Syringe Services Programs: A NACo Opioid Solutions Strategy Brief

Image of Thumbnail_Tile 2.png

Upcoming Events

Webinar

Understanding New Medicaid and CHIP Requirements for Youth in Detention: What Counties Need to Know

Related News

Advocacy

Six years of the SUPPORT Act: Ongoing behavioral health policy priorities for counties

Advocacy

County Countdown – Oct. 22, 2024

Advocacy

FCC adopts geo-routing requirements for the 988 Hotline

"High-quality syringe services programs can prevent the spread of disease, save lives, and connect people to other health services, including treatment for substance use disorder.” 

– Dr. Rahul Gupta, Director of the Office of National Drug Control Policy1

What are syringe services programs?

Syringe services programs (SSPs) provide low-barrier access to sterile supplies for safer substance use, naloxone and overdose prevention tools like fentanyl test strips and drug checking services. SSPs also provide a range of other services, such as options for safe syringe disposal, overdose recognition and response training and help accessing services for HIV, substance use disorders and more.2,3

Community-based SSPs are often led by people with lived experience of substance use who are committed to a harm reduction philosophy and foster a non-judgmental environment for people who are seeking support for their substance use but face discrimination, financial barriers or other challenges when interfacing with other healthcare institutions.2

What evidence supports SSPs as a public health strategy?

The evidence that SSPs prevent overdose is so great that the CDC has endorsed SSPs as one of the most effective, scientifically proven prevention strategies.2

SSPs prevent overdose. SSPs are very effective at providing low barrier access to evidence-based overdose prevention tools, like naloxone4 and fentanyl test strips.5,6 SSPs are also very effective at linking people to medication for opioid use disorder (MOUD), which reduces the risk of overdose.7,8

SSPs link many people to substance use disorder treatment. Studies have found that people who participate in local SSPs are significantly more likely to enter treatment for substance use disorder compared to those who do not.7,9,10 Many SSPs collaborate with healthcare providers to offer MOUD treatment in-person or via telehealth.

SSPs reduce substance use. As many as 4 in 5 SSP participants are interested in reducing or ceasing their substance use.9 SSP participants are more than twice as likely to reduce the frequency of their substance use and more than three times as likely to stop using substances entirely compared to those who do not.10

SSPs prevent disease. Access to sterile supplies significantly reduces the transmission of infectious disease, such as HIV and hepatitis C, and prevents potentially life-threatening bacterial infections causing abscess, endocarditis and sepsis.2

SSPs reduce crime and make neighborhoods safer. SSPs reduce the amount of syringe litter in the neighborhoods where they operate by providing multiple options for safer disposal.11,12 SSPs do not increase or promote criminal activity13,14 and have been linked to crime reduction in cities like San Francisco.15

Click here to view a video tour of Streetwork, an SSP in New York City, and hear from staff and program participants.

Are there risks to my community or institution if we don’t support SSPs?

Yes.

More fatal overdoses may occur. Though it is possible to obtain naloxone through other means, such as a physician or pharmacy, research is clear that SSPs are the most effective way to distribute naloxone to those most likely to save a life by using it. One study found that pharmacies would have to distribute more than twice as many naloxone kits as community-based SSPs to prevent the same number of overdose fatalities.4

HIV outbreaks may occur. Recent HIV outbreaks in Indiana, Massachusetts and West Virginia have been linked to local policies restricting access to SSPs (such as limited hours, proof of residency requirements, distribution limits or outright SSP bans).16-18 In addition to being a serious public health crisis, HIV outbreaks are expensive: each new case costs more than $350,000 to treat over a single lifetime.19

Fewer people will access treatment for substance use disorders. SSPs are the most effective and well-trafficked pathway to effective treatment for substance use disorders. People who utilize SSP services are many times more likely to begin treatment, stay in treatment and cease substance use than those who do not.7-10

What laws and policies present barriers to SSP services?

As of June 2022, 13 states have laws that bar SSPs from operating and many more have drug paraphernalia laws that criminalize possession of public health supplies that SSPs distribute – including sterile syringes (39 states and the District of Columbia) and fentanyl test strips (44 states and the District of Columbia). SSP bans and drug paraphernalia laws that target safer use supplies undermine the public health benefits of SSPs.20

Click here to view a map of the legal status of SSPs in each state. 

What are best practices to support SSPs and related services?

