An article from the April issue of the NHPHA e-Newsletter

This month, the spotlight shines on and welcomes Shannon Bresaw and Granite United Way, a new organizational member and public health friend to NHPHA.  GUW Logo

Granite United Way currently serves as host agency for three (3) out of the thirteen (13) regional public health networks in the state, including the Capital Area, Carroll County and South Central (formerly Greater Derry).  Funded in part by NH DHHS, these networks work to convene, coordinate and facilitate an ongoing network of partners to address regional public health needs.  Granite United Way is committed to improving the lives of individuals and families by supporting programs in the areas of education, income and health.

ShannonMeet Shannon Bresaw, Director of Public Health Services and Prevention for Granite United Way, In her role, Shannon oversees the public health network contracts held with NH DHHS, including the following scopes of service for which each network is responsible: Substance Misuse Prevention; Continuum of Care for Substance Use Disorders; Public Health Emergency Preparedness; Public Health Advisory Council and Community Health Improvement Plan Development.  Shannon graduated with a Master's Degree in Social Work in 2004 with a focus on Community and Administrative Practice.  "I have been connected to the public health network system since 2004 working in Franklin and the Belknap County region before coming to United Way in 2007."  When asked what she liked most about the work that she does, the assessment, strategic planning, and evaluation components of the work as well as grant writing and research were a few of her favorite things.  "I am very focused on understanding the root causes of the problems we face in our communities, followed by the development of a comprehensive plan that is based on research and best practices."
Current projects for Granite United Way include the South Central Public Health Network that has recently developed a Public Health Advisory Council and is working on developing the region's Community Health Improvement Plan.  The Carroll County and Capital Area Public Health Networks are in the process of implementing their Community Health Improvement Plans.  "Each network is also working on an assessment and plan to address gaps and barriers related to the full continuum of care for substance use disorders, from prevention to treatment to recovery supports and services.", Shannon said.  "Priority issues in the regions align with the State Health Improvement Plan and include the misuse of alcohol and drugs, public health emergency preparedness, behavioral health, injury prevention, and more."

As a past member of APHA and having presented at their Annual Meeting, Shannon became very interested in being more connected with NHPHA, particularly concerning advocacy efforts and connecting their public health network members to those types of opportunities moving forward.  In the Capital Area Public Health Network, they are working to implement "Health In All Policies" in the region and will feature a presentation on this strategy at their annual meeting in June.  "We recognize the influence of laws and policies on our public health outcomes and believe that advocacy is a crucial component of our work."

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By Kim McNamara, NH Health Officer

This opioid crisis communities across New Hampshire are facing, is a whole community issue because the entirety of our communities is suffering.  This has rapidly reached unprecedented levels, and continues to accelerate.  From 2010 to 2014, deaths from all drugs in NH increased by 177.8%.  In that same period, heroin deaths increased by 653.8% and fentanyl deaths rose by 663.2%.  Throughout our state, individuals, families, and neighborhoods have been tormented by the personal loss of a relative, friend, or neighbor, affecting the physical and mental health and well-being of our entire communities. 

The heartbreaking loss of life, although the worst outcome possible, is just the tip of the iceberg.  There are innumerable additional poor outcomes piled up beneath.  Accidents and injury rates also increase while people are under the influence.  The effects on the brain and respiration can lead to short- and long-term psychological and neurological effects, including coma and permanent brain damage leading to life-long disability.   There are additional mental health and medical comorbidities that accompany opioid use, such as mood and anxiety disorders, cardiovascular and pulmonary disease, dermatological conditions and GI complications.  Public health strives for healthy people and healthy communities.  With the rising rates of opioid use and misuse, it is clear we are moving away from that most basic tenet on many levels.

Often the largest group of people with substance use disorders are of child-bearing age.  Children of addicted mothers may face neonatal abstinence syndrome (NAS), birth defects and developmental disabilities.   Opiates pass through the placenta to the baby during gestation.  When the mother is addicted, so is the child.  NAS is a painful withdrawal process leaving babies suffering from excessive crying, fever, vomiting, diarrhea, hyperactive reflexes, rapid breathing, seizures, trembling, poor feeding, slow weight gain, increased muscle tone, and other symptoms.  A most awful welcoming into the world.  Among the possible birth defects associated with opioid use, even when carefully prescribed, are spina bifida, hydrocephaly, glaucoma, abdominal wall and congenital heart defects.  

Parents who are incapacitated cannot care for or support their families, leading to children at risk at home, and children in placement outside of the home.  When children lose parents, due to death, incapacitation or incarceration, a heavy toll is paid emotionally and socioeconomically.

There is also significant risk of escalating infectious disease rates with this epidemic.  In January of 2015 a small rural town in Indiana experienced a spike of 11 cases of newly diagnosed HIV infections linked to shared needles used to inject the prescription opioid oxymorphone.  By April, 4 months later, 135 new cases of HIV were diagnosed in a community with a population of only 4,200 persons.  These patients ranged in age from 18-57, and 114 of them (84.4%) were co-infected with Hepatitis C.  373 people with contact with these patients were also identified as potentially at risk.  Of those, 247 were located, 230 tested, and 109, or 47.4% also tested HIV positive.   These people now have an even more difficult medical profile than substance use disorder alone to surmount.  

