Connecting state and local government leaders
Manchester, New Hampshire, learned that there are consequences to seizures and arrests: a risk of overdose may rise for dependent users.
A large-scale “sophisticated” drug trafficking ring allegedly supplying the city of Manchester, New Hampshire, with fentanyl and crack cocaine for at least four years was dismantled over the course of 48 hours earlier this month, when a lengthy law enforcement investigation came to a head.
For local and federal authorities, it was an enormous win; Manchester police called it the largest drug takedown in city history. Twenty-two defendants were indicted or charged, and seized were 1.6 kilograms of suspected cocaine, 250 grams of suspected fentanyl, and 100 bags of suspected controlled substances, as well as firearms and $26,000 in cash.
But there was inadvertently another side to the trafficking breakup, one that doesn’t get much public thought when drug seizures and dealer apprehensions make the headlines.
A major interruption in a drug market can be a dangerous time for those with substance use disorder. The people who depend on the operation to feed their diseases suddenly see their dealers disappear and supply cut off.
It’s something the city of Manchester, which saw 700 suspected overdoses last year, has started watching.
“Law enforcement is really looking to get these networks dismantled so the supply is eliminated, and that’s so very important to focus on, but with every action there are also some potential consequences, and we need to be mindful of those,” said Philip Alexakos, deputy public health director at the Manchester Health Department.
A growing body of national research links law enforcement drug operations to a rise in overdoses after the fact. Published in the American Journal of Public Health on June 7, the same day the news in Manchester broke, a new study drew strong associations between a major opioid bust and fatal overdoses in an Indianapolis neighborhood.
Researchers found that within seven, 14, and 21 days after the law enforcement seizure, the operation was “significantly associated” with increased clustering of overdoses within 500 meters.
When people who use drugs lose access to their dealer or consistent supply, it’s likely they’ll have to transition to an alternate supply, one in which they don’t know the potency or their ensuring tolerance.
Brandon del Pozo—a researcher on the study, former police chief in Burlington, Vermont, and now a Brown University assistant professor researching the intersection of public health, safety, and justice—said this is the first study that illuminates an individual event.
“It’s always been assumed that taking drugs off the street is an unalloyed good and that there’s never a downside to breaking up a drug-dealing operation or taking drugs from people and sticking them in the property room or the evidence locker,” del Pozo said. “But people who use drugs have been telling them, in their view, it puts them in more danger of overdose.”
Those working on the frontlines of Manchester’s opioid crisis used the connections being drawn in the recent study to help guide their response to this month’s law enforcement operation, Alexakos said. They also turned to the matrix of fatality prevention and harm reduction work they’ve been implementing over the last few years.
They contacted street outreach programs, recovery centers, social services, and others across the city about the potential for overdose risk, utilized real-time overdose data to track activity and potential hotspots, and deployed a Rapid Overdose Assessment Response Team.
“At least from where I sit, the takedown of this drug-trafficking organization is massive and it’s important long term,” said Manchester police Lt. Matthew Barter, who monitors the department’s daily overdose data. “But it’s the short term we need to be aware of from that harm reduction lens.”
Barter oversees three internal data dashboards that police examine each morning to see how many overdoses occurred in the past day, and where. The data can help pinpoint locations for outreach and fast interventions, or indicate areas where perhaps a bad batch of drugs is going around.
“We know we don’t get called to everything, but my feeling is it could be an early indicator of a spike,” Barter said. “If we are seeing an increase (on the dashboard), there’s probably more in the community.”
What Barter categorizes as a “spike” in overdoses is five or more in one day. From 2021-2022, the city averaged a little more than two reported overdoses per day, he said.
As of two weeks after the bust, the city had not seen a statistically significant change in overdoses, officials reported. Barter did note the Hillsborough County House of Corrections experienced four or five overdoses, one of them fatal, on Saturday, June 17.
Based on his participation in the study, del Pozo cautioned that impacts don’t necessarily “show up as some huge spike,” but rather can add up over time to a higher level of mortality.
