In this July 26, 2017 photo, a paramedic works in Charleston, W.Va. Paramedics have been flooded with calls related to overdoses, stretching their already limited resources. (Craig Hudson/Charleston Gazette-Mail via AP)

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The Dangerous Misconceptions About the Opioid Epidemic and How We Respond

A paramedic works in Charleston, W.Va. where paramedics have been flooded with calls related to overdoses, stretching their already limited resources on July 26, 2017. Photo: Justin Fowler/The State Journal-Register/AP

Emilie Rose Hanscome remembers the first time her boyfriend overdosed in their bed. He was breathing strangely, keeping her awake. “I kept poking him because I was annoyed,” says Hanscome, a petite blonde. When she flicked on the light, she found the father of her children foaming at the mouth.

“Then he was almost turning gray, black,” she recalls. Paramedics got there in time and administered Narcan, the opioid antidote that reverses overdoses. Deep into the opioid quagmire, the EMTs seemed annoyed about having to revive yet another junkie, she remembers.

Her boyfriend’s descent into addiction had mapped the journey that so many have taken before him, repeated step-by-step in so many journalistic portraits of the heroin epidemic: When Kevin Manchester was a young teenager, he was prescribed Vicodin for football injuries. By the end of high school, he’d suffered so many big hits that he had to stop playing — 13 concussions before his senior year. Giving up the game he loved exacerbated his longtime depression, anxiety, and attention deficit hyperactivity disorder.

He would self-medicate with alcohol, pills, cocaine, and heroin. He ended up in the hospital at least twice, once after injecting cocaine and once after overdosing on opiates.

After graduating, he considered joining the National Guard, where Hanscome, who he’d met through his sister, worked as a cook. But he decided to stay home and help take care of the kids, which might have been the wrong move. “I feel like the military would have helped him with his addiction a lot more. It could have kept him on the straight,” Hanscome says.

Instead, he kept relapsing. There were times he needed heroin just to function normally. “When Kevin did heroin, it made him mellow. Then he could think straight and get his stuff done. But then he’d also get too tired. It was bad/good,” she says.

Quitting is not easy. One January morning, Michelle MacLeod, an acquaintance of Manchester’s who also used, texted him to figure out how to get through the day. “You still want to go, right?” she wrote. “If not, I’m just going to go through another kid.” When he didn’t reply, she called him four times. “Call me, pls, so I can make plans,” she texted. Finally, Manchester wrote her back: “We will leave by 11.”

The two drove from Nashua, New Hampshire, to Lawrence, Massachusetts, to buy fentanyl, a powerful synthetic opioid driving the steep rise in overdose deaths across the country. Of the estimated 64,000 people who died from a drug overdose in 2016, the largest jump in fatalities was related to fentanyl and its analogs, which accounted for nearly a third of those deaths.


Kevin Manchester holding his daughter.

Courtesy of Emilie Rose Hanscome

Later that day, MacLeod and her boyfriend snorted the white powder off a dresser in their Nashua home. They both passed out. When they didn’t pick up their 7-year-old daughter from school, a neighbor grew worried and called for help. First responders showed up and tried to revive them with Narcan. He woke up; she didn’t.

But that’s where the cliché ends and the reality of today’s drug war takes over. A little over a month after MacLeod’s death, police burst into Kevin Manchester’s apartment in Nashua with a battering ram while Hanscome and their daughters, ages 2 and 6, were eating breakfast. In the eyes of the law, meeting his dealer in Massachusetts, then splitting the score with MacLeod, made Manchester a dealer, too. (Manchester, in using some of what he bought and selling the rest, was engaging in a common practice users employ to support a habit.)

Officers raced up the stairs, guns out, as the kids watched in terror, Hanscome recalls. Manchester, then 26, was arrested and charged with “Acts Prohibited, Death Resulting” for selling the fentanyl to MacLeod. The charge carries a maximum sentence of life in prison.

