Syringe services for people who inject drugs are enormously effective, but remain underused

Image

NIDA Image

Nearly 30 years of research show that providing testing, counseling, and sterile injection supplies to people who inject opioids and other drugs helps prevent transmission of infectious diseases, without increasing drug-related or other crimes in the vicinity. Contrary to worries that syringe services programs (SSPs) will encourage or promote drug use, evidence shows that they more often do the opposite, linking people with addiction to effective treatment and even helping prevent overdose deaths.

Unfortunately, prejudices against harm-reduction continue to impede the reach of SSPs. Some states and communities continue to resist or even shut them down, even though history shows that the effects of such prejudice can have a disastrous impact on public health. December 1 is World AIDS Day, an opportunity to underscore the solid science behind the efficacy of this important harm-reduction measure.

The common belief that SSPs encourage more drug use is contradicted by the data. One study in Seattle, for instance, found that people who had used an SSP were about three times more likely to substantially reduce their drug injections or stop injecting altogether than those who didn’t, over one year of follow-up.¹ Partly, this is due to these programs facilitating clients staying in treatment for their addiction or even by providing that treatment. SSPs can be an important tool for reaching people who otherwise are less likely to seek or stay in SUD treatment because of unemployment or homelessness. People who had used SSPs in the Seattle study were 60% more likely to stay in methadone treatment over the year, and current SSP clients were five times more likely to enter methadone treatment compared to never-clients. Another study in Baltimore found an especially strong effect of SSP usage on later drug treatment among people living with HIV.²

Drug use contributes to the spread of HIV and other infectious diseases like hepatitis B and C in multiple ways, including the sharing of drug injection equipment. Use of SSPs can reduce infectious disease transmission both by reducing needle sharing and by providing or linking people to addiction treatment, which can reduce drug use along with infection transmission behaviors associated with it, such as condom-less sex.

Use of SSPs in places where they have been allowed to operate in the United States is associated with a 40-60% reduction in HIV transmission.³ Evidence on transmission of hepatitis C virus (HCV) is less clear, but in Europe, where SSPs are more widely used, high SSP use is associated with a 76% reduction in HCV transmission.⁴

In the current drug landscape dominated by high-potency synthetic opioids like fentanyl, SSPs also help prevent fatal overdoses.⁵ Overdose education and naloxone distribution (OEND) is the cornerstone of overdose prevention, and research suggests it is less costly to implement OEND in SSPs than it is in large health systems, SUD treatment programs, or other community settings, in part because SSP staff may have more experience and knowledge of its use.⁶

SSPs also may distribute fentanyl test strips. In one study, more than 70% of SSP clients in Baltimore and Delaware reported using test strips obtained from their SSP to check for fentanyl in what they were injecting.⁷ In Delaware, over two thirds of clients (69%) reported that getting a positive result with a fentanyl test strip led them to change their drug-taking practices by using less than they would have otherwise, going slower, asking someone to check on them, or taking other precautions.

Some SSPs provide referrals to buprenorphine treatment for people with opioid use disorder or provide buprenorphine treatment onsite. At the IDEA Exchange SSP based in Miami, clients are able to initiate buprenorphine treatment and receive their medication there, as well as receive motivational interviewing from peers. Peers facilitate ongoing telehealth visits with their clinicians, which was found to greatly facilitate staying in treatment.⁸ While stigma and discrimination drive many people living with HIV to discontinue their antiretroviral treatment, IDEA Exchange clients also reported staying in care because staff were welcoming and non-judgmental.⁹

The oft-heard claim that SSPs increase crime in the surrounding neighborhood is another prejudice that is contradicted by available evidence. One study found no increase in drug-related arrests in the vicinity of a Baltimore SSP in the year after it opened, relative to other areas of the city.¹⁰ Another study found no association between proximity to an inner-city SSP in Harlem and experiences of violence.¹¹ Studies conducted in Canada¹² and Australia,¹³ where people can legally obtain syringes as well as use illicit drugs under supervision at overdose prevention centers, have found no increases in drug-related crimes, robberies, or thefts associated with those facilities. 

