Dennis Dutra started drinking alcohol and smoking marijuana when he was 12. By age 15, he was using cocaine and by age 25 he was a regular heroin user. He began using drugs as a way to fit in with the popular kids, he said, and he got hooked.

Without a place to live, Dutra wound up in and out of prison and treatment multiple times. Nothing seemed to stick until a state-funded grant allowed him to enter a treatment program in prison and continue in a residential treatment program while on parole. After that, another grant helped pay for recovery housing, which he said gave him a “safe, stable, sober and semi-structured environment” so that he could transition to life on his own.

kasich U.S. Republican presidential candidate and Ohio Governor John Kasich hugs Jessica Nickel, executive director of the Addiction Police Forum, after she introduced him at the New Hampshire Forum on Addiction and Heroin Epidemic in Hooksett, New Hampshire, Jan. 5, 2016. Photo: REUTERS/Brian Snyder

“Without that grant, I would’ve done what I had done probably 30 times prior. I had no home, no job, no money. I was back in the same environment that I was in and those barriers are so overwhelming,” said Dutra, 43, who has been substance-free since 2011 and works as a recovery coach at Hope for New Hampshire Recovery, the only organization in the state providing recovery support services to individuals struggling with alcohol and drug addiction.

New Hampshire is suffering from a massive drug epidemic, and the state’s plight has become a prominent topic on the 2016 campaign trail as presidential candidates appeal to voters in the Granite State. Many White House hopefuls have visited New Hampshire Hope for Recovery as they learn about the state’s high levels of drug abuse, and Republican candidates have taken to sharing personal stories of family or friends who have struggled with addiction. But as Republicans expressed empathy and promised to address the Granite State’s opioid problem ahead of Tuesday's New Hampshire primary, experts say many of the candidates’ healthcare proposals threaten the progress the state has made in providing treatment to its population.

Repealing the Affordable Care Act, which President Barack Obama signed into law in 2010, has been a top priority for Republicans in the 2016 election cycle. Many of the GOP presidential candidates say they would scrap the law in their first 100 days, if not on their first day in office.

While the healthcare law, also known as Obamacare, has been controversial across the country, Democrats and many experts said it has helped New Hampshire deal with its heroin crisis. Over the past 10 years, the number of people admitted to state-funded treatment programs has increased by 90 percent for heroin use and by 500 percent for prescription opiate abuse, according to the state’s Department of Health and Human Services. More than 400 New Hampshire residents died from drug overdoses in 2015.

“It’s an incredible epidemic in our state that’s killing a lot of people,” said Tym Rourke, chairman of the New Hampshire governor’s commission on alcohol and drug abuse. Rourke emphasized that many states are experiencing similar heroin and opioid problems. “What’s specific to New Hampshire more so than others is that we’ve had some of the highest rates of substance abuse of any state in the country for years — we’ve been living in a state of drug epidemic for years,” he added.

Heroin use has become more common as prescription opioid prices have risen in recent years, making the illegal drug a cheaper alternative. But it's difficult for users to control the purity of heroin, which makes it particularly easy to overdose.

Nationally, drug overdose rates have skyrocketed, too. In 2014, the U.S. Centers for Disease Control and Prevention found that more than 47,000 Americans died from drug overdoses, with more than half of those involving prescription opioids or heroin. Heroin deaths alone increased 26 percent in 2014 and have tripled since 2010. Obama announced last week that his fiscal year 2017 budget would include $1.1 billion in mandatory funding to expand access to treatment for prescription drug and heroin abuse.

While New Hampshire is not alone in its heroin crisis, a 2014 report from the U.S. Department of Health and Human Services found the state was second to last in providing access to substance abuse treatment for those in need. Because state lawmakers in New Hampshire historically were not focused on addiction, the state has very limited resources to spend on substance use treatment or prevention. Among New England states, it had the lowest spending on substance abuse per capita in 2014, according to the annual report from Rourke’s commission. It spent around $8 per person, while Rhode Island spent $14 and Connecticut spent more than $48.

The state’s Bureau of Drug and Alcohol Services has spent most of its money subsidizing the cost of treatment for people who cannot pay, which has left little state funding for recovery, intervention or prevention programs. But under Obamacare, coverage of addiction services and other behavioral health disorders is mandatory for all insurers, including Medicaid.

“Through the Affordable Care Act, people have been able to get better access to care and that doesn’t only mean treatment but also other services,” said Tim Soucy, director of Manchester, New Hampshire’s Department of Health. “We’ve seen our rates of uninsured drop from 80 percent to 30 percent. And we can reinvest that money into other services to help people recover.”

JebBush Republican candidate Jeb Bush, a former governor of Florida, speaks at the New Hampshire Forum on Addiction and Heroin Epidemic in Hooksett, New Hampshire, Jan. 5, 2016. Photo: Brian Snyder/Reuters

Republicans don’t like the Affordable Care Act because they see it an overreach by the federal government, and many have said the law caused people to pay higher premiums or a higher deductible. The law was designed to ensure all Americans have healthcare coverage, and it mandates that plans cover things like maternal care, mental health and substance abuse.

On the campaign trail in New Hampshire, GOP candidates have encountered the state’s heroin epidemic at nearly every campaign event in recent months. They have discussed the issue with voters, they have sat on addiction panels and held roundtable discussions on ways to deal with the problem.

