President Trump said Monday that he would officially declare America's opioid epidemic a national emergency next week, which would provide an influx of funding and policy initiatives across the country.
Few states know the epidemic as viscerally as New Hampshire, which President Trump previously said he won because it was a "drug-infested den."
"It's a terrible combination of factors," including the types of drugs that permeate the state, geography and limited addiction resources, said Lisa Marsch, a professor at Dartmouth's Geisel School of Medicine.
"My hope is that we can think of a more coordinated and multifaceted approach where we can reduce barriers" to treatment, instead of the "siloed responses that we're seeing."
New Hampshire ranks second in overdose death rates across the country, behind West Virginia. But looking only at synthetic opioids like fentanyl, New Hampshire has twice West Virginia's overdose death rate.
The prevalence of fentanyl versus other opioids is one factor that makes New Hampshire's crisis different from some other states, said Marsch. She leads a study that is trying to get to the bottom of what's behind the state's epidemic. Because fentanyl is more potent, the risk of overdose is much higher, she said. The high is shorter than other opioids, so users tend to inject it more often, putting themselves at greater risk of life-threatening infections, too.
Unlike heroin, illicit fentanyl and its ingredients are largely manufactured in labs overseas, particularly in China. It can be up to 100 times more potent than morphine, and the fentanyl molecule can be tinkered with to create even more powerful drugs and subvert regulation. "We have these highly potent drugs in a context that has very little resources," Marsch said.
'An everyday battle'
"I want my kids back," said Caitlyn, a 31-year-old mother of two living under a bridge near the New Hampshire-Massachusetts border who prefers not to use her last name. "I want to get up and go to work every day like every normal human being and not be out chasing the high."
She lost custody of her kids because of her addiction, but she is determined to get them back. "I don't need a detox," she said. "I'm looking for a treatment facility, like a residential, where I can go and live at and get my treatment."
When CNN spoke to Caitlyn, she was calling long-term rehab facilities, hoping to be admitted. But she was turned down because she was on too high a dose of methadone -- an opioid medication that doctors prescribe for people to wean off street drugs like heroin.
Marsch said that New Hampshire residents are suffering while too little is spent on addiction treatment and prevention. The state also lags behind on needle exchange programs and low prescribing rates of an addiction treatment called buprenorphine.
Unlike long-term residential treatment, short-term detoxification doesn't necessarily confront the social and behavioral issues surrounding addiction.
"And then you leave and you're right back out on the streets," Caitlyn said. "It's still an everyday battle."
Location, location, location
"Back when I started this business, if you did CPR once a month, that was a lot. Now it's every single day," said Daniel Goonan, fire chief of Manchester, New Hampshire.
When CNN spoke with Goonan, there had been a dozen calls related to opioids the night before.
"This isn't your father's fire department anymore."
Manchester is at the intersection of several major roads and highways, a 30-minute drive from the Massachusetts border. This is one reason why Manchester has more opioid deaths than anywhere else in the state, said Marsch.
"Particularly in the southern part of the state, we're right along a main trafficking route" for fentanyl, said Marsch, adding that the nearby city of Lawrence, Massachusetts is a key hub of activity.
"There's a really strong business model that incentivizes sales across the border into New Hampshire," she said. "The price that they can get for these drugs in New Hampshire is much higher than it is in Massachusetts."
This is presumably because there are reportedly more fentanyl distributors and manufacturers in Massachusetts, Marsch said, and those who transport the drug across state lines can charge more.
Opioid use has surged in rural communities like those in New Hampshire. Rates of drug overdose deaths in rural areas surpassed urban areas by 2015, having converged in 2004, according to a report released Thursday by the US Centers for Disease Control and Prevention.
Rural areas present many other transportation and economic challenges for people battling addiction, Marsch added. Even if they're lucky enough to get placement in a treatment program, they might deal with a potentially long commute or harsh weather during the winter. This can discourage people who might otherwise seek help.
"Some of those who were interested in treatment, they've just kind of given up," Marsch said.
A way forward
"It's hit us like a ton of bricks in Manchester," Goonan said.
Responding to a community in need, last year the Manchester Fire Department opened every one of its fire stations to people struggling with addiction. The 24-hour program allows people to seek help without fear of being arrested.
"We were sick and tired of sitting in meetings," Goonan said. "So with the 'Safe Station' program, we just jumped in with both feet."
More than 65% of the nearly 2,500 visits they've had have come from outside Manchester, according to Goonan.
"The best part about it is they pass no (judgment)," said Benjamin, 27, who arrived at Goonan's station one night, looking for help. He has struggled with addiction for 12 years.
"I came back in tonight because I had relapsed, and it was going to be a problem if I didn't do something about it," he said.
On Tuesday, the program secured another $150,000 from Governor Chris Sununu. Manchester Mayor Ted Gastas said in a statement that he expects more funding will follow in the future.
Like police units and even libraries around the country, the Manchester Fire Department also carries naloxone, commonly known as Narcan, which can quickly reverse a deadly overdose when sprayed into the nose.
That gives the drug a "route right to the brain," said Christopher Hickey, the fire department's EMS officer.
There are other initiatives popping up around the state, Marsch said, including one program that connects patients in emergency rooms with addiction resources. Another program provides integrated care for pregnant women with addiction, as well as their partners and even their babies after birth.
Programs like these, Marsch said, aim to lower barriers to treatment for entire communities in need.
"The opioid epidemic is something that could strike anybody, anytime, anywhere," said Hickey. "And no one can ever say, it's not going to be my children because no one knows."