Faced with that penalty, Manchester pleaded guilty and got 10 to 40 years. When he entered his plea, New Hampshire Attorney General Joseph Foster essentially called him a murderer by proxy. “Opioid and fentanyl misuse is our most serious public health and public safety problem,” he said in a press release. “Simply put, Mr. Manchester’s sale of illegal fentanyl was a choice to sell poison to another human being. We will continue pursuing individuals who make selling this poison their business of choice and will hold them accountable.”

The case against Kevin Manchester represents an uncomfortable challenge to the discourse surrounding the opioid epidemic. Manchester is white, and New Hampshire is one of the whitest states in America. From both political parties, the rhetoric around the heroin crisis has largely been one of compassion, spoken in the language of public health. That, say critics of a racist criminal justice system, is only the case because so many of the epidemic’s victims are white. As a result, social justice advocates who might otherwise be organizing to end an epidemic that is devastating an entire generation see instead only hypocrisy from the system, and they move on.

That makes the drug war, which continues to be waged with ferocity, invisible to many who oppose its application elsewhere. Just as some conservatives seem to care more about the opioid epidemic because it appears to affect white people, and not just the ones who’ve long been written off, some metropolitan liberals seem to care less for the same reason. But in order to maintain the fiction that only white people are dying in the epidemic, the thousands of black and brown people succumbing to the same epidemic must be erased from the picture. Since 2010, opioid overdose deaths in the Hispanic, African American, and Native American communities have skyrocketed, a trend that has been evident for some time. Citing CDC data, NPR recently highlighted the surging death rates among blacks in both cities and in the countryside.

The exclusive focus on white casualties of the epidemic has obscured the brutality of the drug war being waged against both white and black users. And it misses that while there may be some compassionate rhetoric at work in rural areas, genuine public health approaches are underway in many cities, often existing awkwardly alongside the drug war’s main features, police militarization and brutality. Yet while cities debate safe injection sites, rural areas are still skittish even about needle exchange programs.

As the stubborn epidemic drags on, the approach taken to Manchester is not an anomaly, but part of a pattern of police and prosecutors going after drug dealers as they would murderers. Drug enforcement officials are increasingly investigating fatal overdoses like homicides, gathering evidence at the scene of the death to lead them to the dealer, with prosecutors using measures like New Hampshire’s Acts Prohibited Law to put dealers away for decades or more. Although national data is not yet available, a report by the Drug Policy Alliance found that media mentions of such cases shot from 363 articles in 2011 to 1,178 in 2016, the most recent numbers available.

In September, a Republican member of Congress introduced a bill that would allow federal prosecutors to seek the death penalty for people who sell drugs that result in a death. In his first State of the Union speech, President Donald Trump promised to get “tougher on pushers and dealers.” Earlier this month, the president suggested executing drug dealers as a solution to the opioid crisis, and last week, news surfaced that that administration was looking into policy changes that would make drug dealing a capital crime.

Focusing on the rhetoric while ignoring the reality is nothing new. “This legislation is not intended as a means of filling our jails with drug users,” said Ronald Reagan at the 1986 signing of the Anti-Drug Abuse Act. “What we must do as a society is identify those who use drugs, reach out to them, help them quit, and give them the support they need to live right.”

Reagan’s “gentle, reasonable” promise to help addicts — while punishing dealers — backed legislation that empowered prosecutors to seek long sentences, tied judges’ hands when considering mitigating circumstances, and helped make America the world’s No. 1 jailer. It’s why there are still people sitting in prison for nonviolent drug crimes — including selling or possessing pot, now widely considered a harmless plant, which is making millions for business people in places where it’s legal at the state level.

In today’s opioid crisis, the line between addict and dealer is more blurred than ever.

In today’s opioid crisis, the line between addict and dealer is more blurred than ever. Manchester had struggled with addiction for years, and MacLeod had planned to sell some of the drugs that she’d bought from him to a friend. Manchester was not her only drug hook-up; she’d driven to Massachusetts to get drugs with other people before. In an earlier exchange, she’d complained to Manchester that a previous batch of drugs had not been strong enough. And critics argue that going after dealers isn’t the answer to the opioid crisis. “When punishing individuals turns the tide on the negative public consequences of drug use, let me know,” says Kevin Irwin, a harm reduction specialist working with the New Hampshire Harm Reduction Coalition.

