Two Geisel School of Medicine students have opened a harm reduction center located at the Claremont Soup Kitchen in an effort to reduce opioid overdose deaths in New Hampshire and to prevent blood-borne disease transmission.
The first program of its kind in the Granite State, Project 439 distributes free naloxone (an overdose reversal drug), sharps containers, and clean syringe kits while educating the community about overdose protocol and preventing the spread of diseases such as HIV and Hepatitis C, which are prevalent among intravenous drug users.
“There is strong evidence that harm reduction approaches like needle exchange and access to non-judgmental mental health care work. Pointing the finger and talking about personal responsibility, on the other hand, can feel good for the person doing the judging, but just doesn’t work very well,” says Timothy Lahey, MD, an associate professor of medicine at Geisel and an expert in infectious diseases.
New Hampshire is second only to West Virginia in overall opioid overdose deaths, but leads the country in fentanyl overdose deaths. Seeking a way to stem the state’s rising tide of deaths, then first-year medical students Andrew Blake Geisel ’19, Margot LeNeveu Geisel ’19, and Michelle Scheurich Geisel ’19, founded Project 439 in 2015 (named for the number of New Hampshire deaths that year) as part of their Schweitzer fellowships. Under the auspices of the project, they proposed legalizing needle exchange programs, which were illegal at that time, and worked with state legislators to draft a bill. Blake testified on behalf of Senate Bill 234 in early 2017, and this spring Governor Chris Sununu signed the bill into law.
Chen and Azizgolshani, also Schweitzer Fellows, took over managing the project as first-year students in fall 2016 and began laying the groundwork for the harm reduction center in Claremont.
“There is such a need in New Hampshire for programs aimed toward helping people with substance abuse protect their own health and lives,” says Louisa Chen ’20, who along with Nasim Azizgolshani ’20, expanded the work of their fellow students by establishing the program in Claremont. “It was such a relief when the law passed because people had been telling us every day about how the opioid epidemic has damaged their communities and families. Every single New Hampshire resident’s life has been touched by this crisis at some level.”
Azizgolshani says they chose Claremont because of community need and accessibility. “Access to services is what people struggle with most here in rural New Hampshire and we want to make ourselves as accessible as possible—you can easily get to the soup kitchen by bus and there is quite a lot of daily foot traffic through its doors.”
“Initially, we thought there would be a lot of resistance to our proposal given nothing like this had existed before us, but we were all pleasantly surprised by how ready people were to accept us. Everywhere we went we kept hearing, ‘When are you going to start?’ It was opposite of what we expected,” she says.
A true community project, she and Chen spent countless hours meeting with people in Claremont—the fire chief, the police chief, the mayor, and community organizers such as Hope for Recovery, a well-respected organization that works toward guiding people into the life they want while supporting their recovery, and the Southwestern Shelter, which is across the street from the soup kitchen, making sure Project 439’s goals aligned with Claremont’s goals.
Traveling down to Claremont on the first and third Mondays each month, Azizgolshani and Chen see walk-ins from 4-5:15pm. “The timing is purposeful—it’s the same time that the Claremont Soup Kitchen serves dinner,” Chen explains. “On those two days, we are distributing supplies (clean needles and sharps containers for needle disposal) and whatever else is needed. The singularly most important thing that we distribute is naloxone, and we teach not only users but also family members about how to recognize signs of overdose, how to use the medication, who to call, and appropriate next steps. Each box of Narcan® we give out is a potential life saved.”
They are in talks with both Valley Regional Hospital and Dartmouth-Hitchcock Medical Center to dispose of the sharps they collect for free and thus continue keeping public spaces safe. Safe disposal of used needles not only keeps users healthy, but also protects their families, friends, and community members from disease transmission.
“We really want to be the bridge between people and their needs, to meet them where they are,” Chen says, “to make sure we empower them to protect their own wellbeing by giving them supplies and resources along with a sense of security.”
According to Azizgolshani, the response to their services has been overwhelming. “It’s been going really well. The last time I was there, people were lined up outside the door and coming in for a variety of reasons,” she says. “One woman came out of concern for her daughter—she wanted naloxone because she was afraid her daughter, who struggles with heroin use, would overdose.”
Nationally, more people die from accidental overdoes than from car crashes, guns deaths, and HIV combined, according to preliminary data from the Centers for Disease control.
Given the high per capita overdose rate here in New Hampshire, there is concern in Claremont about the future of Project 439 once Chen and Azizgolshani graduate. When asked if the program will fall apart, Chen replies with an emphatic no. “Our answer to that question is always no; we are going to do whatever it takes to make sure this program is here for however long it is needed—which could be decades. This isn’t a problem that’s going to go away soon. Stepping away from addiction is an incredibly long and difficult journey.”
Both Azizgolshani and Chen are dedicated to the project’s mission—having poured their heart and soul into it for the past year. “While we want to make sure this is all built upon a very stable foundation, we are cognizant of the limitations of our medical school schedule,” Chen says. “The good thing is that while we do plan on grooming a few first-year students to help take over some of the day-to-day operations with us, we both are planning to extend our time in the area beyond the traditional four years.” Chen, for example, is interested in pursuing an MBA.
Whether or not the day-to-day operations are taken over by enthusiastic first-years committed to the mission, Chen and Azizgolshani will be guiding and helping the program as much as possible to ensure its continuous growth and success.
“We truly stand behind the mission of our program—it’s the first of its kind in the state—and we want to make sure we set a precedent so future programs have the support to thrive,” Azizgolshani says. “This is something we want to be sustainable, especially given the high stakes of what we are providing. If it is at all inconsistent, the trust we worked so hard to build will be ruined.”
Together, Azizgolshani and Chen are working on finding additional funding and larger institutional support to make that a reality—something they hope will happen this year. “Other cities in NH have a huge need for similar services and we hope this model will be far reaching,” Chen notes.
Because physicians are partly responsible for the increase in opioid addiction—mostly through overprescribing—Chen and Azizgolshani think it’s vitally important as future physicians to ameliorate the worst aspects of the opioid epidemic. “The best way to do this is to be truly in touch with the people who are struggling with substance use and to understand their needs,” Azizgolshani notes. “And that is something we are doing through Project 439.”
Both Azizgolshani and Chen have experience with harm reduction. Chen started a needle exchange for intravenous drug users as an undergraduate in Orange County, California, and Azizgolshani worked in a harm reduction center in New York City’s Lower East Side.
“It is great to see Dartmouth students pairing compassion with evidence to reach neighbors and citizens who are in trouble,” Lahey says. “I’m really proud they are part of our school.”