Devastating resource, economic and social consequences to their community occurred as well.  Businesses suffered because visitors would not come to town to eat in their restaurants, or receive services.  Neighboring school teams refused to play against their sports teams.  Local resources were not enough to adequately address this outbreak.  This small town in rural Indiana has a higher HIV infection rate than many developing nations.  It doesn’t take much imagination to see how those additional community effects could happen in many places in our own state. 

This outbreak requires we think differently about who is at risk of co-occurring morbidity.  It occurred in a rural population, historically at low-risk for HIV.  Infection spread rapidly because of a large network of people injecting prescription opioids within a community that lacked resources to adequately prevent and treat the substance misuse that was brewing within. 

The Indiana outbreak highlights the vulnerability of many rural, resource-poor populations to drug use, misuse, and addiction nationwide, and highlights the need for expanded mental health and substance use treatment programs in medically underserved rural areas.  Although much work is being done to build capacity here, most of New Hampshire has large gaps in prevention, treatment and recovery services, particularly in rural areas.

This calamity also illustrates why a public health response to this crisis is necessary. Intervention requires a coordinated and rapid response of different branches of public health; disease surveillance, drug monitoring, and behavioral health services.   However, other community resources separate and distinct from public health are also vital for a comprehensive and effective response.  Education and prevention efforts require involvement of our educators.  Law enforcement continues to be a vital partner with drug courts, diversion programs, drug take back, community outreach, and the all-important stemming the tide of illicit drugs within our communities.  Our EMS, community and regional medical and behavioral health partners carry a significant role in detox, treatment, and recovery services. Non-governmental organizations are also an important ally.

There are numerous other community consequences.  Crime increases to support addiction or due to the effects of substance misuse.  Our EMS, emergency departments, health care providers and legal systems are under considerable stress with the pace and breadth of this issue.  The far reaching affects are too numerous to list and many are unquantifiable, but the fabric of communities is in jeopardy.

A key social measure that requires community buy-in is eliminating the stigma which is a significant barrier to care and recovery of individuals and their families.  Even if services exist, because of public attitudes, there is reluctance to seek treatment.  Communities must embrace, care for and protect those among us who are struggling and suffering.  This acceptance and support often brings non-traditional partners such as the arts and humanities groups into the fold. They quite frankly often bring heart to the issue and are better at telling stories, raising awareness and raising capital than the more clinical and statistical approach of traditional public health and law enforcement groups.

Significant barriers to treatment and recovery remain.  The importance of evidence-based therapies cannot be overstated.  Medication Assisted Treatment (MAT) has been proven to be an effective intervention for opioid addiction.  MAT was originally developed in response to the proven ineffective treatment regime of detox followed by abstinence, which did little to slow relapse.  MAT began with the use of Methadone in 1964, and in 2000 buprenorphine under the brand names Subutex and Suboxone was FDA approved.  Naltrexone followed in 2014.  MAT has been show to allow patients to remain abstinent, or greatly reduce the use of illicit opiates, reduce the use of other illicit drugs, decrease criminal and risky behaviors, and with careful monitoring, improve neonatal outcomes.

Although MAT has been proven to be clinically and cost effective, and significantly reduce the need for detox and inpatient services, it is still underutilized.  Reimbursement, regulatory and workforce barriers have been cited for these lost opportunities.  The requirement for prior authorization, limitations on time during treatment medications can be used, and a lack of reimbursement are some of the financial barriers.  These issues are being worked on, but legislation always lags behind need.

A more perplexing barrier is the specific restriction on MAT practices.  In 2000 the DATA 2000 law was passed, allowing physicians to prescribe these newer (buprenorphine and naloxone) opioid-based medications for the treatment of addiction.  However, for unclear reasons, this law restricts the number of patients a physician can treat in the first year of their new certification to 30.  After one year of providing MAT, providers can expand their treatment to 100 patients.  This arbitrary limitation is specific to medications used in MAT only.  No other prescription practices are similarly restricted, including those that govern the prescription opioids that are at the heart of this crisis.  

Numerous other barriers exist and the State of New Hampshire’s Department of Health and Human Services, through regional public health networks are embarking on an updated assessment of NH gaps and assets, due out this summer.  The goal of public health is to assist in building a state-wide Continuum of Care for all persons struggling with substance use disorders. The continuum spans health promotion and prevention, early identification and intervention, detox and treatment, and recovery supports.  Some pieces of the puzzle are falling into place in NH, but there is a long way to go and it takes our collective effort to help ourselves.

Acute emergency treatment for overdose/detox is short-term. Inpatient rehabilitation centers, intensive outpatient programs, and recovery support services are very much needed beyond the acute phase of the Continuum of Care to help individuals remain safe and rebuild their lives.  A few inpatient treatment facilities and recovery centers currently exist in NH, and a few more are on the horizon.

Recovery centers bring together a system of prevention and recovery, and meet the need of ongoing care after formal short-term treatment.  Recovery centers follow a national model, and provide vital education, training, referral, and support services to persons in recovery, their families and loved ones. Peer Recovery and Support Services efforts are most effective when leadership in the peer recovery organization are people who are in long term treatment themselves, and success can be measured.   Indicators of effectiveness include numbers of people participating in long-term recovery, fewer incidents of recidivism in judicial system, reduced Emergency Department visits and, number of trained individuals in recovery and peer support services. 

