The county wasn’t growing. But its supply of painkillers was.
Between 2006 and 2009, the number of oxycodone and hydrocodone pills shipped annually to pharmacies in Cheshire County increased from about 1.6 million to 2.3 million, according to recently released U.S. Drug Enforcement Administration data — a 50 percent rise in four years.
“How could there possibly be a medical justification for that?” Dr. Anna Lembke, an addiction expert at the Stanford University School of Medicine and author of the book “Drug Dealer, MD,” said after a reporter described the increase. “I mean, even if there’d been a major natural disaster in your town in that time frame, it wouldn’t justify that amount of opioids.”
Nearly every pharmacy in this county of 77,000 people filled prescriptions for increasing numbers of opioid pain pills in those years.
At the time, the nation was in the midst of a prescription-opioid epidemic that would later morph into an even deadlier heroin and fentanyl crisis. Orders of hydrocodone and oxycodone rose across the country at roughly the same time as they did in Cheshire County, according to The Washington Post, which published and analyzed the national data.
The data, filed under seal as part of an ongoing court case, were released after The Post and the company that publishes the Charleston (W.Va.) Gazette-Mail fought a lengthy legal battle for access.
Hydrocodone and oxycodone — opioids found in prescription pain medications such as Vicodin, Percocet and OxyContin — can produce effects resembling those of heroin. Both are federally controlled substances due to their potential for misuse and addiction.
Nearly 15 million such pills were shipped to Cheshire County from 2006 to 2012, or about 27.5 per person per year, according to the DEA data. That’s below the national average for those years, and far less than in the hardest-hit parts of Virginia, West Virginia and Kentucky, where The Washington Post identified counties that received hundreds of pills per resident.
The largest local seller, the CVS on West Street in Keene, received 333,000 oxycodone and hydrocodone pills in 2006, 466,300 in 2007 and 561,900 in 2008, according to a Sentinel analysis of the DEA data.
Michael DeAngelis, a CVS spokesman, said in an email that the location’s “overall prescription business grew steadily during the years in question” after switching to a 24-hour pharmacy in the mid-2000s. He said many of the pharmacy’s customers were treated in the Dartmouth-Hitchcock system, including patients who were prescribed pain medication after emergency room visits or cancer treatment.
“It created a market”
Prescription opioids and illicit opioids like heroin caused nearly 400,000 overdose deaths in the U.S. between 1999 and 2017, according to the U.S. Centers for Disease Control and Prevention.
Public-health researchers have described three “waves” of the epidemic. The first started by 1999, with rising deaths due to prescription opioids. Around 2010, heroin deaths started to climb sharply. The past several years have seen a spike in deaths due to fentanyl, a synthetic opioid 50 to 100 times more powerful than morphine.
New Hampshire has been hit hard by the epidemic, with a rate of overdose deaths well above the national average in recent years. In 2017, according to the CDC, it was tied with Delaware for the sixth-highest drug death rate in the nation.
Lembke, the addiction expert, said the national increase in the pain-pill supply during the 2000s reflects the medical profession’s increasing use of opioids to treat pain, including chronic pain. That followed a push by pharmaceutical companies to portray the drugs as safe, effective and not especially addictive, she said.
Some of that medication was diverted — ending up in the hands of people who weren’t prescribed it, for illicit use. But much of the increase reflects prescribing for legitimate patients, some of whom became addicted, Lembke said.
“What happened in that timeframe is that not only were there a lot of people who were started on opioids, but many of the people who were already on opioids went much, much higher on their doses,” she said. Some patients were prescribed opioids “for years,” she said. “And that was really a departure from past practice.”
Drug makers now face a wave of lawsuits from local, state and tribal governments — including Cheshire County and the city of Keene — alleging they aggressively marketed opioids for new uses while downplaying the risk of addiction and abuse, deceiving doctors and the public. The lawsuits also claim drug distributors and, in some cases, retail pharmacies failed to adequately monitor orders and prescriptions, leading to abuse and diversion.
The companies have generally denied responsibility for the drug epidemic, saying they were working to ease the pain of legitimate patients.
Several people who observed it recall prescription-opioid misuse as a problem in the Monadnock Region in those years, though painkillers were by no means the only drugs around.