  • Help secure funding for SSP operations. Lack of funding is a common and significant barrier to SSP operations.21 Access to a diversity of funding streams can strengthen SSPs and ensure the availability of robust, reliable services over time.22,23
  • Help secure funding for the purchase of naloxone. The amount of naloxone distributed across the United States is far below the levels needed to ensure that most accidental overdoses can be reversed.4 Funding naloxone procurement for SSPs can reduce overdose deaths.
  • Support needs-based distribution policies. Limiting the number of supplies an SSP can distribute is unnecessary and harmful.24,25 One-for-one exchange policies have been implicated in HIV outbreaks.26,27
  • Prioritize SSPs led by people with lived experience of substance use and/or substance use disorder.2,22 Involving people with lived experiences in the planning, implementation and evaluation of SSPs is a CDC-endorsed best practice22 and is strongly encouraged in a number of federal funding opportunities.28
  • Help secure funding for the purchase of multiple forms of safer use equipment. SSPs are highly effective at preventing overdose and linking people to treatment.3 To make these services inclusive to all people who use drugs, SSPs must be able to procure safer use equipment for various forms of use (e.g., injection, smoking).29,30
  • Help secure funding for drug checking services at SSPs. Fentanyl test strips and point-of-service drug checking are newer, evidence-based strategies for preventing fatal overdose.5,6,31
  • Fight stigma by voicing strong support for SSPs and other harm reduction services.32,33 Stigma and misinformation about SSPs and other harm reduction services pose significant and persistent barriers to implementing this evidence-based strategy.32,33
  • Consider policies that legalize possession of public health supplies distributed by SSPs. 

What are some examples of successful SSPs?

The Eastern Band of Cherokee Indians established the Tsalagi Public Health SSP in 2018. In addition to providing access to sterile supplies and naloxone, the SSP has linked nearly 1 in 14 participants to treatment for substance use disorders.34

Sonoran Prevention Works (SPW) is a nonprofit harm reduction organization founded by people who use drugs. In addition to operating three urban service locations, SPW conducts community-informed outreach programs in Arizona’s southern and rural counties. In 2021, SPW trained over 1,000 individuals in harm reduction best practices for overdose prevention and naloxone administration in Cochise, Graham and Santa Cruz counties and distributed nearly 2,500 naloxone kits in these communities.35

Prevention Point Philadelphia is an SSP in Philadelphia’s Kensington neighborhood. In addition to other essential public health services, like access to naloxone and sterile supplies for safer substance use, Prevention Point also offers MOUD treatment onsite.36

The North Carolina Harm Reduction Coalition offers mobile SSP services in several North Carolina counties, expanding access to rural areas of the state where community members face long travel times and other barriers to seeking services often clustered in urban areas.37

These and many other model programs are described online at the Brandeis Opioid Resource Connector.

Tagged In:

Author

Jennifer J. Carroll, PhD, MPH

Dr. Carroll is a medical anthropologist, research scientist and subject matter expert on substance use and public health. She is currently an Assistant Professor of Anthropology at North Carolina State University.

Additional Resources

Implementation Guidelines and Best Practices

Legal and Legislative Tools

National Harm Reduction Technical Assistance Center (NHRTAC)

The NHRTAC was established by the U.S. Centers for Disease Control and Prevention and the U.S. Substance Abuse and Mental Health Services Administration to provide free assistance to those implementing harm reduction services in their community. Technical assistance for implementing SSPs may be requested through the NHRTAC website. 

Rural Health Information Hub (RHIhub)

On its website, RHIhub hosts a toolkit to support community leaders in establishing SSPs, including considerations for program planning, implementation, and evaluation.

National Association of State and Territorial AIDS Directors (NASTAD)

NASTAD provides technical assistance for the implementation of SSPs to health departments and community-based organizations. They also provide regional harm reduction support through a network of professional consultants working across the United States as well as regional SSP technical assistance call series.