While some law enforcement officials argue that jailing dealers deters others from selling, drug policy experts say it’s unlikely to have much long-term impact. “You’re talking about a worldwide, billion-dollar trade. If demand is there, someone will step up and supply,” says Art Way, a senior director at the Drug Policy Alliance. “All we know how to do is to be punitive. We should be getting people treatment, without having them going into the criminal justice system.”

Hanscome admits that Manchester messed up a lot, but says he needs help with his addiction, not a decade or more behind bars.  “They should deal with the issue, instead of just locking addicts away,” she says.

At Manchester’s trial, prosecutors cited the severity of the opioid problem as a justification for putting people like him in prison. But Hanscome doesn’t see how making an example of him will change anything: “It was supposed to scare people into saying, ‘OK, we’re not selling anymore. But it’s like … not to sound mean, but drug addicts and dealers don’t really watch the news. It’s more like, ‘This is our world, who cares?’”

NEW YORK, NY - AUGUST 09:  Students learn to put together a Naloxone spray gun in a class on opioid overdose prevention held by non-profit Positive Health Project on August 9, 2017 in New York City. The weekly class offers individuals free training with Naloxone and everyone receives an overdose kit on completion of the hour course. According to the latest data available from the National Institute on Drug Abuse, nearly 35,000 people across America died of heroin or opioid overdoses in 2015.  (Photo by Spencer Platt/Getty Images)

Students learn to put together a Naloxone spray gun in a class on opioid overdose prevention held by non-profit Positive Health Project on August 9, 2017 in New York City.

Photo: Spencer Platt/Getty Images

“The Syringe Has Become the Murder Weapon”: Law Enforcement’s Response

When the New Hampshire Department of Justice announced Manchester’s indictment, officials made no mention of his history of addiction. Instead, they drew a stark line between addict and dealer, victim and criminal. “Those suffering from the disease of fentanyl and heroin addiction need access to treatment and recovery,” Drug Enforcement Administration agent Michael Ferguson said in a press release. “However, those responsible for distributing these lethal drugs like heroin and fentanyl need to be held accountable for their actions. In response to the ongoing opioid epidemic, DEA and its local, state, and federal partners are committed to bringing those to justice that distribute this poison.”

Since opioid deaths began to surge in the mid-2000s, many law enforcement officials have embraced the language of health policy instead of punitive approaches. But the federal government and many states have continued to pursue policies that end up shuttling people into the criminal justice system. In the past few years, New Hampshire — deemed “ground zero” in the opioid crisis by one DEA official — has ramped up its police response, doubling down on some of the “tough-on-crime” strategies for addressing substance use disorder.

One example is Operation Granite Hammer, launched in 2015. A collaboration between the DEA, state police, and local police in the city of Manchester, the program aims to get dealers — and dangerous synthetic opioids — off the streets. In 2016, the legislature voted to hand out an additional $1.5 million to expand the program. At the time, DEA agent Jon Delena stressed to New Hampshire public radio that law enforcement would go after “anybody that’s peddling in death, anybody that’s selling heroin, fentanyl, or opioids.” That’s including low-level and mid-level dealers, not the pharmaceutical companies producing, marketing, and distributing the product, and not Mexican cartel leaders or Chinese factories, where the deadly synthetics have been known to originate. But in some cases, Granite Hammer operations have also ended in people getting charged with heroin possession, like this bust from June, suggesting that users are also getting swept up.

Meanwhile, as part of the strategy of treating fatal overdoses as crime scenes, an inter-agency strike force that includes a homicide detective and a prosecutor has aided police in gathering evidence for more “Acts Prohibited, Death Resulting” prosecutions like Manchester’s. “The syringe has become the murder weapon,” a DEA official based in Manchester told a reporter earlier this year in an article for Fox News about the strike force.

So far, the state has secured 10 guilty pleas in cases of overdose with death resulting, while 10 people are currently facing charges, and there are “numerous cases in the investigative stage,” says Assistant Attorney General Danielle Horgan Sakowski.