Art Walker served as Keene police chief for about six years in the 2000s, retiring at the end of 2009. During that time, he said there seemed to be an increase in heroin use. He also saw some diversion of prescription opioids and other medications, but doesn’t remember that as the primary concern.
Bob Collinsworth, a retired Keene police detective, said he remembers the volume of drug cases increasing starting around 2010.
“It would be usually like a cocaine investigation, and then we would notice that people would have some pills on them,” he said. “That wasn’t why they were there, they weren’t selling or buying, they just had pills on them. And then slowly, over the next couple of years, they would have a lot of pills on them, and not as much cocaine or meth.”
Some people would steal drugs from parents or grandparents with legitimate prescriptions, Collinsworth said. People also traveled to communities in Massachusetts to buy pills on the black market.
When Collinsworth retired in 2016, pills were still around. “But by the time I left, heroin was prevalent,” he said. “It was the big thing.”
Kurt White started working at the Brattleboro Retreat in 2005, in a unit of the mental health facility that handled detox patients. Most used either alcohol or opioids.
“The primary opioids that we saw being abused at that time were prescription opioids,” said White, now the Retreat’s senior director of ambulatory services.
While some people locally also used heroin in those days, White thinks the availability of opioid painkillers — followed by changes in prescribing practices that made the pills harder to obtain — fed the subsequent wave of heroin use.
“The initial supply that basically came from prescriptions created the demand,” he said. “It created a market, a new market for opioids, where there had not been a market before. And nature abhors a vacuum.”
The CVS in central Keene sold more oxycodone and hydrocodone pills — 3.6 million — than any other pharmacy in the county between 2006 and 2012.
But it was not unique in seeing opioid painkiller sales rise every year.
A few blocks away, Walgreens received 261,500 hycrodocone and oxycodone pills in 2006 and 369,900 in 2009. Across the street, Hannaford’s orders nearly doubled, rising from 43,500 in 2006 to 83,400 in 2009.
A mile away on Ash Brook Road, Price Chopper and Target both opened in early 2006. The following year, each sold roughly 40,000 oxycodone and hydrocodone pills. Two years later, Price Chopper received 57,000 of the pills. Target got 120,600.
The Walmart stores in Hinsdale and Rindge, the Rite Aid locations in Jaffrey and Winchester, the Hannaford in Rindge and the Walgreens in Walpole all saw increases in hydrocodone and oxycodone orders in those years.
After increasing for several years, county-wide sales plateaued at about 2.3 million from 2009 to 2012. Opioid orders leveled off at most area pharmacies, and some saw them start to decline.
Just one local chain pharmacy, the Keene Rite Aid, sold fewer hydrocodone and oxycodone pills in 2012 than it did in 2006.
Pharmacy-company representatives said their pharmacists take care to fill only legitimate prescriptions and touted what they said were efforts to reduce diversion and misuse.
“We maintain stringent policies, procedures and tools to help ensure that our pharmacists properly exercise their professional responsibility to evaluate controlled substance prescriptions before filling them,” DeAngelis, the CVS spokesman, said. “ ... Keep in mind that doctors have the primary responsibility to make sure the opioid prescriptions they write are for a legitimate purpose.”
Walgreens said in a statement that its pharmacists are “highly trained professionals committed to dispensing legitimate prescriptions that meet the needs of our patients.”
Hannaford said it has worked to address misuse and to increase access to overdose-reversal medication. “We take seriously our commitment to work with prescribers in the proper prescribing and dispensing of controlled substances,” the company said in a statement.
John R. Genovese, a clinical pharmacist and administrator who retired recently from Cheshire Medical Center in Keene, said prescribing practices around opioids have evolved in recent years. In 2016 the state adopted new standards that, among other things, require doctors to consult New Hampshire’s prescription drug monitoring program before prescribing opioids. The program, implemented in 2014, allows prescribers and pharmacists to check a patient’s prescription history for suspicious activity.
Though the publicly available DEA data stops in 2012, separate data from the CDC show that opioid prescription rates have fallen in Cheshire County, from 91 prescriptions per 100 people in 2010 to about 53 per 100 in 2017.
Fatal overdoses in New Hampshire are now driven largely by fentanyl, which caused or contributed to 82 percent of drug-overdose deaths in the state last year, according to the N.H. Office of the Chief Medical Examiner. Cocaine and meth were found in some fatalities, though typically in combination with fentanyl or another opioid.