  1. The White House. White House Releases Model Law to Help States Ensure Access to “Safe, Effective, and Cost-saving” Syringe Services Programs. The White House. Published December 8, 2021. Accessed October 7, 2022. https://www.whitehouse.gov/ondcp/briefing-room/2021/12/08/white-house-releases-model-law-to-help-states-ensure-access-to-safe-effective-and-cost-saving-syringe-services-programs/
  2. Carroll JJ, Green TC, Noonan RK. Evidence-Based Strategies for Prevention Opioid Overdose: What’s Working in the United States. Published online 2018. Accessed October 10, 2018. http://www.cdc.gov/drugoverdose/pdf/pubs/2018-evidence-based-strategies.pdf
  3. Carroll JJ, Asher A, Krishnasamy V, Dowell D. Linking People with Opioid Use Disorder to Medication Treatment. Published online 2022. Accessed June 8, 2022. https://www.cdc.gov/drugoverdose/pdf/pubs/Linkage-to-Care_Edited-PDF_508-3-15-2022.pdf
  4. Irvine MA, Oller D, Boggis J, et al. Estimating naloxone need in the USA across fentanyl, heroin, and prescription opioid epidemics: a modelling study. The Lancet Public Health. 2022;7(3):e210-e218. doi:10.1016/S2468-2667(21)00304-2
  5. Peiper NC, Clarke SD, Vincent LB, Ciccarone D, Kral AH, Zibbell JE. Fentanyl test strips as an opioid overdose prevention strategy: Findings from a syringe services program in the Southeastern United States. International Journal of Drug Policy. 2019;63:122-128. doi:10.1016/j.drugpo.2018.08.007
  6. Park JN, Frankel S, Morris M, et al. Evaluation of fentanyl test strip distribution in two Mid-Atlantic syringe services programs. Int J Drug Policy. 2021;94:103196. doi:10.1016/j.drugpo.2021.103196
  7. Strathdee SA, Celentano DD, Shah N, et al. Needle-exchange attendance and health care utilization promote entry into detoxification. J Urban Health. 1999;76(4):448-460. doi:10.1007/BF02351502
  8. Havens JR, Latkin CA, Pu M, et al. Predictors of opiate agonist treatment retention among injection drug users referred from a needle exchange program. J Subst Abuse Treat. 2009;36(3):306-312. doi:10.1016/j.jsat.2008.07.002
  9. Frost MC, Williams EC, Kingston S, Banta-Green CJ. Interest in Getting Help to Reduce or Stop Substance Use Among Syringe Exchange Clients Who Use Opioids. J Addict Med. 2018;12(6):428-434. doi:10.1097/ADM.0000000000000426
  10. Hagan H, McGough JP, Thiede H, Hopkins S, Duchin J, Alexander ER. Reduced injection frequency and increased entry and retention in drug treatment associated with needle-exchange participation in Seattle drug injectors. J Subst Abuse Treat. 2000;19(3):247-252.
  11. Doherty MC, Junge B, Rathouz P, Garfein RS, Riley E, Vlahov D. The effect of a needle exchange program on numbers of discarded needles: a 2-year follow-up. Am J Public Health. 2000;90(6):936-939.
  12. de Montigny L, Vernez Moudon A, Leigh B, Kim SY, Young K. Assessing a drop box programme: a spatial analysis of discarded needles. Int J Drug Policy. 2010;21(3):208-214. doi:10.1016/j.drugpo.2009.07.003
  13. Marx MA, Crape B, Brookmeyer RS, et al. Trends in crime and the introduction of a needle exchange program. Am J Public Health. 2000;90(12):1933-1936.
  14. Galea S, Ahern J, Fuller C, Freudenberg N, Vlahov D. Needle exchange programs and experience of violence in an inner city neighborhood. J Acquir Immune Defic Syndr. 2001;28(3):282-288. doi:10.1097/00042560-200111010-00014
  15. Davidson PJ, Lambdin BH, Browne EN, Wenger LD, Kral AH. Impact of an unsanctioned safe consumption site on criminal activity, 2010-2019. Drug Alcohol Depend. 2021;220:108521. doi:10.1016/j.drugalcdep.2021.108521
  16. Peters PJ, Pontones P, Hoover KW, et al. HIV Infection Linked to Injection Use of Oxymorphone in Indiana, 2014–2015. New England Journal of Medicine. 2016;375(3):229-239. doi:10.1056/NEJMoa1515195
  17. Cranston K, Alpren C, John B, et al. Notes from the Field: HIV Diagnoses Among Persons Who Inject Drugs — Northeastern Massachusetts, 2015–2018. MMWR Morb Mortal Wkly Rep. 2019;68. doi:10.15585/mmwr.mm6810a6
  18. Atkins A, McClung RP, Kilkenny M, et al. Notes from the Field: Outbreak of Human Immunodeficiency Virus Infection Among Persons Who Inject Drugs — Cabell County, West Virginia, 2018–2019. MMWR Morb Mortal Wkly Rep. 2020;69(16):499-500. doi:10.15585/mmwr.mm6916a2