“There’s not just one solution to this problem,” she told me, noting the need for treatment and community outreach. “But what we’re responsible for is to set an example to those who would deal or sell what is poison, [to show] that there are consequences.”

But two years and more than $1 million in funding later, Operation Granite Hammer doesn’t appear to have made a large dent in the state’s drug problem. Fentanyl and the even deadlier carfentanil are still in the drug supply. The overdose rate remains stubbornly high. According to data collected by the Manchester Fire Department, there were 74 suspected overdoses in the city through mid-February 2018. There were 72 suspected overdoses in January and February of last year.

Nor have the deaths decreased. In the 12 months leading up to July 2017, 459 people in New Hampshire died from a drug overdose, according to CDC data (that number is likely low, due to incomplete data). A significant number of those deaths stemmed from fentanyl or fentanyl mixed with other drugs.

And putting people in jail for drugs can backfire. That’s what Republican Jim Rubens found out during his 2016 Senate challenge to Kelly Ayotte, when he went to the Cheshire County jail to talk with the women there about their opioid addictions. They had all ended up in jail for crimes related to drug use. They assured Rubens that once they got out, they’d use again, maybe within minutes of release if the friends who picked them up brought a shoot-up rig in the car. “It was jaw-dropping for me,” Rubens says over the phone. Not only did jail fail to curb their addictions, it helped strengthen their drug connections, making it even easier to get drugs when they left. “So you broke up a drug ring — great,” Rubens says. “A politician will run on that, get elected on that. But will it solve the problem? Are they fulfilling their obligation to make the state stronger? No. Are you doing something to get re-elected? Yes.”

Way, of the Drug Policy Alliance, sees a more productive role for law enforcement: building trust with users and dealers so that they know when there’s a dangerous product out there and steering people in trouble to services.

“If you’re dealing with a public health issue, are you trying to save lives or are you sending a message? By cracking down, you drive drug use further and further underground,” says Way. “It makes it more difficult for people to reach out and get assistance.”

The Econolodge in Manchester New Hampshire, July 2017.

The Econolodge in Manchester New Hampshire, July 2017.

Photo: Roger Holcombe

“People Do It Anywhere”: First Responders on the Front Lines

The Econo Lodge in Manchester has a grim, brick facade that makes it look more like an old hospital or mental asylum than a welcoming place for visitors. Flanked by a highway on one side and a river with a large homeless encampment next to it, the cheap motel has become a hub for drug use and dealing. And lots of overdoses.

“We go there a lot,” says Rocco Caprarello, a manager at AMR ambulance services. Caprarello has a white buzzcut and tendency to ruefully laugh and shake his head in resignation at the city’s overwhelming opioid problem. It’s 10:30 in the morning and they’d already gone out on three calls for reported overdoses (two people told EMTs that they’d just been asleep; a third had to be revived with Narcan).

As we ride in his ambulance on a drug tour of the city, Caprarello rattles off spots where they’ve had to help people. “Wealthy houses, on the railroad tracks, homeless camps, in cars, the off-ramp of a highway. A cemetery. People do it anywhere.” He points to a baseball diamond and tells me that before Little League games, parents scour the area for discarded needles.

Street after street, he points to the places where drug fatalities have happened in Manchester. “We’ve had them in vehicles, we’ve had them in restaurants, we’ve had them in port-a-potties. … Someone takes a little bit too much, and next thing you know, you go in to use the bathroom, and, well … ” he trails off and shrugs.

Street after street, he points to the places where drug fatalities have happened in Manchester.

Caprarello doesn’t have a great amount of sympathy for people who deal drugs that lead to someone’s death — he thinks it is just fine to “lock ’em up for a long time.” But nor is he persuaded that such prosecutions could save his city from a crisis that has turned New Hampshire, in Trump’s words, into a “drug-infested den.” Caprarello thinks it comes down to basic economics — once one dealer is caught, another will step into his place. “How do you stop it, if someone is making money? If you’re smart, you don’t do your own product, because you don’t want to kill yourself. So how do you stop it?”

