Several years ago, during the worst of the opioid crisis, the calls would come at any time, from rural areas, small towns or cities. But the urgency would be the same: Someone was overdosing, and local emergency response technician Mark Kraemer was on the clock to save a life.
“No matter the outcome of that call, you have to put your emotions aside because that pager’s going to go off again,” said Kraemer, who now serves as interim chief of Cheshire EMS and has worked as a first responder in Peterborough and Lowell, Mass., two states where overdose death rates outpace the national average. When first responders arrive in time to reverse an overdose, he added, they then must help the patient through one of the darkest moments of their life. “You don’t have time to process that, and it’s hard.”
The overdoses were happening to all age groups, from teenagers to grandparents who had been prescribed opiates for knee pain, according to Danielle Bishop, an EMT at Cheshire EMS. “I don’t know how many times I’ve woken up a mom with her kid standing right there. It affects everybody.”
But over the past year, Kraemer, Bishop and other local first responders have noticed the calls growing less frequent, bringing cautious optimism to a crisis that has taken the lives of more than a million Americans since the late 1990s, according to the Bloomberg School of Public Health. For the first time in decades, overdose deaths are declining significantly across the United States, with recent CDC data showing a 16.9 percent decline in yearly overdose deaths. In New Hampshire, the Office of the Chief Medical Examiner issued its year-end report Dec. 13, which recorded 238 overdose deaths in 2024, a 45 percent decrease from the 431 deaths it recorded in 2023; although the data may change based on 46 pending toxicology reports, the state’s current overdose death rate is now at its lowest since 2012.
Cheshire County’s lower quantity of data makes comparisons of year-over-year overdose numbers less conclusive than state numbers. The county’s highest year for overdoses was in 2018, when 32 people died of overdoses. Between January and August 2024, 13 overdose deaths occurred in the county, putting the county on pace for fewer deaths than in 2023, when 26 people died.
Although drug overdoses remain a leading cause of preventable death in New Hampshire, state and local public health agencies now believe that their interventions are finally kicking in.
“It provides optimism for us here in New Hampshire that the work we’ve been doing has been making a difference,” said Jonathan Ballard, the chief medical officer of the N.H. Department of Health and Human Services. “We’ve certainly come a long way since the time that we had a high point in opioid overdose deaths.”
Yet, between the distribution of the overdose reversal medication Narcan, strategies to reduce harm, access to recovery and treatment programs, explanations vary for why overdose deaths have fallen so rapidly; between 2015 and 2023, more than 400 Granite Staters were dying each year. As the crisis has proceeded, NHDHHS opted for an “all of the above” approach to addressing overdose deaths, which Ballard attributes to the state’s sharp reductions in deaths.
To understand why overdose deaths are falling and what barriers still remain for those with substance use disorders, The Sentinel examined different overdose prevention strategies being implemented by public health agencies and local recovery centers. Public health experts and local organizations attributed the changing numbers to a combination of public health interventions, and said sustaining the reductions will require strengthening overdose prevention and pathways to recovery.
During previous attempts to get sober, Swanzey resident Dante Diffendale found that stigma was one of the biggest barriers he faced. Stigma from both communities and health institutions can increase the likelihood of relapses and overdoses, according to research by the National Institutes of Health. After surviving seven overdoses, Diffendale recently celebrated two years of sobriety.
“I was a sick individual who was hurting,” said Diffendale, describing how judgements from communities and people without substance use disorders fed into negative perceptions of himself that worsened his mental health. “I wasn’t bad. I’m not bad. … People look at me and they judge me. I know how hard that is and how it makes me feel belittled and less than.”
On a national level, negative perceptions surrounding opioid use and substance use disorder are slowly beginning to change, according to David Herzberg, director of the Drugs, Health, and Society Program at the University of Buffalo. Until recently, Herzberg said, opioid addiction has been treated as a decision made by individuals, as opposed to a symptom of emotional trauma, physical pain, economic insecurity and a lack of public health infrastructure like housing and health care.
“Very few people these days are going to publicly say it’s not worth saving the life of someone who uses drugs,” Herzberg said. “That used to just be an assumption.”
For Kraemer and other local EMS providers, understanding overdoses as a symptom of deeper physical and emotional pain has become a new approach to responding to overdoses.
“Our role as EMS providers is not to be judgmental, but to be supportive,” Kraemer said. “Sometimes that means helping someone who has gone through a lifelong battle with trauma and has now turned to substance abuse to try to escape that reality in which they live.”
Previously, Kraemer said, stigma from EMS providers has resulted in poor relationships with patients who experience overdoses. But a $200,000 grant through the Substance Abuse and Mental Health Services Administration is helping fund trainings for first responders in departments throughout Cheshire County on how to best address mental health crises that frequently occur after being saved from an overdose. Those trainings are informed by Kraemer’s experiences as a first responder, where he saw a need for mental health consciousness among first responders.
“I’ve seen providers be extremely judgmental and ridiculing people who are having the worst day of their life,” Kraemer said. “When you go to EMT school, they teach you patient advocacy, but as far as [training] for dealing with someone who’s in an acute crisis emotionally, it’s really low. The entire industry as a whole is having a shift to mental health awareness.”
Little data exists on the extent to which reducing stigma prevents overdose deaths, but local organizations are beginning to make changes.