Peer recovery and support centers meet people where they are in their illness or recovery.  Not everyone’s needs are the same, therefore, not every step on the Continuum of Care is needed for every person.  A person can step in and out in the areas that fit their particular situation.  A multi-purpose recovery center responds to the specific needs of the community and as such services will evolve as indicated.  Therefore, because of the wide variety of services they provide these have the potential to serve a large portion of our population.

It is easy to get overwhelmed in the face of the opioid crisis.  The challenges seem insurmountable.  The seriousness of this epidemic is haunting.  However, part of the message to our communities has to be that SUDs are treatable.  Many people do recover and lead happy, healthy and productive lives.  There are countless members of our own communities that are living proof of that and we, as a community must help those who are caught in this struggle to believe that they too will have a successful recovery.  There are a lot of good souls working hard towards that.  Hang in there.
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By Gail Brown, Director, NHOHC

The NH Oral Health Coalition is pleased to be working with Hugh Silk, M.D.,  University of Massachusetts and the NH-based North Country Health Consortium in Littleton to be providing statewide training for the implementation of fluoride varnish in the medical setting.
OHC Update Photo In accordance with the Affordable Care Act, the US Preventive Services Task Force, and recent changes within the NH Medicaid program, NH’s primary care medical providers for children age 6 months through 5 years, can provide an oral health risk assessment and, if indicated, fluoride varnish as a preventive oral health measure. 

Dental decay, the #1 chronic disease in children within NH and the nation, is caused by bacteria and is thus both transmittable and preventable with proper care and prevention. 

Fluoride varnish is considered a simple, cost-effective and efficient part of the prevention toolkit and within NH can be applied by dentists, hygienists, and trained medical primary care providers. 

The availability of fluoride varnish application in many schools, WICs, Head Starts, and now, primary care settings brings this important intervention to the locations that young children and their families frequent naturally in early childhood. 

For more information on fluoride varnish and the prevention of early childhood caries, please see: www.fromthefirsttooth.org.  For specific information regarding NH benefits and reimbursement CLICK on “My State” and then the “New Hampshire” page.  Medical providers interested in a no-cost training for their staff, contact info@nhoralhealth.org
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By Shasta Jorgensen

As NPHA’s new Affiliate Representative to the Governing Council (ARGC), I’m excited to share with NHPHA members all things APHA. If you have questions regarding APHA or want more information about a specific topic covered in this newsletter, please feel free to drop me a line at shasta.jorgensen@gmail.com.  Here are a few things that have crossed my inbox related to APHA recently . . .

The Flint Water Crisis and Beyond
APHA is assisting with the Flint, Michigan, water issue by hosting webinars, facilitating resources for residents and community leaders, printing news stories/article in AJPH, working with APHA Environmental Health Section, and collaborating with other organizations. To view the webinar series, The Flint Water Crisis and Beyond, click here

Recognize National Health Observances with Plan4Health

Plan4Health is working in partnership with the national organizations involved in the Partnering4Health project to create grab-and-go packets for select National Health Observances.  These packets are full of great resources, including sample social media posts and other templates.

APHA Launches 1 Billion Steps Challenge
Join APHA and take small steps for big change. With a goal of reaching 1 billion steps by May 31, the challenge is the perfect way to jumpstart healthy changes in our own lives and encourage our friends, families and co-workers to do the same. Now, we know that 1 billion steps sounds like a lot. But if we all come together and start logging our steps, we can easily reach 1 billion and beyond. Join us in taking small, but meaningful, steps toward creating the healthiest nation in one generation. Let’s step into a healthier future together! Learn more about the 1 Billion Steps Challenge, including how to sign up, log your steps, and win prizes!

Healthiest Cities & Counties Challenge Launched
APHA, the Aetna Foundation, and the National Association of Counties, in partnership with CEOs for Cities, have launched the Healthiest Cities & Counties Challenge.  This multi-year program will award more than $1.5 million in prizes for cross-sector work that results in measurable changes in a variety of health-related areas, including tobacco use, walkability and community safety.

APHA Stories on Storify
Be sure to check out APHA on Storify, a platform that uses social media to crate compelling stories.  Make sure to chekc out the recent recap of NPHW and the NPHW Twitter chat.

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By Keryn Bernard-Kriegl, NH Children's Trust Executive Director

It seems that incidents of parental wrong-doings are a regular item in the news. Blame and hatred are spewed at individuals but few solutions come forth. 

KBernardKriegl 2In the early 1980s, Congress made a commitment to identify and implement solutions to child abuse. Recognizing the alarming rate at which children continued to be abused and neglected and the need for innovative programs to prevent child abuse and assist parents and families affected by maltreatment, the U.S. Senate and House of Representatives resolved that the week of June 6-12, 1982, should be designated as the first National Child Abuse Prevention Week. They asked the President to issue a proclamation calling upon government agencies and the public to observe the week with appropriate programs, ceremonies and activities. The following year, April was proclaimed the first National Child Abuse Prevention Month. Since then, child abuse and neglect awareness activities have been promoted across the country during April of each year.  Here is President Obama's 2016 proclamation.