“There’s been a lot of them right here in the office and the first thing I’ve said to them is that they need to address the heroin crisis,” Republican Mayor Ted Gatsas of Manchester said of the presidential candidates. Gatsas endorsed Republican Mitt Romney in 2012, but declined to back a candidate before Tuesday's primary. 

Gatsas said he views stemming the flow of drugs into his state as the most important factor in reducing drug overdose deaths. Manchester, New Hampshire's largest city, had 96 deaths by drug overdose in 2015. 

There, the city is creating a public-private partnership that will allow New Hampshire Hope for Recovery to expand and work with other drug treatment organizations to provide residents with a one-stop-shopping type of facility that can address many aspects of the treatment and recovery process.

Candidates such as New Jersey Gov. Chris Christie, Ohio Gov. John Kasich, former Florida Gov. Jeb Bush and former Hewlett-Packard CEO Carly Fiorina have been particularly outspoken about the need to address the Granite State’s heroin and opioid problems. Last fall, an emotional video of Christie talking about his mother’s smoking addiction and a friend who was addicted to prescription painkillers went viral.



Chris Christie Makes Emotional Plea To Rethink Drug Addiction ...

"Somehow, if it's heroin or cocaine or alcohol, we say, 'They decided it, they're getting what they deserved.'"(Read more here:

Posted by HuffPost Politics on Friday, October 30, 2015


Many in New Hampshire said they appreciate Christie’s personal stories, and they connect with Fiorina and Bush, who each had children struggle with addiction. Like Christie, many of the candidates have acknowledged the need to eliminate the stigma around addiction, but the Republicans have largely avoided talking about specifics of what they would do to help states like New Hampshire.

In September, Democratic front-runner Hillary Clinton proposed a $10 billion plan to combat drug and alcohol addiction. Last week, Texas Sen. Ted Cruz told his family story of coming in contact with addiction and said that more Alcoholics Anonymous-style programs would help the Granite State.

“Those programs are what we need more and more of,” Cruz said, BuzzFeed News reported. “It’s certainly not going to be Washington, D.C., that steps in and solves these problems,” he added.

Other candidates, too, have drawn on family experiences when speaking at addiction-focused events in New Hampshire.

“As a father, I have felt the heartbreak of drug abuse,” Bush said at a substance abuse forum in New Hampshire last month. “My daughter Noelle suffered from addiction, and like many parents facing similar situations, her mom and I struggled to help.”

Bush, who wants to repeal Obamacare, would replace it with a system that would get rid of the law’s requirements that insurance plans cover “essential health benefits” such as substance abuse and mental health. His plan would also roll back Obamacare’s guaranteed coverage for preexisting conditions.

Not all the Republican candidates have put forth proposals, and those who have done so have not all offered as many specifics as Bush has. Donald Trump has struggled to answer what he would do to replace Obamacare, and even Kasich, who took advantage of the law to expand Medicaid in his state, is against the idea of any mandates in a federal healthcare policy. As with Bush’s plan, this could potentially lead to insurers no longer covering substance-abuse treatment services.

Democratic New Hampshire Gov. Maggie Hassan expanded Medicaid in her state, and legislators there are now working on a number of bipartisan bills aimed at helping provide more funding for substance use treatment. The governor's office called the Medicaid expansion “essential” for combating the state's epidemic. “Gov. Hassan is deeply troubled by continued attempts in Washington to repeal New Hampshire's successful healthcare expansion plan, which is making a real difference for our people and boosting our economy,” said William Hinkle, a spokesman for the governor.

Not everyone in New Hampshire thinks the Affordable Care Act has been perfect. There are many ways funding could be better, critics argue. But Richard Turner, vice president for New Hampshire and Vermont programs at Phoenix House, which runs treatment facilities for those recovering from alcohol and drug addiction, said starting over with a new healthcare law would create trouble for his organization.

Since New Hampshire expanded Medicaid under Obamacare, more previously uninsured patients have been able to get beds at facilities like his. “Right now we’re learning about the five managed care operations that are handling Medicaid funds. Soon we’ll know what information we need to give each one of them and it will become a smoother and smoother process as we learn about that,” he said. “If there’s a big chance we’ll have to go through those learning experiences again, that would slow things down.”

For Dutra, the recovery coach at Hope for New Hampshire Recovery, a slower process would have likely landed him back on the streets. “The difference between that time and the previous times was I had a recovery center and peer support network in place,” Dutra said, reflecting on the program that allowed him to kick his addictions. “For eight months I lived in a recovery house, and I had the community center I went to daily, I participated in sober social events.”

Now he supports others going through the same journey he experienced, whether that means helping them decide to enter group therapy, regularly meeting with someone working to stay sober in college or simply playing Cards Against Humanity. He would like the government to cover more support services like the ones he offers, he said, not fewer.

Rourke, chairman of the governor’s task force on substance abuse, put things more bluntly. “If the Affordable Care Act went away tomorrow, it would be catastrophic,” he said. “The existing capacity we have would vanish.”

He said that he has been grateful the presidential candidates are talking about this issue, but he remains concerned that he does not know the specifics of how the Republicans would replace Obamacare.

“There is no other disease that is as affected by the Affordable Care Act,” Rourke said. “That’s where it gets challenging for presidential candidates, because you can’t talk about the Affordable Care Act without talking about substance abuse.”