Growing associations between drug busts and overdoses
Del Pozo was one of eight researchers on the study looking at the neighborhood in Indianapolis. He said as the country’s drug supply becomes more adulterated and dangerous, “We need to understand how all of the moving parts of our response either address the problem or in some cases inadvertently make it worse.”
While the study states it can’t assert a causal relationship between law enforcement drug market disruptions and an increase in overdoses, it builds upon mounting evidence and establishes a strong association.
In the case of this 500-meter area in Indianapolis, about a third of a mile, the study found fatal overdoses doubled within seven days, which del Pozo said represents a small number at the neighborhood level, but adds up over time. Calls to 911 and use of naloxone, or Narcan, also increased.
In the aftermath of a significant drug market disruption, del Pozo said community partners and agencies should expand access to naloxone and fentanyl test strips, while issuing public advisories and breaking down any immediate barriers to treatment services.
“Public health and public safety have a duty to partner with each other and have a thoughtful comprehensive approach,” he said.
The federal Drug Enforcement Agency is often a lead player in major trafficking takedowns. It was one of several agencies that helped investigate the ring that operated between Dorchester, Massachusetts, and Manchester. Court documents allege that customers called dispatch telephone numbers to order drugs, and drug runners drove to meet them at predetermined locations to sell them the product.
The growing associations between law enforcement drug action and overdoses raise the question of what role, if any, federal agencies like the DEA play in assisting a local community with any potential inadvertent fallout. The DEA declined to comment for this story.
How Manchester mobilized after the bust
Alexakos, of the Manchester Health Department, said they didn’t necessarily have a playbook for responding to the potential aftermath of a large-scale trafficking takedown, but the city’s related work over the last few years made them poised to act.
Before the COVID pandemic, various agencies and organizations in the city began working to establish a better framework to disperse community resources for substance use disorder and homelessness. In March 2021, the city created a harm reduction strategy using federal pandemic funds from the Governor’s Office for Emergency Relief and Recovery.
Starting last year and continuing today, Manchester has been able to participate in the fourth cohort of “Implementing Overdose Prevention Strategies at the Local Level,” a funding opportunity through the National Association of County and City Health Officials and the Centers for Disease Control and Prevention.
Through that, the city has convened first responders, hospitals, social services, and substance use partners to “look at all of these buckets around access to treatment, harm reduction, and stigma reduction,” Alexakos said.
The city also leveraged some federal American Rescue Plan Act dollars to create community response units made up of plain-clothes police officers and health workers, small teams that visit with people who have recently overdosed.
“Because they are in that vulnerable window after an overdose, every interaction that you can help support someone in that period of time is critical,” Alexakos said. “We’re trying to build trust and establish that rapport. Folks that are engaged with outreach workers are much more likely to be successful.”
The community response units provide naloxone, fentanyl test strips, and contact information for support services, health care, or food stamps. Sometimes it’s something as simple as food or water—daily check-ins with conversation.
Next up was the hiring last December of Andrew Warner, the city’s director of overdose prevention, using a grant from the National Association of County and City Health Officials. And this winter, the health department formed per-diem basis “strike teams” to rapidly respond to overdose spikes or fatalities, using the real-time data collected by the Manchester Police Department.
When news of the major law enforcement action went public on June 7, local police promptly notified city health officials. Barter was quick to communicate his concerns about the risk of overdose for those who had depended on the alleged dealers and their supply. Alexakos said that enabled stakeholders to mobilize—namely deploying a Rapid Overdose Assessment Response Team to monitor what was happening on the street.
Alexakos emphasized that outreach workers are visiting with the same people daily, establishing relationships and trust. Treatment is not a simple solution, and typically, a lot has to come before someone reaches that stage—if they ever do.
“This work goes on very discreetly and it’s every day,” he said. “[Overdoses] may be numbers, but they’re humans and they have a disease.”