Safe Syringe Programs: An Exploration of Federal, State, and Local Level Responsibilities

Needle exchange interventions have a long history in the U.S., dating back to the 1980s [3]. According to the Centers for Disease Control and Prevention (CDC) (2019) [4], decades of studies have demonstrated inverse correlations between SSPs and transmission of hepatitis C and HIV as well as needle waste in communities. There is no statistically significant evidence linking SSPs to an increase in community crime or drug use. In fact, new SSP participants are more likely to seek drug treatment and discontinue drug use than those not engaged with SSPs (CDC, 2019) [4]. A primary goal of SSPs is disease reduction. Programs aim to reduce negative health consequences associated with drug use by decreasing the probability of disease transmission. Interventions include providing clean sharps and supplies, education on best practices, and a safe place to dispose of used sharps.

From 2011-2015, the state of Indiana saw a surge in blood borne infections (BBIs), including human immunodeficiency virus (HIV) and hepatitis C [1]. The vast majority of persons testing positive for BBI reported using IV drugs. Scott County, Indiana was hit particularly hard, and consequently, a public health emergency was declared in March 2015 with legislation passed shortly thereafter allowing county health departments in Indiana to seek permission to establish SSPs. Currently, there are eight active SSPs in Indiana’s 92 counties [5]. The initial end date for the legislation was 2019. This was later amended to July 1, 2021, and a bill attempting to repeal the end date was defeated in February 2020 [6].

Public health agencies’ efforts focus on ensuring public health and wellbeing. At the state level, this involves legislation, without federal interference, of the laws governing their residents’ public health [7]. Indiana’s newly developed State Harm Reduction and Syringe Service Program (SSP) falls under the Division of HIV, STD, and Viral Hepatitis. It provides support to local health departments across Indiana in their execution of SSPs. There have been barriers to the implementation of SSPs in Indiana. Namely that each request requires either the declaration of a local state of emergency or approval by county or city legislation with renewal every two years thereafter [6]. Additionally, SSPs in a conservative state are more likely to face public stigmatization, lack of support from law enforcement, and funding difficulties. In spite of these obstacles, Indiana’s State Harm Reduction and Syringe Service Program reports a total 12,000 participants and a syringe return rate of 81% [5].

At the local level, health departments are tasked with delivering programmatic services to the public directly. The eight SSPs open in Indiana provide a variety of intervention services in carrying out the principles of harm reduction [1]. SSP participants are supplied with new syringes in a quantity that will meet their self-reported needs of daily injection frequency, clean ancillary supplies that if reused might increase infection rates (e.g., cotton, mixing bowls, rinse water), sterile supplies (e.g., bleach, alcohol pads), and safety supplies (e.g., sharps containers, tourniquets). Returning used needles is encouraged but not required and supply of new syringes is not contingent upon return. Testing for HIV, hepatitis (B and C), tuberculosis (TB), and sexually transmitted diseases (STDs) is offered as are adult immunizations, condoms, and various service referrals. Wound care is provided in cases of infected injection sites. Education is offered on topics such as BBI transmission, safer injection practices, wound care, and overdose prevention and response. County programs do not report participant information to law enforcement. A minimal amount of non-identifiable information is recorded for program evaluation and state reporting purposes.

According to the U.S. Constitution, federal public health agencies have the authority to tax and spend in service of public welfare, including funding health services [7]. The majority of federal public health programs are governed by the Department of Human Health Services (HHS). The CDC is among these agencies. The CDC’s role in addressing the opioid crisis is to provide macro-level support. Their initiatives are similar to state and local agencies but are national in scope. Goals include addressing patient safety with actions like providing best practice guidance to health providers; educating the public; assisting states to implement effective strategies through funding, resources, and information; collaborating with public safety entities; and collecting data to inform public health policy recommendations [8]. While state and local legislation govern establishing, accessing, and implementing the day-to-day operations of SSPs, it is the CDC that develops the guidance that state and local health departments should follow [4]. The CDC makes these research-based recommendations in an effort to maximize all factors of public health, including secondary impacts, such as needlestick injuries to first responders and environmental pollution from improperly discarded needles.

SSPs have been in practice and thoroughly researched for the past forty years. They are a vital component in responding to the opioid crisis in the state of Indiana, the U.S., and the world. They address not only individual IV drug use and dependence but also community factors related to public health, including transmission of BBIs, overdose deaths, occupational needlesticks, and environmental pollution. State and local health departments regulate and deliver SSPs as part of harm reduction programming. Federal agencies, such as the CDC, provide support to make the delivery of individual services possible through research and policy recommendations.

None.

No conflict of interest.

1. Indiana State Department of Health (2020) Indiana State Department of Health Harm Reduction & Syringe Service Program Guidance Version 4.
2. National Harm Reduction Coalition (2020) Principles of harm reduction.
3. McLean K (2011) The biopolitics of needle exchange in the United States. Crit Public Health 21(1): 71-79.
4. Centers for Disease Control and Prevention (CDC) (2019) Summary of information on the safety and effectiveness of syringe services programs (SSPs).
5. Indiana State Department of Health (2021) Syringe service program: Did you know?
6. Giles B (2020) Conservative Indiana adopted needle exchanges but still faces local resistance. Kaiser Health News.
7. Schneider M J (2017) Introduction to public health (5^th). Jones & Bartlett Learning.
8. Centers for Disease Control and Prevention (CDC) (2021) CDC’s role in the opioid overdose epidemic.