  19. Schackman BR, Fleishman JA, Su AE, et al. The Lifetime Medical Cost Savings From Preventing HIV in the United States. Medical Care. 2015;53(4):293-301. doi:10.1097/MLR.0000000000000308
  20. Singer JA, Heimowitz S. Drug Paraphernalia Laws Undermine Harm Reduction. Cato Institute. Published June 7, 2022. Accessed June 14, 2022. https://www.cato.org/policy-analysis/drug-paraphernalia-laws-undermine-harm-reduction-reduce-overdoses-disease-states
  21. Green TC, Martin EG, Bowman SE, Mann MR, Beletsky L. Life After the Ban: An Assessment of US Syringe Exchange Programs’ Attitudes About and Early Experiences With Federal Funding. Am J Public Health. 2012;102(5):e9-e16. doi:10.2105/AJPH.2011.300595
  22. Javed J, Burk K, Facente S, Pegram L, Ali A, Asher A. Syringe Services Programs: A Technical Package of Effective Strategies and Approaches for Planning, Design, and Implementation. US Department of Health and Human Services, National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, Centers for Disease, Control and Prevention; 2020. Accessed September 5, 2022. https://www.cdc.gov/ssp/docs/SSP-Technical-Package.pdf
  23. Sherman SG, Purchase D. Point Defiance: a case study of the United States’ first public needle exchange in Tacoma, Washington. Int J Drug Policy. 2001;12(1):45-57. doi:10.1016/s0955-3959(00)00074-8
  24. Bluthenthal RN, Anderson R, Flynn NM, Kral AH. Higher syringe coverage is associated with lower odds of HIV risk and does not increase unsafe syringe disposal among syringe exchange program clients. Drug Alcohol Depend. 2007;89(2-3):214-222. doi:10.1016/j.drugalcdep.2006.12.035
  25. Kral AH, Anderson R, Flynn NM, Bluthenthal RN. Injection risk behaviors among clients of syringe exchange programs with different syringe dispensation policies. J Acquir Immune Defic Syndr. 2004;37(2):1307-1312.
  26. Hyshka E, Strathdee S, Wood E, Kerr T. Needle Exchange and the HIV Epidemic in Vancouver: Lessons Learned from 15 years of research. Int J Drug Policy. 2012;23(4):261-270. doi:10.1016/j.drugpo.2012.03.006
  27. Barocas JA, Baker L, Hull SJ, Stokes S, Westergaard RP. High uptake of naloxone-based overdose prevention training among previously incarcerated syringe-exchange program participants. Drug Alcohol Depend. 2015;154:283-286. doi:10.1016/j.drugalcdep.2015.06.023
  28. U.S. Substance Abuse and Mental Health Services Administration. Harm Reduction Grant Program. SAMHSA. Published 2022. Accessed September 4, 2022. https://www.samhsa.gov/grants/grant-announcements/sp-22-001
  29. Wang Y, Yu M, Yan B, Martin P, Robertson B. Effects of Food on the Bioavailability of Amphetamine in Healthy Adults After Administration of SHP465 Mixed Amphetamine Salts Extended-Release Capsules. Drugs R D. 2019;19(2):167-175. doi:10.1007/s40268-019-0267-y
  30. Ronsley C, Nolan S, Knight R, et al. Treatment of stimulant use disorder: A systematic review of reviews. PLoS One. 2020;15(6):e0234809. doi:10.1371/journal.pone.0234809
  31. Laing MK, Tupper KW, Fairbairn N. Drug checking as a potential strategic overdose response in the fentanyl era. International Journal of Drug Policy. 2018;62:59-66.
  32. Oliva EM, Bounthavong M. Commentary on Rege et al. (2018): Naloxone reports to US poison centers highlight overdose prevention opportunities. Addiction. 2018;113(12):2316-2317.
  33. Ibragimov U, Cooper KE, Batty E, et al. Factors that influence enrollment in syringe services programs in rural areas: a qualitative study among program clients in Appalachian Kentucky. Harm Reduction Journal. 2021;18(1):68. doi:10.1186/s12954-021-00518-z
  34. U.S. Centers for Disease Control and Prevention. Tribal Syringe Services Program Helps Reduce Harm from Injection Drug Use. Public Health Professionals Gateway. Published 2020. Accessed October 29, 2021. https://www.cdc.gov/publichealthgateway/field-notes/2020/cherokee-hepatitis.html
  35. Sonoran Prevention Works. Our Story. Sonoran Prevention Works. Published 2022. Accessed August 7, 2022. https://spwaz.org/about/
  36. Prevention Point Philadelphia. ​STEP. Prevention Point. Published 2020. Accessed June 8, 2022. https://ppponline.org/node/125/step
  37. Knopf T. Mobile Syringe Exchange Serves People Where They Are. North Carolina Health News. Published August 10, 2017. Accessed June 14, 2022. http://www.northcarolinahealthnews.org/2017/08/10/mobile-syringe-exchange-serves-people-where-they-are/