Though we’ve been aware of the consequences of child maltreatment for decades, we have failed to create the urgency needed to really make change. Unlike EEE, West Nile Virus, Ebola, Measles or even the recent Zika Virus, child maltreatment does not get the attention or funding from media, the public, or our Division of Public Health Services.

Why is this? I believe it is because it is too close to home. We know that one in four women and one in six men experience abuse or neglect before the age of 18. The Adverse Childhood Experiences Study tells us that more than 60% of the adult population have had at least one ACE and are dealing with the effects of childhood trauma. We shy away from the issue because our cultural norms view this as an individual’s issue that requires an individual’s solution. 

We now know child maltreatment is really a community issue. Communities that celebrate and welcome new infants by hosting community baby showers and neighborhood or faith group check-ins and casserole support help parents raise children. Communities that facilitate family connections through public recreation areas, sidewalks, and events help parents raise children. Communities that provide intergenerational opportunities in schools, community organizations and faith groups help parents raise children. Communities that have the empathy and compassion to do small acts of kindness when a child is having a tantrum, wandering away or overcoming an obstacle help parents raise children.  We have compiled some additional ideas on ways you can suport children and families and we hope you will post and forward them so we can build caring communities.

We need you to get involved.  New Hampshire Children's Trust created a toolkit to help public health providers and others participate in National Child Abuse Prevention Month. The pinwheel is the national symbol for the great childhood that every child deserves. You can show your support by displaying pinwheels on social media, your desk and in your garden. 

We know that children thrive when in safe, stable and nurturing families and communities. The CDC has created a community of state public health departments, children’s trust funds, Prevent Child Abuse America chapters and others that are implementing the Essentials for Childhood.  Unfortunately, New Hampshire has not been able to identify resources provide this to our communities. You can help bring this to New Hampshire by learning more and sharing resources provided for free by the CDC with colleagues and friends.

This April, let’s make a shift from expecting stressed families to raise their children in isolation to creating communities of support. Let’s look at the 271,000 children in New Hampshire as OUR children and make decisions and take actions in OUR children’s best interest. For more information, you can contact the New Hampshire Children’s Trust at www.nhchildrenstrust.org.  #StandUpNH and take a stand against child abuse.

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By Jeanie Holt, former Affilate Representative to the Governing Council

First I am pleased to introduce NHPHA’s new Affiliate Representative to the (APHA) Governing Council (ARGC), Shasta Jorgensen. Many of you know Shasta since she has been active in public health and NHPHA for several years. Shasta and I will be alternating months writing this column and I will let her further introduce herself next month.


I continue to be active with APHA. I am Chair-Elect of the Council of Affiliates (CoA), a body which includes an ARGC elected in each of 10 regions to serve as the regional representative to the CoA. Shasta and I plan to work closely together to ensure that Affiliate strengths and needs are clear to APHA and to facilitate NHPHA members in working for good Federal public health policy.

One of the responsibilities of the Governing Council is to adopt public policies for APHA. Like NHPHA, these policies guide APHA action, education, advocacy and lobbying. Shasta and I need feedback from subject matter experts in NHPHA to ensure that policies are science-based, propose clear actions for APHA to take, and are non-partisan. Below is a list of the TITLES of proposed policies (some titles make the APHA position clear, others to do not). If you are interested in reviewing any of these policy statements, please email me (jeanienhpha@gmail.com) and I will get the text for you. And thanks for your help.

Group A: Access to Care, Health Promotion and Prevention

A1: Supporting Dementia Care as a Public Health Issue and Promoting Public Health Approaches to Population Health and Secondary and Tertiary Prevention

A2: Access to Integrated Medical and Oral Health within Improved Public Health Systems of Care for Persons with Intellectual and Developmental Disabilities (I/DD)

A3: Strengthening the National HIV AIDS Strategy to Achieve an HIV AIDS-Free Generation (Update)

A4: In-flight medical emergencies and public health

A5: Enhancing the role of the arts and humanities in public health


Group B: Environmental and Occupational Health


B1: Improving Fall Safety and Related Usability of Bathrooms within Buildings through Safety Standards, Building Codes, Housing Codes and Other Mechanisms

B2: Environmental Public Health for Children: Expanding Prevention

B3: Reducing human exposure to perfluoroalkyl and polyfluoroalkyl substances (PFASs)

B4: Compulsory Pasteurization of all Milk Products Intended for Human Consumption


Group C: Social Determinants of Health and Equity


C1: Equity Strategies to Address Social Determinants of Health and Learning to Ensure On-Time High School Graduation

C2: Promoting Policy Change to Eliminate Health Inequities

C3: Opportunities for Health Collaboration: Leveraging Community Development Investments to Improve Health in Low-Income Neighborhoods (2015 late-breaker resubmission)

C4: Improving Health by Increasing the Minimum Wage

C5: Police Violence as a Public Health Issue


Group D: Human Rights, Immigration and International Health


D1: Opposition to Immigration Policies Requiring HIV Tests as a Condition of Employment for Foreign Nationals (2015 late-breaker resubmission)

D2: The Public Health Imperative for Gender Inclusive Policy Reform

D3: Public Health Impact of US Immigration Policy


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Over a year ago, a partnership formed in Nashua between public health and planning to advance street design that supports health by providing safer and easier ways to get around for pedestrians and bicyclists. After applying for and receiving a grant from the American Planning Association, the Plan4Health Nashua coalition was formed to conduct a street study and develop a Complete Streets guidebook and policy recommendations. Over the next few months, the coalition will present the guidebook and provide Complete P4H MarchStreets training to members of the city staff, elected officials, residents, and members of the business, healthcare and nonprofit communities.