Overdoses in Cheshire County caused 32 deaths last year, according to the medical examiner’s office.
“I think that the opioids are a problem, just like I thought that cocaine was a problem, just like I thought meth — so it seems to me that things are almost cyclical,” said Collinsworth, the retired detective. “ ... I think that we’re always going to be treating something.”
NORTH SWANZEY — The Horsing Around Show, new at the Cheshire Fair this year, does not share the mysteries of a magician’s act.
Tracy Davis is quick to reveal her secrets, and she explains to the audience at Friday’s 2 p.m. showing the purpose of the thin dressage whip she’s holding, which is between 3 and 4 feet long.
“We use these to communicate with the horses,” she said. “… We use the whip or crop as an extension of our arm and we just gently touch them with it — we don’t hit them — and that is their signal to perform a different trick.”
With the end of the whip, she gently tickles the nose of Silver Flash, a saddle-bred white horse, and encourages him to smile at the crowd by tickling his nose.
Later during her performance, she “hypnotizes” Little Joe, and the 9-year-old Shetland pony lies down as if asleep. After the crowd wakes him up, though, Davis divulges that Little Joe was never under a spell — he’s simply smart enough to repose when tapped a certain way with the whip.
“All the tricks that the horses do are things they would do naturally,” Davis told The Sentinel after the show.
When a horse bows, for instance, it’s the same movement it would make when trying to reach grass under a fence. She compared it to dog training: You teach a dog to sit, which is a normal movement, and you reward that, she said.
Plus, she added, “we also pick animals that enjoy traveling to fairs.”
Based in Washington, Vt., the Horsing Around Show is visiting about six fairs this year, but Davis said she doesn’t force an animal to go if it’ll be unhappy. She once trained a horse for two years, but when he finally went to a fair he hated the travel and the environment.
“It was very disappointing to me because I had invested all that time training him, but he was nervous, and we don’t use animals that are nervous at fairs,” she said.
Adjacent to the Horsing Around Show is a large tent offering a reprieve from the unrelenting heat, and a chance to feed an emu.
Pine Meadows Children’s Zoo is another new feature at the fair this year. The shady tent is home to several pens, many of which have goats and sheep. But there are also alpacas, tortoises, macaws, a wallaby, a baby coatimundi (which is in the raccoon family) and a yak.
The zoo is based in Mattapoisett, Mass., and travels to about 10 fairs a year, according to the owner, Jeff Paine. He said many of the animals were rescued; some of the goats were intended for slaughter or were given away by owners who couldn’t keep them.
Paine said the zoo also inherits some young exotic animals that need to be bottle-fed every couple of hours — such as the coatimundi — and not everyone is willing or able to handle their care.
Some of the animals in Horsing Around were rescued, too.
Davis told the crowd during her show that, before she took Little Joe, an older woman owned him and was concerned for people’s safety around the horse because he reared his front legs and kicked in the back.
“We were able to use his natural wanting to rear and kick to make it into a trick,” Davis told the audience after Little Joe pretended to be a bucking bull in a rodeo.
Despite the name, horses aren’t the only animals in the troupe. Louie the miniature donkey was rescued after a family in Davis’ hometown couldn’t afford to care for him anymore, and he and Little Joe became instant best friends.
Though Louie doesn’t have many tricks up his sleeve, Davis said he enjoys the fair environment, the audience loves him and he keeps Little Joe company.
“I would just take him out, talk about donkeys, educate people,” she said.
Davis’ 6-year-old daughter, Eva, works with a miniature horse named Stryker in the last leg of the show. Eva had difficulty finishing the final trick when her finger was pinched in Stryker’s harness, and Davis, while talking with a reporter, used the opportunity as a teaching moment.
“We know what it’s like when it’s perfect and the horses do all the perfect tricks at the perfect time, and maybe they do it even to the beat of the music, and it’s just magical,” she said.
Then she turned to Eva.
“And then there’s times when it’s not going right, and your finger gets pinched or your toe gets stepped on or its really hot,” Davis said. “At those times you just have to try to keep on going and do the best you can. ... But it’s not about being perfect.”
Eva, clinging to her mother’s leg, shot back: “Of course it is.”
Davis, laughing, explained that Eva is a fourth-generation trick performer on her father’s side.
“I’m more about let’s just have fun and enjoy and not worry about perfection.”