Syringe Service Programs (SSPs)

In 2017, there were 206 overdose deaths­­­ involving opioids in Iowa. The greatest rise occurred among heroin-involved deaths, which more than quadrupled from 14 deaths in 2012 to 61 deaths in 2017. Deaths involving synthetic opioids other than methadone (mainly fentanyl), rose threefold from 29 cases in 2011 to 92 cases in 2017. Since 1999, prescription opioid-involved deaths steadily rose to a peak of 132 in 2012, but since then, they have declined by 20 percent to 104 cases in 2017.

While opioids have dominated the news for the past decade, meth has long been the more popular drug in Iowa. From 2014-2017, there was a 38 percent increase in methamphetamine treatment admissions in Iowa. Similarly, the Iowa Department of Public Health (IDPH) reports there was an eight-fold increase in Iowa deaths related to amphetamines, which includes methamphetamine. Meth is now the second most commonly used drug in Iowa, surpassing marijuana in 2019 but trailing behind alcohol.

While it might be assumed that people use one drug exclusively, the use of multiple drugs in combination is common and becoming more popular in Iowa. This is referred to as poly-drug use and involves the use of multiple substances over the course of a day or week, not necessarily at the same moment. Among participants in Iowa Harm Reduction Coalition’s program (a set of services that can be best understood as a precursor to a SSP), the following drug use trends emerged from January – June 2020:

• 65.1% use meth
• 51.2% use heroin
• 26.5% use prescription opiates (not prescribed)
• 26.0% use cocaine
• 9.8% use crack
• 12.1% use benzodiazepines (eg. xanax) (not prescribed)
• 23.3% use other substances not listed here (not including alcohol)

• Hepatitis C is a viral infection that damages the liver and can ultimately cause liver failure and death. It is a common cause of liver cancer and sometimes contributes to the need for liver transplantation.
• Unlike the other viruses that attack the liver (hepatitis A and hepatitis B), there is no vaccine for hepatitis C.
• Hepatitis C is the number one killer among infectious diseases in the nation, killing more than the next 60 leading infectious diseases combined. (Data is from prior to COVID-19).
• Injection drug use is the primary risk factor for viral hepatitis C (HCV) in the United States. Injection drug use accounts for 68% of all new infections.  A 2017 report from the CDC warned that the opioid crisis is the key driver of the explosive increase in HCV infections. 
  Recently, Iowa has experienced a significant increase in rates of hepatitis C infection. From 2000 to 2015, the number of Iowans diagnosed with hepatitis C nearly tripled. As of 2015, there were 21,748 Iowans diagnosed with hepatitis C.

• HIV is a virus that damages the immune system. When the immune system becomes severely damaged by the virus, the infection progresses to AIDS (acquired immunodeficiency syndrome). At this point, the immune system cannot protect the body, and the person may die.
• As of December 2019, there are 2,938 Iowans known to be living with HIV. 14% of these people report having used injection drugs.
• A warning: In 2017, the CDC notified Governor Reynolds that Iowa is at risk of a HIV outbreak due to the state’s recent increase in IV drug use, hepatitis C cases, and overdose deaths. The situation in Iowa is much like the situation that foreshadowed an outbreak of new HIV cases in Scott County, Indiana in 2015:
• A cautionary tale
  • Much like Iowa: Scott County, IN is a county like many of Iowa’s counties along the Missouri border. In 2019 the county’s population was just under 24,000. 
  • A rare illness: HIV was previously exceptionally rare in Scott County. Between 2004 and 2013, there were 5 HIV infections reported in the county. SSPs were illegal in Indiana, and none operated in Scott County. 
  • The outbreak: Between November 2014 and November 2015, there were 181 new cases of HIV.  Almost 90% of these cases were linked to injection drug use. By the end of the outbreak, 235 cases were documented.
  • A warning: This outbreak of HIV functioned as a national alarm, warning communities around the U.S. that the opioid crisis was giving birth to multiple other epidemics (syndemics), and that many communities might expect to see a rise in HIV cases as IV heroin use increased in communities where syringe exchange programs were illegal or nonexistent. 
  • The impact: At the time of the outbreak, the CDC Director Tom Freidan observed that Scott County had one of the highest rates (for its population size) of anywhere in the world. Aside from the impact on human health and the lives of the people who were impacted, the impact on state, local, and federal healthcare systems is immense: it is estimated that the lifetime cost to treat HIV for all 235 individuals will exceed $260 million. 
  • Never again: A 2019 study from Brown University found that if a syringe exchange program had been established prior to the outbreak, 90% of the HIV cases would have been prevented. 