FILE - In this June 17, 2016 file photo, Erika Marble visits the gravesite of Edward Martin III, her fiancé and father of her two children, in Littleton, N.H. The 28-year old died Nov. 30, 2014, from an overdose of the opioid Fentanyl. Drug overdose deaths increased by 33 percent in the past five years across the U.S. as of 2016. New Hampshire saw a 191 percent increase while Massachusetts, North Dakota, Connecticut and Maine saw death rates jump by more than 100 percent.(AP Photo/Jim Cole, File)

Erika Marble visits the gravesite of Edward Martin III, her fiancé and father of her two children, in Littleton, N.H on June 17, 2016. The 28-year old died Nov. 30, 2014, from an overdose of the opioid Fentanyl.

Photo: Jim Cole/AP

“More Heartbroken Families”: Can the State Prevent All These Deaths?

On a Friday afternoon, a young man with a shaved head is visibly jittery as he sits in Manchester’s main fire station. He’s come there to enroll in the Safe Station program, launched by the city’s Fire Chief Daniel Goonan in May 2016 to link drug users to treatment: No judgment, no shaming, and no threat of being arrested.

Arms crossed, a pack of firemen politely probe the man about his drug use. He replies that he doesn’t do illegal drugs, just drinks alcohol. When they gently ask him if he’s sure that he doesn’t do cocaine, crystal meth, or heroin, he snaps, “You mean like, never? In my entire life?” Later, his aunt tells Goonan that he uses “everything and anything” he can get his hands on, including heroin and meth.

“You’re a good man!” she tells her nephew before he’s packed off in an ambulance to safely detox at the hospital. “You’ve got so much to live for!” As the ambulance leaves, Goonan casually throws away a half-drunk can of Pabst from the young man’s car. “Usually it’s Natty Daddies,” he jokes about the malt liquor he finds on people who come to get help.

A tall, rugged native of Manchester and self-described townie, Goonan doesn’t know why the city has become an epicenter for addiction in the state. But when he was appointed to lead New Hampshire’s largest fire department, he decided that firefighters had to help with the crisis. “I’m really invested in this problem, in helping people out,” he says. “I think that’s what the fire department does best.”

Under the Safe Station program, drug users can voluntarily walk into the fire station to get help. Firefighters assess their immediate medical needs, and they can dispose of drugs or needles. They then connect people with family members, hospitals, treatment programs (of which there are never enough to meet demand), or a shelter, depending on their needs. If someone doesn’t have health insurance, they help the person apply for Medicaid.

Since Safe Station opened on May 4, 2016, 3,127 people have sought help, according to Manchester Fire Department data. They come from all over New Hampshire and even out of state to seek services. The station has repeat visits — the relapses — but Goonan says that any time someone comes to them, it’s a victory.

Although the firefighters closely collaborate with law enforcement, he thinks the fire department is in a unique position to help. “Early on, I asked a lot of these people the question, ‘Would you be here if this were the police department?’ And they replied with a resounding, ‘No.’” The department also gets helpful information. “People come up and say, ‘Chief, there’s carfentanil on the streets.’ So, I knew we had a carfentanil issue probably before the police did.”

Goonan is looking to get federal funding and expand to more parts of the state. Having experienced addiction in his own family, he doesn’t think that the threat of a long sentence serves as a deterrent, for users or dealers. “So yeah, let’s say you put someone away for life. Some guy’s just going to take his place. And when people are in the throes of addiction, they’re not thinking straight. They’re not thinking about their children, only about how they’ll get more drugs.”

If all the media covered was the fire station – and that’s all that is typically covered — it would be reasonable to come away with the idea that the U.S. really is softening its approach to drug policy. But peel back the layer, and the town has some well-meaning public servants with no serious backing from the federal government. And when the young people are shipped off to treatment, there are precious few mechanisms in place to prevent them from winding up in the hands of fraudsters looking to profit from their ongoing misery. Goonan briefly met Trump in Washington, D.C., at a “Listening” roundtable session with the first lady, where he spoke about the program and later tweeted a photo of himself sitting with White House counselor Kellyanne Conway, who was later put in charge of the opioid epidemic response. But as of March 2018, Safe Station hasn’t gotten any federal funding.

