People who inject drugs (PWID) are at risk for overdose and also the transmission of infectious diseases, particularly when sharing unsterile injection equipment. To mitigate these harms, syringe services programs (SSPs) provide access to and disposal of drug use equipment such as syringes as well as social services and referrals to substance use and mental health treatment. They also often distribute naloxone, a drug that reverses the effects of an overdose. Decades of research show that SSPs successfully reduce the rates of HIV and hepatitis C virus (HCV), boost proper disposal of used needles, and increase engagement in treatment among participants.
Based on this evidence, the federal government supports and funds the implementation of SSPs in jurisdictions that have or are at risk of increases in cases of HIV or HCV. However, because of stigma and misconceptions about these programs and their participants, communities may face many state policy barriers to establishing and operating SSPs. Consequently, not enough programs exist for the number of PWID in the United States who could benefit from them. To increase the quantity and effectiveness of SSPs, state policymakers should consider enacting policies that address the following.
Interested state policymakers should pass SSP-authorizing legislation that does not require additional local approval for implementation, as is currently the case in nine of the 31 states that authorize SSPs. Such additional layers of approval allow jurisdictions to effectively prohibit new SSPs from opening through policy or zoning changes in response to community stigma against PWID.
Additionally, some states place limits on the number of syringes that can be distributed per person because of concerns about their disposal, though the evidence shows that SSPs facilitate access to the safe disposal of used needles and syringes. Programs that provide unlimited syringes to individual participants are more effective at reducing the number of people reusing syringes, and they also have more flexibility to adjust services as necessary in times of emergency.
States should consider decriminalizing the distribution and possession of all syringes and other safer drug use materials (e.g., cookers and drug-checking devices that can identify contaminants). Drug paraphernalia laws typically prohibit possession of syringes for the purpose of illicit drug use and can precipitate police encounters with SSP participants even when these programs are authorized by the state. Evidence shows that the burden of police interactions falls disproportionately on participants of color and that the real and perceived risk of police encounters may cause people to use SSPs less frequently and also increase syringe sharing. Program administrators report that paraphernalia laws are a barrier to program operation and effective public health prevention efforts. In 2019, New Mexico became the first state to remove criminal penalties attached to the possession of any drug paraphernalia. The District of Columbia took this step as well in December 2020.
Additionally, state government entities should work with local law enforcement to develop and deliver training on the value of SSPs and explain the state laws that govern them and drug paraphernalia. Many officers are unaware of state laws decriminalizing possession of syringes and continue to stop and arrest SSP participants, which deters program participation.
States should incorporate adequate SSP funding into their budgets as determined by the number of counties experiencing infectious disease outbreaks, the number of programs operating, and the number of people participating. Public funding for SSPs is correlated with increased syringe distribution and other health services that lead to lower or consistently low HIV incidence over time, compared with programs lacking public funding. Furthermore, states should permit funding to be used for the purchase of needles and syringes to reduce reliance on unstable private grant funding. For example, the California Budget Act of 2019 committed $15.2 million over four years to SSPs across the state.
States should also allocate funding (e.g., federal grants or state funds) to facilitate on-demand treatment with buprenorphine, an FDA-approved medication that is considered the gold standard for SSP participants with opioid use disorder (OUD). Although SSPs primarily seek to reduce the harms of injection drug use, people who participate in these programs are more likely to enter treatment but often face barriers related to payment, transportation, and stigma at standard treatment programs, which can be mitigated by initiating buprenorphine treatment through an SSP. States can fund these services in a variety of ways; for example, New Jersey’s Department of Human Services used its Substance Abuse and Mental Health Services Administration State Opioid Response grant to fund a mobile advanced practice nurse and case manager to provide buprenorphine treatment services to SSP participants as part of a two-year pilot project.
SSPs can help address the opioid overdose crisis and play an important role in reducing the harms of injection drug use and engaging participants in treatment and other services. These programs are also critical distributors of naloxone—recent evidence suggests that because of this, SSPs are associated with reduced overdose-related hospital admissions. Despite the clear benefits of SSPs, barriers remain to the effective establishment and implementation of them, which limits their reach. Expanding the resources and reach of SSPs could equip states to better address the opioid overdose crisis and improve the health of the overall population.
Beth Connolly is the director and Jenna Bluestein is a senior associate for The Pew Charitable Trusts’ substance use prevention and treatment initiative.