcohol abuse, drug abuse, eating disorders, and even suicide. Moreover, heavy drug users may avoid or alienate friends or family who are not using. The social control hypothesis suggests that the absence of caring friends and family lead people to neglect themselves and indulge in health-damaging behaviors, such as eating unhealthy and not exercising.
7. The journey of a thousand miles begins with one step
Choices that create an undesirable way of life are made one day at a time. They are not made at the level of a long-term lifestyle consideration. On any occasion, using drugs (or overeating) produces limited harm. The damage occurs after repeated indulgences. No one would choose to be an addict. One day of drug use does not mean addiction. As the days accumulate, the addictive behavior emerges. Consequently, a person who never chose to be an addict ends up an addict (Hyman, 2009). Similarly, someone who has a second helping of dessert every night ends up twenty pounds heavier without any intention.

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Certain people are at risk for substance abuse and for developing addiction disorders. Their vulnerability might originate from a variety of factors, including their genetic endowment, family background, psychological factors, and social norms. Overall, these factors make the person value drug use highly, even though the decision might be against their long-term interests.

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New Hampshire info

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New Hampshire info

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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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What Factors Led New Hampshire to Be Ground Zero for the Opioid Crisis? - InsideSources

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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.

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Baltmore info

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Traffic in cocaine, heroin, Ecstasy assessed by DEA

Baltimore's notorious drug epidemic is even worse than law enforcement officials had realized previously, a new federal assessment shows.

The report on Baltimore's drug culture, from a three-month study by the federal Drug Enforcement Administration, concluded that the problem cannot be solved quickly - or by police alone.

DEA officials briefed top police commanders this week on the assessment, which Police Commissioner Edward T. Norris requested this spring.

"It confirms a lot of the suspicions we had," Norris said yesterday. "The drug problem is more serious than most major cities in America."

Baltimore officials say they plan to use the information to bolster their argument that the city has a crisis that requires more help from the federal government if it is to stand a chance of reversing the decades-long trends.

That help, Norris said, might include requests for more DEA agents in Baltimore, more money for drug-enforcement police and more money for drug-treatment facilities for addicts.

The assessment, based on DEA intelligence and statistics, as well as independent research, concluded Baltimore is the "most heroin-plagued" city in the United States and has one of the most severe crack cocaine epidemics in the nation.

The DEA reported that the city has become a major market for South American heroin that is "significantly" purer than the national average. The study also asserted that use of the designer club drug "Ecstasy" has rapidly increased, particularly among suburban users, who come to the city to buy it.

Norris said DEA officials told him that at least $1.5 million in cash is exchanged every day during street-level drug deals - a statistic the commissioner called "a conservative estimate."

Special Agent William R. Hocker, a DEA spokesman, would not say how agents formed their assessment, but he released a summary of the agency's findings last week.

Dr. Peter L. Beilenson, Baltimore's health commissioner, said he was surprised by the DEA findings regarding the use of Ecstasy and crack cocaine because so few of those addicts have shown up in city drug treatment programs.

"Ecstasy and crack is not something we have heard a lot about," he said. "Clearly we have a major heroin problem and somewhat of a cocaine problem, but by far the primary drug of choice is heroin."

Baltimore leads the nation in per-capita heroin use, DEA said.

"None of it terribly surprises me," said Mayor Martin O'Malley, who was elected last year on an anti-crime platform. "Part of it is our fault for not having asked for help and more money sooner."

Norris is expected to announce the details of the assessment within a few weeks after briefing top city officials and the region's congressional delegation.

O'Malley and Norris said they want to develop a strategy for leveraging more resources from the U.S. Department of Justice and the DEA.

The police commissioner said he wants more DEA agents assigned in Baltimore and more federal funds to help the department triple its number of drug enforcement officers, now about 100.

City officials also estimate they need at least $25 million to provide enough drug treatment slots so that every addict who seeks help or is ordered into treatment can get it within 24 hours - another of O'Malley's goals.

Baltimore is estimated to have at least 60,000 drug addicts - roughly 10 percent of the population - and police say drugs are a factor in eight of every 10 city homicides.

O'Malley also said a third piece of his administration's anti-drug strategy is the launch of "faith-based youth intervention" programs.

With the federal help and the three-pronged approach, Norris and O'Malley said, they believe the drug epidemic will be under control - but certainly not gone - in two to three years, similar to New York's success in stemming its crack cocaine outbreak recently.

The crack epidemic, which officials say largely missed Baltimore when it swept through other cities in the late 1980s, is now "a large, entrenched market with violent and dynamic distributors," according to the DEA summary.

The city has had a thriving heroin market since the 1970s, but the DEA reported that Baltimore has now become a center for distribution of a unique form of heroin processed in South America that is "significantly higher in purity" than the national average.

A few years ago, South American cocaine cartels began producing high-grade heroin to respond to American's increasing demand for the drug, the DEA's Hocker said.

The cartels - trying to avoid a battle with traditional heroin distributors from Southeast Asia who were established in New York and Miami - chose Baltimore as one of their U.S. distribution points, he said.

Baltimore also continues to lead the country in both heroin- and cocaine-related hospital emergency room admissions, according to the DEA.

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Traffic in cocaine, heroin, Ecstasy assessed by DEA Baltimore's notorious drug epidemic is even worse than law enforcement officials had realized previously, a new federal assessment shows. The report on Baltimore's drug culture, from a three-month study by the federal Drug Enforcement Administration, concluded that the problem cannot be solved quickly - or by police alone.