Read on to learn more about Indiana’s response to the crisis.

Ever since the 2015 outbreak of HIV and hepatitis C virus (HCV) in Scott County, Indiana, it has been clear that the sharing of syringes among people who inject drugs is fueling the spread of these diseases in rural America.

• Many bacteria live on our skin that are normally harmless to us. However, when these bacteria get under the skin or into the blood (by injecting with a non-sterile needle or injecting through skin that wasn’t properly cleaned first), they can cause serious infections.
• Skin and soft tissue infections (such as abscess & cellulitis)
  • Abscesses occur when an infectious agent (usually Staphylococcus aureus, which lives on the skin) is introduced under the skin. In response to the infectious agent, the body mounts its defenses and forms a mass full of pus and debris under the skin. Abscesses are very painful and require prompt treatment with antibiotics. If not treated early, they may require surgery to drain the wound.
  • Cellulitis is an infection of the deeper layers of the skin, usually caused by group A Streptococcus, which normally lives on the skin but is dangerous when introduced beneath the skin. It appears as a red, swollen, painful patch on the skin. If not promptly treated with antibiotics, the infection can spread through the skin and even to the blood, bones, and heart, leading to serious illness and even death.
    Skin and soft tissue infections are common among injection drug users without access to sterile injection equipment. One study of injection drug users in San Francisco found that nearly one-third of injection drug users had experienced skin or soft tissue infections.
  • Bacteremia, sepsis, endocarditis, osteomyelitis, and septic arthritis
    • Bacteremia occurs when bacteria gets into the bloodstream. From the bloodstream, the bacteria can travel to other places in the body and cause sepsis (a very dangerous immune response to infection), infectious endocarditis (infection of the heart valves), osteomyelitis (infection of the bone), and septic arthritis (infection of the joint).

Providing needles to people who use drugs may seem counterintuitive, and these programs can appear to enable or promote drug use. For many people, intravenous drug use is something that they have little experience with, and it is a health issue that can feel remote from their day to day lives. Because of the stigma associated with addiction, it can be difficult to get a clear picture of what life is like for people who use and inject drugs. This also results in limited understanding or knowledge of how access to sterile needles and syringes may or may not impact an individual’s health behavior.

Although it can be difficult to understand, being handed a new needle or syringe does not have much influence on drug use among people who regularly use drugs (eg. if they will use drugs, when they will use drugs, how much they will use). Think of it like this:

You walk into a doctor’s office. The nurse hands you a brand new, empty, red plastic cup. What do you do with the cup? How do you decide what to use it for? Odds are, you aren’t going to high tail it to the nearest bar, fill the cup to the brim with liquor, and drink the contents as quickly as possible. Instead, you may save the cup for later or have a glass of water. You might also toss the cup aside, or hand it back to the nurse if you are not thirsty.

Like cups, needles exist simply to deliver a liquid into the body – albeit through a different path. For people who use drugs (and just as importantly, for people who do not), walking into a doctor’s office and receiving a sterile needle from the nurse does not inevitably result in drug use. The needle may be used for administering medication to a pet, taking insulin in the setting of diabetes, or fertility treatments. For people who do not use intravenous drugs / have not used needles in the past, the process of beginning to inject is complicated: public health researchers find that many people do not begin to inject drugs until 1-4 years after initiating use of heroin, methamphetamine, or cocaine, and often do so at first with the assistance of an acquaintance, friend, or intimate partner. IV drug use (IVDU) is extremely intricate and involves considerable skill. Thus learning to inject drugs may take a person anywhere from several months to several years. For those who do use IV drugs (PWID), it is most common to use a needle between 1 and 10 times per day, with an average of 2-4 times daily. The vast majority of PWID report that they will use drugs regardless of whether or not they have access to a new needle. This means that in order to maintain daily use, individuals will share syringes with another person, or re-use their syringes repeatedly. Both are dangerous and are associated with numerous viral and bacterial infections. Access to a needle is rarely a factor in whether or not one uses drugs on a given day or at a given time, with access to the drug itself being the crucial component.