“Stigma is still very real for substance use disorders, and there’s still a lot to learn in the medical field,” said Martha Barnard, a community public health worker at The Doorway in Keene, a substance use disorder referral hub run through Cheshire Medical Center. “That said, I do believe a lot of professionals in the medical field have learned a lot. Language is so important when it comes to stigma.”
According to Barnard, such language changes include identifying patients as people suffering from a disorder, and acknowledging the role of mental health in overdoses and addiction.
Boxes of Narcan, the first over-the-counter opioid overdose reversal drug, began appearing in public not long after it was approved by the Food and Drug Administration in March 2023. For years Kraemer and other first responders have used naloxone, the active ingredient in Narcan. But now, the lifesaving drug has now proliferated into communities across New Hampshire and the United States.
“It’s in schools, it’s in libraries, it’s in town offices, it’s at McDonalds,” Kraemer said. “I think that’s what’s driving your [overdose death] numbers down.”
This would explain an enigma within NHDMI data: Despite large reductions in overdose deaths, EMS Narcan administration was at its lowest recorded level in 2024.
“If you have someone in need and they’re having an overdose, if they have a friend there that gives them naloxone and brings them back, they’re not always calling EMS after,” said Lt. Thomas Phelan of the N.H. Information and Analysis Center, which began the NHDMI in 2013 as a response to a lack of data regarding the crisis in the state.
Jodi Newell, who represents Keene’s Ward 4 in the N.H. House of Representatives, has been a leading legislative advocate for addressing the crisis by making Narcan available in settings where overdoses occur. Having Narcan available during opiate use allows for faster response time than waiting for an ambulance to come since “people whose lives are saved are often saved by people who were also using,” said Newell, whose husband died of an overdose in 2008.
Increasing access to test strips for fentanyl — the highly potent opiate involved in 182 of New Hampshire’s 232 overdoses so far in 2024 — has also been a strategy of federal, state and local public health agencies.
“If you have those resources there, if you have drug tests, you can make more informed decisions,” Newell said. In the upcoming legislative session, Newell is sponsoring a bill that would expand resources for drug tests that show of the potency of fentanyl in a mix drugs; currently, the widely available test strips only test for the presence of fentanyl.
Although the widespread availability of Narcan is preventing overdose deaths, longer-term support for people in recovery needs to be strengthened to prevent repeat overdoses, according to Sophie Nathenson, a medical sociologist at the Oregon Institute of Technology.
“The distribution of naloxone is really saving people, but right before they’re dying,” said Nathenson. “It’s a bit like mopping the floor instead of turning off the faucet.”
To sustain the current reductions in overdose deaths, Ballard said NHDHHS is turning its attention to addressing the root causes of overdoses. This consists of “improving our treatment system, build[ing] out recovery supports, and doing a lot of work on upstream prevention, to prevent individuals from using in the first place.”
For Diffendale, who now works in addiction prevention and advocacy, those root causes were trauma that he traces back to early childhood, as well as physical pain from injuries and lifelong health problems. During his unsuccessful attempts to stay sober, the overdoses stopped, but the physical and emotional pain didn’t; Diffendale experienced homelessness multiple times during sobriety. “Society failed me and didn’t provide me with the basic necessities a child needs, like support and love and compassion and safety. I was looking for something so that I didn’t kill myself.”
Every person with substance abuse disorder has different needs, and what may work to help one person recover may not work for another, according to Barnard of The Doorway, which has locations throughout the state. Holistic approaches, like deepening ties between local organizations, recovery centers and communities, Barnard said, will be the next step in sustaining the downward trend of overdose deaths.
While strategies to prevent people with substance use disorders from dying are working, long-term solutions to prevent addictions from forming and create recovery conditions are always in need of more funding and resources, according to Ryan Gagne of Live Free Recovery, a treatment provider with locations in Keene and throughout New Hampshire.
“A real good portion of recovery is connection,” Gagne said. “It has nothing really to do with the addiction itself. If you’re on good footing and connected to good people, your chances of staying sober are going to be exponentially higher than somebody that’s not.”
That’s why Gagne and others in public health don’t yet see the decline in overdose deaths as a reason to let up. Although the danger of fentanyl’s potency has become widely understood, drug use can always change forms like it currently is in New Hampshire, according to Phelan of the NHDMI.
“People have noticed fentanyl has been killing people,” he said. “Fentanyl is still a highly used drug here, but there’s also been this shift to methamphetamine because the chance of dying is much lower than fentanyl.”
In the eyes of public health departments and local social workers involved in recovery, sustaining the reductions in overdose deaths will also require resolving larger social issues within communities to prevent the feelings of isolation that can lead to addictions forming or relapses.
“The loneliness epidemic is affecting everybody,” Gagne said, who is 16 years sober. “For people suffering from addiction and alcoholism, the return back to [loneliness] can be fatal. Their life depends on some type of connection to head down the path to healing.”
If you or a loved one is struggling with a substance use disorder, The Doorway — a recovery services referral hub at 24 Railroad St. in Keene — is open Monday through Friday, 8 a.m. to 5 p.m. Support through the state’s 24/7 hotline is also available at 2-1-1.
These articles are being shared by partners in the Granite State News Collaborative. For more information, visit collaborativenh.org.