New Hampshire Charitable Foundation Takes the Lead in Battling Opioid Abuse

Cheryl Senter/NHCF

Tym Rourke was working in the late 1990s at a small, nonprofit substance-abuse-prevention program in New Hampshire when he found himself on the phone with a mother desperate for help. Rourke referred her to a state hotline, even as he warned her that finding treatment would be hard.

“I feel like I have to dig my daughter dead out of a ditch before anybody pays attention,” the distressed mother told Rourke. That phone call has always stuck with him, in part because she was right. New Hampshire was spending just $25,000 annually in state funds on addiction services of any kind, despite high rates of substance use.

Calling for more resources was like “screaming into the wind,” Rourke says. “You’d be really hard pressed to find a legislator proactively moving a piece of legislation to make the lives of people with substance-use disorder better.”

Some 20 years later, Rourke is now at the New Hampshire Charitable Foundation, where he fields different kinds of calls — from the campaigns of candidates for president of the United States and from nonprofit leaders across the country. In the last gubernatorial race, two New Hampshire politicians launched their election bids at the same Manchester substance-abuse recovery center. And the state legislature has passed a slew of bills to tighten prescribing practices, establish clean-needle exchange sites, legally protect “good Samaritans,” and increase access to mental-health and treatment services via Medicaid expansion.

“Addiction five or six years ago would not have registered on the top 10 issues that voters, elected officials, and business leaders say are the biggest issues facing New Hampshire,” says Dick Ober, president of the New Hampshire Charitable Foundation, citing a poll conducted by the University of New Hampshire. “It is currently No. 1.”

That slow-building turnaround has intensified amid a national opioid-abuse crisis and widespread scrutiny of drug companies’ marketing and sales practices of highly addictive prescription drugs. But public officials and nonprofit leaders in the Granite State also credit two decades of advocacy work and capacity building powered by the New Hampshire Charitable Foundation.

The grant maker is in a unique spot: It operates a rare addiction-focused, multimillion-dollar charitable fund born of a bequest made to the foundation in the late 1990s. And it does so in a state with the second-highest opioid-related death rate in the country.

The demand for treatment and recovery services is high, and the organization does make some grants accordingly. But that’s not the primary focus. Instead, the foundation offers a compelling case study in how one nonprofit is using its resources to encourage a much broader, forward-looking response than it could have mustered on its own.

“You could look at this opioid epidemic in isolation, pour a bunch of money on the ground, see the opioid epidemic decline, and wash your hands and walk away,” says Rourke, who has led the foundation’s substance-abuse work since 2008. “And 10 years from now, we will be back at it again. And it won’t be opioids. It will be something else.”

A Chicken-Farm Millionaire

The foundation’s dedicated fund has its roots in chicken farming.

In the late 1990s, New Hampshire poultry mogul Oliver Hubbard was alarmed by news coverage of a spike in substance abuse, particularly among young people. There was heavy heroin trafficking along the state’s western border — a key corridor from Canada to Boston and New York — giving rise to an earlier opioid epidemic.

Hubbard decided he wanted to do something about it. Over several years, the chicken farmer donated his entire estate — $43.5 million — to the New Hampshire Charitable Foundation to combat addiction. The gift culminated with Hubbard’s death in 2001, when he was publicly identified. (His file at the community foundation still contains a Boston Globe clipping of a news article that Hubbard mailed to the then foundation president, Rourke says.)

The foundation assembled a team of advisers — experts in health care and addiction treatment, among other things — to assess how to use the gift. The community foundation could exhaust it paying for treatment, the assembled experts determined, but the grant maker would never get ahead of the tidal wave of substance abuse in the state if the policy and fiscal environment remained unchanged. A better use of Hubbard’s largess, they told the donor and the foundation’s leaders, would be advocacy to propel public attention and spending.

“We made the decision to increase the capacity of the sector, of the people in New Hampshire who deeply care about addiction and behavioral health, increase their capacity to have a voice and to engage in public policy and public investment,” Ober says.

It was the reverse of what many donors do, says Rourke, which is to start by paying for programs or innovative pilots.

“Often then what happens is those pilots, those promising practices, those innovations don’t self-sustain when the funder withdraws,” Rourke says. “The reason is, nine times out of 10, the policy environment, the fiscal environment, isn’t conducive to sustaining that work.”

Indeed, for nearly the first five years following Hubbard’s gift, no grants were made to service providers. That didn’t go over well with some.

Critics of the approach said, “We need more beds. We need more counselors getting paid to sit down and help people get through their addiction,” explains Ober of the debate at the time. But the foundation and its advisers were determined that “the more important thing was to advocate for sensible public policy and public investment, which is a much larger lever.”

A ‘Pittance’ for Treatment

One of the first moves for the foundation and the philanthropist was to endow a new advocacy organization, New Futures. In 2000, it scored an early, pivotal victory: the passage of a bill, over a veto from the governor, mandating that 5 percent of the state’s alcohol sales revenues be placed in what became known as the “alcohol fund” for “alcohol education and abuse prevention and treatment programs.” At the time, the state’s liquor commission was netting a profit of about $70 million from alcohol sales.

“This state was spending nothing on treatment. It was just a pittance,” says Edward Gordon, a district judge who was serving in the legislature at the time and helped get the bill passed.