Nashua is joined by many other New Hampshire cities and towns that are considering Complete Streets policies to create healthier communities that attract residents and businesses. Five New Hampshire municipalities have officially adopted Complete Streets policies or resolutions—Portsmouth, Concord, Dover, Keene, Swanzey—while others are in the process. Each community has chosen a different path toward implementing the policies, from city policy to city council resolution.

Defined by Smart Growth America, Complete Streets are streets for everyone. They are designed and operated to enable safe access for all users, including pedestrians, bicyclists, motorists and transit riders of all ages and abilities. Complete Streets make it easy to cross the street, walk to shops, and bicycle to work. They make it safe for people to walk to and from bus stations. There is no singular design prescription for Complete Streets; each one is unique and responds to its community context. A complete street in a rural area will look quite different from a complete street in a highly urban area, but both are designed to balance safety and convenience for everyone using the road.

P4H March2Portsmouth and Concord are two good urban examples of Complete Streets policies that have been in effect for multiple years. The Portsmouth City Council adopted a Complete Streets policy in 2013 and the same year was ranked 7th in the country by Smart Growth America for its quality Complete Streets policy. Portsmouth recently revised its Capital Improvement Program selection criteria so that all transportation-related projects are evaluated to ensure compliance with the Complete Streets Policy. Concord adopted its Complete Streets policy in 2009 called the Comprehensive Transportation Policy. The city has excelled at making incremental improvements since adopting their policy, and that work paid off when federal funding was secured in 2012 for the revitalization of its Main Street, with Phase I completed in 2015.

The small town of Swanzey is the latest community in New Hampshire to adopt a Complete Streets policy. Adopted in October, 2015, Sara Carbonneau, Swanzey’s Director of Planning & Community Development, hopes that Swanzey becomes a model and inspiration for other small towns. She has already heard great feedback from several other small communities saying, “If Swanzey can do it, we can do it!”

There are a number of reasons communities are adopting Complete Streets policies. Complete Streets support the safety, health and well-being of community members. A recent Southwest Region Planning Commission Safe Routes to School study illustrates the impact of a Complete Streets approach to planning on health. The study showed that after improvements in sidewalk infrastructure, 26% of children at one Keene elementary school now walk to school compared to 11% when their Safe Routes to School program began five years ago. Complete Streets also create economic opportunity through increased tourism and retail sales, as well as attracting skilled young workers who prefer to live and work where they can walk, bike and take transit. Having Complete Streets policies in place actually save municipalities money in the long-run by preventing costly delays and retrofits.
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By Kim McNamara, NH Health Officer

If we truly value life, human dignity and compassion, we will financially, ethically and without uneducated preconceptions, whole-heartedly provide the care and support needed by our community members and their families who are being decimated by the current opioid addiction tragedy.

Advanced studies in neurobiology at the cellular, molecular and genetic levels have led us out of the dark ages when “drug abuse” and “addiction” were not understood as the pathophysiological conditions they are. Substance Use Disorder (SUD) is the common terminology used for what is now known to be a chronic, relapsing disease of the brain; and as such is much more effectively addressed by therapeutic interventions than punitive ones.  We begin to see a science-based progression from solely a law enforcement approach to this crisis, to a public health response.  Public health is much better suited (or should be) to advocate and provide support for services across a complete continuum of care.  A public health response must include education, prevention, medical intervention, therapeutic and recovery services for the entire community, at the time they are needed. Currently New Hampshire comes up woefully short, despite the hard work of many dedicated souls because we began so very far behind.

In opioid abuse, the structure and function of the brain is altered and can cause changes in thoughts and behaviors. This leaves many people suffering from SUD incapacitated to a level they would not have imagined. Understanding the medical basis of this current crisis and how it is so intricately tied to our medical practices, as well as the role of a health care approach in successful treatment and recovery, allows us to embrace it as the public health issue that it is. From there we can compassionately and effectively join in the fight. Public health operates on a community level, and this issue needs a community response.  Approaching this as a health issue allows us to use the infrastructure and concepts we already have in place to address other public health issues.  Care on all levels must be available and coordinated so people can move successfully out of the grips of SUD through treatment and into sustained recovery.  SUD can and is being treated successfully every day. There are many happy, productive, successful people in our communities that are living proof that therapeutic intervention works.  

