© Matt Kenyon

Kicking off the US primary calendar gives a small state big sway over the national debate. Corn-growing Iowa’s first place in the presidential caucuses has resulted in a federal ethanol subsidy that defies economic logic. New Hampshire, which holds the first primary, has not had a single issue to rival Iowa’s corn. Tragically, it now does.

The leafy New England state, which votes on Tuesday, nearly tops the US in deaths from heroin and opioids. Suddenly almost every candidate says defeating the epidemic should be a national priority. They are right. US deaths from drug overdoses have tripled since 2000. The heroin-opioid mortality rate now rivals HIV-Aids at its peak.

But who will benefit on Tuesday night? And why New Hampshire? Virtually every White House hopeful recites moving stories about addiction in New Hampshire’s town halls. Jeb Bush’s daughter, Noelle, was arrested with cocaine when he was Florida’s governor. She was also addicted to painkillers.

Ted Cruz’s half-sister, Miriam, died from an accidental overdose in 2011. Carly Fiorina’s stepdaughter, who was addicted to prescription drugs, also died from an overdose in 2009. Chris Christie’s best friend from law school was found dead in his hotel room in 2014 with painkillers in his blood.

With the exception of Donald Trump, who has shown scant interest in the epidemic, there is little to distinguish Republicans from Democrats. No more talk of a “war on drugs” or “zero tolerance” for addicts. That would lose votes. Mr Trump’s solution is to build a wall with Mexico, which supplies most of America’s heroin. The rest emphasise the need to treat addiction as a disease rather than lock up its victims.

There is barely a citizen in New Hampshire who is unaffected by the tragedy. In a recent poll, state voters cited it as their top concern — ahead of jobs and the economy. In a state of just 1.3m people, more than 400 people died last year from overdoses and tens of thousands are at risk. Its drugs mortality has doubled since 2013.

If New Hampshire’s voters mean what they say, Mr Trump will do less well on Tuesday than expected. Mr Bush, who talks on the subject with a passion he brings to few others, would benefit.

Either way, the state has put America’s heroin epidemic on the frontburner. In her annual “state of the state” address last week, Maggie Hassan, New Hampshire governor, said it was the state’s number one challenge.

It claims more lives than breast cancer, traffic accidents or diabetes, yet pinning down its causes is hard. With unemployment at 3.1 per cent, New Hampshire has barely half the nation’s jobless rate. The state’s drug overdose deaths rank third behind New Mexico and West Virginia.

Yet New Mexico and West Virginia suffer from jobless rates far above the US average. Nor is race a pointer. New Hampshire is almost entirely white. New Mexico is diverse. It would be hard to think of three US states that differ more from each other than these.

Clearly the epidemic is America-wide. But why now? Anger is the word that most often describes the US electorate’s volatile mood in 2016. It explains the surge by outsiders, such as the socialist Bernie Sanders, and the bombastic Mr Trump, who lead their party’s fields in New Hampshire. Pessimism would capture it just as well.

The explosion in US drug overdoses offers a window on why. Some of the deaths are accidental, some are suicides. It can be hard to distinguish. There is little dispute, however, that overdoses are a leading cause of the rise in mortality rates among young and middle-aged white Americans — the first decline in life expectancy for either group since the Great Depression. Annual US deaths from drugs now exceed homicides and traffic deaths combined.

The epidemic’s rise is linked to two larger trends. The first is the rapid spread of prescription painkillers. It is hard to believe the US incidence of acute pain has quadrupled since the late 1990s, yet prescriptions for painkillers have. Sales of OxyContin, the strongest opioid on the market, have risen from $45m in 1995 to $3.1bn last year.

Purdue Pharma, the manufacturer, was fined $600m in 2007 for “misbranding” the drug as having a lower threat of addiction. In reality, OxyContin is as addictive as heroin if badly prescribed. Hard-up painkiller addicts, such as those dying each day in New Hampshire, turn to heroin, which retails at roughly a fifth of the price.

You can choose your culprit. Heroin comes from Mexico. Painkillers come from your family doctor. Or you can blame the Food and Drug Administration, which last year said OxyContin could be prescribed to children as young as 11. Hillary Clinton said the FDA’s ruling was “absolutely incomprehensible”.

The second trend is the US middle-class squeeze. Median income is lower today than in the 1990s when the prescription boom began. Economic hopelessness leads to medical distress. The US healthcare industry is there to ease your pain. The result is a perfect storm of rising supply and demand. Doctors supply the drugs. Stagnating small town and rural America fuels the demand.

Such is the backdrop to New Hampshire’s most watched primary in years. On Tuesday, its voters will get to pick their poison. Will they go for the heroin rush of Mr Trump? Or the methadone substitute offered by the others? The outcome will influence America.


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