State leaders subsequently established a governor’s commission to decide how the new dedicated funding stream would be spent and to develop and execute a statewide plan for combating substance abuse. There, too, the foundation has played a key role, helping to pay for things like data collection, research, strategic planning, and staffing for the commission.

“It is not just about the flexibility, it is about the quickness” of the foundation’s ability to deploy resources when needed, says Amy Pepin, project director of the New Hampshire Center for Excellence, which receives at least $300,000 a year from the community foundation for technical work to support the governor’s commission, among other things.

Cheryl Senter/NHCF

The foundation took another critical step to bolster the state’s capacity to address substance abuse in 2010 when Rourke assumed the role of chairman of the governor’s commission. During eight years in that position — his chairmanship ended in December — Rourke estimates he spent more than half of his working hours on commission business.

With the foundation providing Rourke’s time to build up the commission, it evolved from a traditional state-level panel of questionable capacity, Rourke says, to one with more than two dozen active members, 200 volunteers, and a robust plan. Rourke’s time at the helm also produced better, more streamlined relationships between nonprofits and state agencies, Rourke says. The governor and agency heads attend meetings, as do law-enforcement officials and nonprofit service providers.

“When the epidemic hit, we were more ready than other states because all the right players were already sitting at the table thinking about how do we do better in building the system,” Rourke says.

More to Come

The community foundation’s advocacy focus continues. It grants about $1 million to New Futures annually. In recent years, the advocacy group has helped push key legislation, including passing a law that allows for clean needle-exchange sites in New Hampshire and another that established a prescription-drug monitoring program with stronger prescribing requirements. In a state with a once highly restrictive Medicaid system that did not cover addiction services, the advocacy organization also battled successfully, three times, for Medicaid expansion, most recently this spring when lawmakers approved an additional five years.

New Hampshire has a relatively large legislature composed of 424 unpaid citizens that turns over every two years, so there is a tremendous amount of education that must take place each term, says Michele Merritt, president and CEO of New Futures. The long-running support of the community foundation helps make that possible.

“New Futures is able to serve in that role of providing evidence-based, evidence-informed information to legislators so that they can make smart decisions when it comes to policy,” she says. “If there wasn’t an organization like New Futures in New Hampshire, we’d be in a very different spot.”

Insisting on Partnerships

The New Hampshire Charitable Foundation has held steady in its philosophy that sustainable solutions must be done in partnerships. When it does directly pay for prevention, treatment, or other types of programs, it strives to secure additional public dollars for the efforts, Rourke says.

In 2017, for example, a donor put on the table a $3 million gift to help pregnant women affected by substance-use disorders. The governor’s commission was already talking about the needs of pregnant women, and Rourke went to the state’s Bureau of Drug and Alcohol Services with the private dollars as a sort of carrot. New Hampshire subsequently earmarked $2.5 million, a portion of the money it received from the federal 21st Century Cures Act, for a program to train hospitals in how to screen and address substance use in pregnant women.

“We came almost out of the gate with our donor’s gift with a match from the state,” Rourke says.

Todd Heisler/The New York Times/Redux

In another instance, the New Hampshire Charitable Foundation worked with the Conrad N. Hilton Foundation to test a program to screen adolescents for substance abuse. Knowing there also needed to be increased screening of adults, Rourke again went to the state with private philanthropy dollars in hand to ask for cooperation.

“So the state leveraged their own money through the federal qualified health systems to make sure health-care centers had resources to screen adults,” Rourke says.

In 2017, New Hampshire spent a total of $76.1 million in state and federal funds to address substance abuse in the state.

Serious Challenges

New Hampshire Charitable Foundation leaders and others working to turn the tide on substance abuse know there is a long way to go. In 2016, New Hampshire logged 485 drug-related deaths, excluding alcohol, according to statistics from the Office of the Chief Medical Examiner; 87 percent were opioid-related. In a state with a population of 1.3 million, it was the second highest opioid-related death rate in the country. Nationally, 42,249 people fatally overdosed on opioids in 2016, according to federal statistics.

In 2017, there were 483 drug-related deaths in New Hampshire, 88 percent opioid-related. Toxicology reports are pending on six more suspected drug-related deaths. And the state has confirmed 40 drug-related deaths so far in 2018, with another 86 pending toxicology results.

Opioid use, of course, is just part of the problem. Spikes in opioid abuse are often followed by spikes in the use of methamphetamines, Rourke says, and evidence shows that is already underway in the New Hampshire. Then there is the fact that alcohol consumption dwarfs drug use. New Hampshire ranked first in alcohol consumption in 2014-15, with 64 percent of residents over age 12 reporting they drank at least once a month, according to data collected for the National Survey on Drug Use and Health.

“The State of New Hampshire has had the highest rates of per capita addiction of any state in the U.S. for the last 30 years,” Rourke says. “More people die of the overconsumption of alcohol than any other illicit drug.”

But what the intense attention being paid to the current opioid crisis provides is an extraordinary opportunity to address addiction writ large, he says.

He and others liken the current addiction crisis to the early years of the HIV/AIDS epidemic. In both cases, the government had to be dragged into the search for solutions.

“We are fighting against enormous issues of pharmaceutical policy, law enforcement, undiagnosed mental illness,” says Ober. “We are fighting against forces way larger than any one foundation or even any one coalition.”