Opioids, also known as narcotics, are substances derived from the opium poppy, or synthetic compounds produced for similar effects. They are some of the most addictive drugs known. They come with many names, both generic and brand name. Many are legally prescribed such as morphine, tramadol, codeine, fentanyl, hydrocodone, Vicoden, hydromorphone, Dilaudid, Demerol, methadone, oxycodone, OxyContin, Percocet, etc. Consumers often do not understand that they are all “opioids.” Others are illicitly produced and may go by the same names, and of course, heroin is a well-known street opioid. It is an important part of public health education to teach parents, grandparents, caregivers, students and other citizens about the many names of this drug class, so they recognize the powerful and potentially dangerous medications they may come across in their homes, when visiting friends and relatives, at work, school or elsewhere in the community. Even legally prescribed medications become illicit drugs when they are taken by people for whom they were not prescribed.

Many compounds today are more powerful than those of earlier generations. Fentanyl, an opioid first developed for the hard-to-treat, severe pain associated with cancer, is up to 100 times more potent than morphine. The availability of illicit fentanyl has exploded in New Hampshire and is largely responsible for the overdose death rates we are experiencing.

Consider this: in the 1960’s, 80% of heroin addicts began their addiction with heroin. Only 20% were first addicted to prescription opioids. Today that trend is reversed. Current studies show that up to 85% of persons suffering from heroin addiction were first addicted to prescription opioids. There were many contributing factors in this reversal. For instance, vital signs measure the body’s most basic functions. Prior to the 1990’s, four signs – temperature, pulse, respiration rate and blood pressure were typically monitored in patients. In the 1990’s, pain became the “fifth vital sign” and was measured on a self-reported scale of 0-10. It was no longer a sign of a condition, rather it became a parameter that needed to be addressed and alleviated.  Since pain measurement is subjective, the evaluation and management of pain levels proved to be a difficult task for physicians, as was the promotion of non-opioid pain management alternatives. The 90’s also saw increased drug marketing campaigns for new opiate choices and more liberal prescribing practices for their use.

Once in the body, heroin and other opioids act on the brain, spinal cord, GI tract and other organs simultaneously.  In the brain stem where the critical autonomic processes are regulated, opioids cause changes in blood pressure and respiration. Most overdose deaths are caused by the opioid depressing the respiratory center to the point where the person stops breathing.  In the pain pathway of the brain and spinal cord, opioids produce pain relief. In the reward pathway where many functions necessary for the survival of our species occur, opioids can produce euphoric effects.  These effects can lead to persistent opioid use despite harmful consequences.  The changes in brain structure and function can occur quickly, long before a person realizes they are dependent.  It has been shown that as little as one month of medically monitored opioid administration can cause measurable changes in the brain. These drugs are also dangerous because the difference between the amount required to produce the desired effect and the amount that will cause respiratory depression is small and difficult to predict.

New Hampshire has a significant opioid problem.  According to The National Survey on Drug Use and Health (NSDUH) in 2012-2013, 18-25 year old NH residents reported the highest rates of illicit drug use in the nation at 10.04%.  Prescription practices and an abundance of opioids sitting in medicine cabinets throughout New Hampshire are not the only sources feeding this beast.  Much of the heroin and fentanyl flooding our streets is trafficked from Mexico through the interstate system.  These drugs are abundant and cheaper than purchasing medications.  In 2013, 193 New Hampshire citizens lost their lives to drug overdoses.  In 2014 that number rose to 325. In 2015 we lost 428.  For comparison, in 2015 we lost 114 lives to traffic accidents.

Making escape from the spiral of substance misuse even more difficult is the excruciating physical withdrawal people experience when opioids are discontinued.  They can be haunted by overwhelming cravings, cold sweats, muscle and abdominal pain, nausea, vomiting, diarrhea, involuntary body movements, severe agitation, anxiety and sleeplessness.  Medication Assisted Treatment (MAT) includes the use of medication along with counseling and other support, and has been shown to be an effective method of achieving long-term success. 

New Hampshire’s residents are particularly vulnerable to disastrous outcomes because we do not have nearly the amount or type of intervention and treatment services required.  It is nothing short of cruel when a person desperately seeking help to save their own life is told that there is no available treatment, or if they don’t have money, they can’t receive treatment, or the waiting list is several months long, or call back every day to see if we’ve had a cancellation (or death)…This is a an epic failure of public health in our state and we need to work tirelessly and with lightning speed in each of our communities to bring the resources needed to ensure adequate and timely treatment for all who suffer  from SUD.

In the next edition of the newsletter, we will look at the community effects and costs of this epidemic and review the gaps and assets in service capacity within our state to address it.
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By Gail Brown, Director, NHOHC

OHC Photo March 2016 Newsletter
With the support and effort of many NH oral health leaders, the Coalition, working with the No. Country Health Consortium has implemented NH - From the First Tooth, a training program designed to provide the clinical and administrative training needed by pediatric and family physician offices to have medical providers provide in-office oral health assessment, anticipatory guidance, fluoride varnish application, and dental referral.

Using the national oral health curriculum of “Smiles for Life,” the NH program provides for a trained dental hygienist and an administrative partner to teach the curriculum on-site in the medical office.  Funding is provided by the DentaQuest Foundation through a grant to Hugh Silk, M.D., a family physician champion of oral health services in the medical setting from the University of Massachusetts Medical Center.  Silk notes that "Pediatric patients see their physician about a dozen times before they ever see a dentist," making the medical setting a natural setting for the delivery of oral health risk assessment and preventive intervention. 