And if it takes a Melania Trump roundtable to get a firehouse program attention, and even that attention doesn’t lead to a nickel of funding, that’s not a scalable solution. Evidence of true compassion in the overall policy dating back to the beginning of the epidemic evaporates quickly once you look at where the money is going.

Irwin, the harm reduction specialist, says that New Hampshire is only now starting to get up to date with evidence-based policies. In June 2017, state legislators passed a bill legalizing needle exchanges, which mitigate disease transmission and the health dangers of shooting up. As head of the New Hampshire Harm Reduction Coalition, Irwin has taken on the task of educating people on how to open and operate needle exchanges. The state is years behind many cities and, in the end, hasn’t shown itself to be serious yet about the reform: The state hasn’t provided funding or any resources to get the program off the ground.

And needle exchanges are just the start of evidence-based strategies for attacking the opioid epidemic: A more sustainable strategy would also include easy access to medicines like Suboxone, supervised injection facilities, and public education campaigns and treatment programs not based entirely on abstinence. Portugal, which has decriminalized all drugs, has an annual overdose rate that’s well below that of New Hampshire.

Portugal, which has decriminalized all drugs, has an annual overdose rate that’s well below that of New Hampshire.

Michelle MacLeod became one of those drug fatalities on January 22, 2016. She was only 31 and had two young kids when she died. Her mother sobbed while she read a letter about her at Manchester’s sentencing. “Michelle had many friends in Nashua. She was kind and the type of person that would be there to lend a helpful hand if she knew someone needed it,” Barbara MacLeod read in court. She noted that Michelle’s kids, at ages 1 and 7, were not likely to remember much about their mother. “No penalty will bring back my baby girl,” she said, sobbing. Nevertheless, she said she hoped Manchester’s incarceration would save his “damaged soul.”

But rather than punish Manchester after the fact, could a different approach from the start have prevented her death? MacLeod’s autopsy concluded that she had died of acute fentanyl toxicity. But she also had traces of klonopin in her system. As Carl Hart recently wrote in Scientific American, many opioid deaths are caused by a combination of drugs, especially sedatives and benzos like klonopin. Could she have been helped by a harm reduction campaign informing people to reduce risk by not mixing opioids and benzodiazepines? Could things have turned out differently for MacLeod if the small city of Nashua offered supervised drug use stations, where users are monitored for adverse reactions? Although MacLeod had wanted fentanyl, other users get it by accident. Might future overdoses be prevented by the widespread distribution of testing kits for fentanyl, a program floated in the Bronx, New York?

It’s impossible to know for sure, but according to the New Hampshire Department of Corrections, it costs $34,155 a year to keep someone in prison. That we know.

“I do agree we need all hands on deck,” the DPA’s Art Way says. “The amount of fentanyl is beyond what we’ve seen historically. But we think we can send messages by throwing the book at someone, but it’s not a viable solution. The type of policy that looks to punitively throw the book at someone is not going to build these relationships to find out where this is coming from.”

At Manchester’s trial, his defense attorney pointed out that the state had failed MacLeod, Manchester, and other people struggling with addiction. “Unless we as a society begin to treat addiction, there will continue to be record numbers of addicts seeking drugs, sharing drugs, and selling drugs,” she said. “And there will be more Michelles, and more Kevins, and more heartbroken families.”

Kevin Manchester took responsibility and apologized for MacLeod’s death at his sentencing. “It’s certainly a tragedy, what happened to Michelle. One that I wish had never occurred,” he read in court.

“I was doing what I was doing to support my habit, so that I wouldn’t have to rob and steal from people. I’m not trying to justify my actions; I’m simply trying to help you understand that I’m not a monster who doesn’t care for other people.”

Top photo: A paramedic works in Charleston, W.Va. where paramedics have been flooded with calls related to overdoses, stretching their already limited resources on July 26, 2017.

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