People who get needles from SSPs are less likely to share or re-use needles

• In a Connecticut study on injection drug users before and after the implementation of new laws that removed legal barriers to purchasing and possessing syringes, researchers observed a 39% decrease in syringe sharing.
• In a Chicago study comparing people who inject drugs who went to an SSP versus those in an area without an SSP, the people who went to the SSP were 70% less likely to share needles.

In places where SSPs are implemented, rates of new HIV and hepatitis C infections decrease substantially

• Many studies have shown significant decreases in hepatitis C virus transmission following the implementation of SSPs. One study in Europe showed a 76% reduction in places with high coverage SSPs. Another study in the UK found a 59% reduction of hepatitis C virus transmission in areas with SSPs.
• In a meta-analysis of data from six high-quality studies on SSPs and HIV transmission, it was found that SSPs were associated with a 58% reduction in HIV transmission among people who inject drugs.

Contrary to popular belief, SSPs do not increase rates of drug use. Often, they have the opposite effect.

• • • In a study on people who use injection drugs in Seattle, people who had participated in an SSP were 3.5 times as likely to stop injecting during the study than those who had never participated in an SSP.
    • This same study showed that people who participated in an SSP were 3 to 5 times as likely to enter drug treatment than those who did not participate in an SSP.

Why do SSPs have this effect? It is hard to say for sure. Many of the participants in IHRC’s services want drug treatment, but face barriers to getting it – they don’t know how to get it, can’t afford it, or face long wait times to get into a treatment program. SSPs are able to connect people to treatment who might not be able to get it otherwise.

SSPs reduce the number of improperly disposed of needles

• • • In comparison of similar neighborhoods in San Francisco, CA (a city with SSPs) and Miami, FL (a city without SSPs), a study found:
      • 8-fold more improperly disposed needles in the city without SSPs.
      • 95% of injection drug users in the city without SSPs reported improperly disposing of their needles, versus 13% in the city with SSPs.

SSPs reduce needlestick injuries in police and first responders

• • • In a survey of San Diego police officers, 29.7% had experienced at least one needlestick injury in their career.
    • Fewer improperly disposed of needles means fewer needlesticks. Additionally, during police searches, people are more likely to tell the officer that they have a needle on them if they know that they won’t get arrested for it.

SSPs do not increase crime

• • • Several studies have found that there is no correlation between SSPs and crime, – that is, introducing an SSP into a neighborhood does not lead to increased crime.

The cost per HIV infection prevented through an SSP is estimated to be between $51,601 and $61,302. The estimated lifetime cost of treating an HIV positive person is $379,668. That means that for every $1 spent on preventing HIV by funding SSPs, $6.38-$7.58 is saved.

In 2013, the yearly cost of treating Hepatitis C in the United States was estimated to be $6.5 billion. Since injection drug use accounts for 68% of hepatitis C infections in the United States, this expense could be greatly reduced through SSPs.

Year SSPs implemented: 1994
Legal status: Distribution and possession of paraphernalia was never prohibited via WI state code. Did not require policy change to implement programs.
SSP infrastructure: Operated by a private non-profit health care agency (14 sites across the state) and a county public health department in one community.
Key players: Vivent Health (Formerly AIDS Resource Center of Wisconsin)

Year SSPs implemented: 1993
Legal status: Programs formally legalized in 2019. Legal exemption granted in 1995 for programs to operate legally (without change to state code) as research projects
SSP infrastructure: State health department does not coordinate. Few programs (2-3) exist outside of Chicago. Chicago / Cook County Dept. of Public Health is a major funder.
Key players: Chicago Recovery Alliance

Year SSPs implemented: 1996 or before
Legal status: Distribution and possession of paraphernalia was never prohibited via WI state code. Did not require policy change to implement programs.
SSP infrastructure: State health department does not coordinate or oversee programs – programs are independently run by nonprofits. Few programs exist outside of the Twin Cities.
Key players: Southside Harm Reduction

Year SSPs implemented: 2018
Legal status: Legalized in 2018, one program (Fargo) operated for several years in advance of law change.
SSP infrastructure: Programs primarily operated via county health departments.
Key players: n/a

Scott County, IN is a county like many of Iowa’s counties. In 2019 the county’s population was just under 24,000. HIV was previously exceptionally rare in Scott County. Between 2004 and 2013, there were 5 HIV infections reported in the county. SSPs were illegal in Indiana, and none operated in Scott County. But in late 2014 and early 2015, disturbing reports began to emerge of dozens of people testing positive for HIV. Between November 2014 and November 2015, there were 181 new cases of HIV.  Almost 90% of these cases were linked to injection drug use. By the end of the outbreak, 235 cases were documented.