With recent in-state changes in both public and private reimbursement for fluoride varnish in the medical setting, it is the right time for NH to do training and move forward.  Initial trainings in Franklin, Rochester and Manchester were well-attended and those practices intend to begin service shortly.    

In addition to the support from Dr. Silk, NH physicians Steve Chapman, DHMC, and Kelly White are appointed as Community Oral Health Advocates by the American Academy of Pediatrics.  They are strong supporters of this medically-based opportunity for early intervention.  Dr. Chapman provided a recent, hands on training at a medical meeting at the Mt. Washington Resort.  For more information on the application of fluoride varnish in the medical setting:  contact the NH Oral Health Coalition at info@nhoralhealth.org or 603-415-5550.   On-line, NH-specific information is available at: http://www.fromthefirsttooth.org/healthcare-providers/state-pages/new-hampshire/

Photo:  NH dental hygienists Ruth Doane and Annette Cole, with NHOHC MPH intern, Rob Sheikhabdou, prepare with Maine hygienist Susan Cote for the first NH-From the First Tooth training session in Franklin
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By DHHS, DPHS

Your health is important wherever you go or live. Today many people are spending most of their day sitting at a desk or inside an office.  Employers are beginning to recognize the importance of implementing health programs inside the workplace and see this as a vital component of a healthy lifestyle. Across the United States, many workplaces encourage work site wellness programs.  These programs may be a health promotion activity or organization-wide policy designed to support healthy behaviors and improve health outcomes while at work. These programs consist of a variety of activities ranging from health education and coaching, weight management programs, medical screenings, on-site fitness programs, informal walks during lunch breaks, and more.

Go Red DHHS DPHSIn New Hampshire (NH), the Department of Health and Human Services (DHHS), Division of Public Health Services (DPHS) celebrated Go Red For Women and National Heart Month this February by sharing information on heart disease and the importance of living a healthy lifestyle.  In NH heart disease is the second leading cause of death, and in 2014 there were 1,445 deaths due to coronary heart disease.  As public health professionals, we are aware more than most occupations of the health risk factors people face.  However, life and the great many stressors that come along with it (work, family, finances, car trouble, etc.) may distract anybody from maintaining a healthy lifestyle. 

In order to increase awareness about heart disease and the importance of maintaining a safe and healthy lifestyle, the DPHS Heart Disease & Stroke Prevention (HDSP) Program coordinated a variety of activities this February.  DPHS employees were provided with heart health information by materials in the DPHS lobby on heart disease and risk factor information (tobacco, diabetes, high blood pressure, high cholesterol, and sodium reduction). DPHS also collaborated with the DHHS Wellness Coordinator to share heart health emails with the DHHS staff that included, “good to know” information.  Also in February, the HDSP Program coordinated a presentation for the DPHS staff meeting to increase awareness about heart disease.  The agenda included information on the importance of participating in CPR/AED (cardiopulmonary resuscitation/automated external defibrillator) training, NH AED laws, Heart Safe Communities in NH, and the First Aid Stabilization Team (FAST) at 29 Hazen Drive.  Featured guest speakers included Rick Hill, the DHHS Training Coordinator, and William “Bill” Wood, Coordinator, Preparedness and Special Projects, NH Department of Safety, Bureau of Emergency Medical Services.   In addition to the above heart month activities, DPHS in collaboration with the Division of Environmental Services (DES) held a blood drive on their campus. 

Way to go, DHHS! We hope you continue to help guide NH’s workforce in leading healthier and safer lives!
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By Jeanie Holt, former Affilate Representative to the Governing Council

New NH Representative to APHA! We have a new Affiliate Representative to the Governing Council (ARGC). Shasta Jorgensen agreed to take on this important role. She and I will be meeting soon to start an orientation and transition process. But don’t start thinking you won’t be hearing from me about APHA—because I am still very involved and I will continue to make efforts to keep you all informed of our work with APHA.

Other APHA news: One of the advantages of being affiliated with the American Public Health Association is our connection to other affiliates. We find out what others are doing and can take advantage of their experiences. Our neighbor public health associations in Vermont and Maine think proposals to legalize recreational marijuana won’t be far behind the medical marijuana laws. In both states, the PHA has begun educational efforts which you can see on YouTube. Maine’s webinar “Marijuana in Maine, the Science, Policy Trends and Lessons” can be seen here. Vermont also posted a presentation on the health effects of marijuana here
. Given the experience of other states, it seems likely that NH will face this in the coming years. Educating ourselves now is a good place to start.
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By Marie Mulroy, NHPHA Past President

HB 1696
, the bill to extend the NH Health Protection Plan, had a public hearing before the Finance Committee in the House on February 17th.    While there are still some critical issues with the bill that need to be fixed, this hearing was strictly to determine the financial aspects of the New Hampshire Health Protection Plan (Medicaid Expansion).    The hearing ran about 2 hours and was limited to testimony from the hospitals, insurers, clinics and providers. 


The questions from the Finance Committee revolved around several major themes: 
  • Whether the cost savings would be passed on to the insureds and those receiving services.
  • If the hospitals and insurers, who have agreed to pay for the cost of the expansion through various methods, would pass the cost of expansion onto consumers or would they absorb it into their overhead.
  • Were there any general funds being used to finance this - directly or indirectly.
These central themes will be developed and explored further this week in Finance during two work sessions on March 1st and March 2nd as well as a final executive session on March 3rd .  HB 1696 will then head to the floor of the House for a final vote on March 9th or 10th before moving over to the Senate should it pass.

This is a crucial time because the fate of the 47,000 people who no longer had to decide whether to buy food or seek medical attention is going to be decided.   It also is a crucial time for those providers in rural or "safety net" settings who struggle with the financial impact of uncompensated care. 

WE NEED YOUR HELP!


NHPHA's ask this week of our members is to check and see if any members of the Finance Committee are in your district and reach out to them and let them know how important Medicaid Expansion is to public health and to the health of the economy of New Hampshire.  It will also be helpful if everyone reaches out to their House of Representatives member to encourage passage of HB 1696 when it comes up for a vote. You will have a more receptive listener/reader if you begin the conversation with, "I am a constituent of yours..."

If you do reach out, please send an email to info@nhpha.org so that we can keep track.     Thanks.  

RECENT ARTICLES that may be of interest:

Concord Monitor:  
NH Medicaid Expansion gets frosty welcome from House Finance Committee

NH Public Radio:  
Debate on Medicaid Expansion Centers on Who Will End Up Paying
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by Jeanie Holt, NHPHA Public Policy Co-Chair

With a great group of volunteers, the Policy Committee has been very active in advocating for science-based public health policy.  To receive our weekly policy update via the Health In All Policies eNewsletter, subscribe here


While we focus most of our work, especially when the Legislature is in session, on the immediate present, we can be more effective in promoting good policy if we can look ahead and plan ahead. Jeanie Holt, Policy Committee Co-Chair, represents NHPHA in a group developing a strategic plan to get an adult safety belt law passed in New Hampshire. As many of you know, NH is the only state without such a law. NHPHA worked with others in 2005, 2008, and 2009 to get a law passed, but was unsuccessful each time. Public health people are persistent, however, and many injury prevention folks believe it is time to try again. The work group has met twice. We sent out a survey to NHPHA’s Public Health Champions and to the state first-responders group seeking input as we begin crafting a strategic plan. We currently think it best to spend the 2017 legislative session getting a feel for the policy climate since elections held in November of 2016 may change that landscape. In addition, the 2017 session focuses on the biennial budget, so we plan to introduce legislation for the 2018 session. Jeanie will update NHPHA on this work from time to time.
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By Jeanie Holt, NHPHA Public Policy Committee Co-Chair

I loved the movie “Paint Your Wagon” (dating myself?). One scene I found especially funny comes toward the end of the movie. The two lead men had noticed that a lot of gold dust got spilled on the floor of the bar in this California mining town. They get the bright idea of digging under the bar to mine that gold. Once there, they move on to the next and the next and the next bar. Eventually their tunnels start to collapse and the whole town falls down. One of the men, shaking his head as he watches the bars and brothels collapsing, says, “How do you like that? We built a town just the way we liked it and then we destroyed it.”


I feel a bit like that with SB320. Public Health (and medicine, and nursing, and many others) has worked hard to publicize the importance of using data (evidence) to design programs and to evaluate their effectiveness. And now, while it isn’t us who are destroying “the town”, bills like SB320 will destroy the very foundation of public health.

SB320 says, “no student shall be required to volunteer for or submit to a nonacademic survey or questionnaire,…without written consent of a parent or legal guardian”. The bill defines a nonacademic survey as one “designed to elicit information about a student's social behavior, family life, religion, politics, sexual orientation, sexual activity, drug use, or any other information not related to a student's academics.” (One could perhaps argue that information about drug use or sexual orientation or behavior is related to a student’s academics!)

1.     How valid would the information actually be if the only students who filled it out were the ones who a) remembered to give the consent form to their parent; and b) had a parent who willingly signed permission; and c) remembered to return the consent to the proper school authority in time to take the survey? Talk about a small and very skewed sample?

2.     How will school districts, community agencies, and other know what health issues need to be addressed? Could we rely on anecdotal “evidence”? As in, “Gee, it seems to me I see more kids smoking this year than I did last year.”

3.     How will NH compete for scarce dollars (you know, the ones we paid in taxes that go to CDC and then come back home to address NH issues) without good data?

4.     And finally, how will we know if the programs we put in place actually have an impact on the problem we identified? How will we know we aren’t wasting those scarce resources?

How can you help defuse this dynamite before it damages the foundations of public health in NH? We are collaborating with the NH Research and Evaluation Group and with UNH to create a multi-stranded message to oppose SB320. NHPHA will collect information from “the trenches” to add to the arguments made by researchers. So:

1.     We need your examples of how you have used data from nonacademic surveys administered in schools. Don’t worry about being a good writer-just send Jeanie the details and she can help craft the story. (jeanieNHPHA@gmail.com)

2.     We can help you testify when the hearing on SB320 gets scheduled. Let us know if you are interested.

3.     We can help you contact your elected Senator or Representative to let them know how you would like them to represent you.

We look forward to hearing from you.
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