A 2019 study from Brown University found that if a syringe exchange program had been established prior to the outbreak, 90% of the HIV cases would have been prevented. 

On March 25, 2015, former Indiana Governor Mike Pence declared a public health emergency in response to the outbreak and signed an executive order that temporarily authorized needle exchange program. The program was successful, with 277 enrollees and more than 90,000 syringes distributed and returned between April and October 2015 and the number of new HIV infections decreased. The Scott County outbreak was a wake-up call for advocates, epidemiologists, policymakers, and program administrators throughout the United States. Never before had the country seen such a swift outbreak of HIV in a rural community.

Soon after the outbreak ended, Congress overturned a long-standing ban on using federal funding to support syringe-exchange programs. The Centers for Disease Control and Prevention (CDC) then released a report identifying the 220 rural counties in the United States that were most vulnerable to HIV and HCV outbreaks among people who inject drugs. The director of the CDC at the time, Tom Frieden, called the sharing of unsterile syringes a “horrifyingly efficient route for spreading HIV, hepatitis, and other infections” and called for states to implement more syringe-exchange programs.

Key players: Harm Reduction Ohio

Year SSPs implemented: 1990s (underground), mid-2000s (underground)
Legal status: Legalized via state legislature 2016
SSP infrastructure: State health department hosts application process to authorize organizations that wish to operate a program. ~25 authorized programs across the state, <10 with effective programming, few receive state funds.
Key players: North Carolina Harm Reduction Coalition; Olive Branch; Urban Survivors Union; Western North Carolina AIDS Project; Twin City Needle Exchange; Steady Collective; 

Key players: Community Health Awareness Group Detroit; Grand Rapids Red Project; Harm Reduction Michigan

Year SSPs implemented: 2018
Legal status: Legalized via state legislature 2018
Key players: Idaho Harm Reduction Project

Year SSPs implemented: 1995 (Atlanta program implemented)
Legal status: Legalized statewide 2019 via legislative process
Key players: Atlanta Harm Reduction

Year SSPs implemented: 2016 (Miami only), 2018 (statewide)
Legal status: Legalized via state legislature for initial pilot program (municipal level), followed by entire state legalization (revision to drug paraphernalia code)
SSP infrastructure: Independent organizations may implement programs. 2 established to date, with 2 others planning for implementation
Key Players: IDEA Exchange, Rebel Recovery
Key Outcomes

• • Hospital Costs of Injection Drug Use in Florida
    
  • Interest in linkage to PrEP among people who inject drugs accessing syringe services; Miami, Florida
    
  • Syringe disposal among people who inject drugs before and after the implementation of a syringe services program
    
  • A comparison of syringe disposal practices among injection drug users in a city with versus a city without needle and syringe programs
    
  • A Cost Analysis of Hospitalizations for Infections Related to Injection Drug Use at a County Safety-Net Hospital in Miami, Florida
    
  • Baseline differences in characteristics and risk behaviors among people who inject drugs by syringe exchange program modality: an analysis of the Miami IDEA syringe exchange
    
  • Rapid Identification and Investigation of an HIV Risk Network Among People Who Inject Drugs –Miami, FL, 2018 
    
  • The University of Miami Infectious Disease Elimination Act (IDEA) Syringe Services Program – A Blueprint for Student Advocacy, Education, and Innovation
    
  • Examining risk behavior and syringe coverage among people who inject drugs accessing a syringe services program: A latent class analysis
    
  • Student-Run Free Clinic at a Syringe Services Program, Miami, Florida, 2017–2019
    
  • Baseline prevalence and correlates of HIV and HCV infection among people who inject drugs accessing a syringe services program; Miami, FL
    

Year SSPs implemented: 2016
Legal status: Legalized 2016, no programs operated prior to legalization
SSP infrastructure: Over 50 programs operate via county and local health departments. Lack of reach into rural communities. Often criticized for poor community engagement and lack of trust among people who use drugs.
Key players: Kentucky Harm Reduction Coalition