Overdose prevention centers are a somewhat different and less-studied harm-reduction service, but they also provide sterile syringes and have similar associated stigma. A recent study analyzing crime reports in an undisclosed U.S. city found a faster decline in reports of assault, burglary, larceny, and robbery in the vicinity of an unsanctioned overdose prevention center over the five years after it opened in 2014 than in other areas.¹⁴ Another study found no change in crime or disorder associated with two government-sanctioned overdose prevention centers in New York City that opened in 2021.¹⁵

Besides concerns over crime, there has also been a concern that SSPs may lead to more syringe litter, but this too is contradicted by evidence.¹⁶ One NIDA-funded study found an eight-fold greater quantity of improperly disposed syringes in a major city without SSPs compared to a major city with SSPs.¹⁷ In another study, people who received syringes from an SSP were half as likely to dispose of them improperly compared to people who got them from other sources such as pharmacies.¹⁸

Failure to offer these kinds of services can have disastrous consequences, as was shown a decade ago in Scott County, Indiana: Sluggishness to permit the opening of an SSP allowed an unmitigated outbreak of HIV among people who injected drugs in that rural community. According to a 2018 modeling study, at least 127 infections could have been prevented had an SSP opened two years sooner than it did.¹⁹ A 2014 study funded in part by NIDA found that modest increases in national funding for SSPs would have an enormous return on investment: An additional $10 million invested per year (in 2011 dollars) was estimated to save $76 million in treatment costs—a 7.6-fold return on investment.²⁰

Participants in a study of SSP operators and health officials in rural Kentucky said that people in their community who were skeptical of the concept of harm reduction sometimes came around when they saw these approaches as ways to help people with different life circumstances or “meet people where they are”.²¹ Infectious disease transmission and other adverse outcomes of substance use are liable to increase when we fail to meet people with addiction where they are and put compassionate, science-supported solutions in place. SSPs are one of the best-studied and solidly supported approaches to HIV prevention and should be utilized widely as part of a comprehensive public-health approach to the drug crisis. 

References

1. 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 Oct;19(3):247-52. doi: 10.1016/s0740-5472(00)00104-5. PMID: 11027894.
2. Strathdee SA, Celentano DD, Shah N, Lyles C, Stambolis VA, Macalino G, Nelson K, Vlahov D. Needle-exchange attendance and health care utilization promote entry into detoxification. J Urban Health. 1999 Dec;76(4):448-60. doi: 10.1007/BF02351502. PMID: 10609594; PMCID: PMC3456698.
3. Aspinall EJ, Nambiar D, Goldberg DJ, Hickman M, Weir A, Van Velzen E, Palmateer N, Doyle JS, Hellard ME, Hutchinson SJ. Are needle and syringe programmes associated with a reduction in HIV transmission among people who inject drugs: a systematic review and meta-analysis. Int J Epidemiol. 2014 Feb;43(1):235-48. doi: 10.1093/ije/dyt243. Epub 2013 Dec 27. PMID: 24374889.
4. Palmateer N, Hamill V, Bergenstrom A, Bloomfield H, Gordon L, Stone J, Fraser H, Seyler T, Duan Y, Tran R, Trayner K, Biggam C, Smith S, Vickerman P, Hickman M, Hutchinson S. Interventions to prevent HIV and Hepatitis C among people who inject drugs: Latest evidence of effectiveness from a systematic review (2011 to 2020). Int J Drug Policy. 2022 Nov;109:103872. doi: 10.1016/j.drugpo.2022.103872. Epub 2022 Oct 3. PMID: 36202039.
5. Wenger LD, Doe-Simkins M, Wheeler E, Ongais L, Morris T, Bluthenthal RN, Kral AH, Lambdin BH. Best practices for community-based overdose education and naloxone distribution programs: results from using the Delphi approach. Harm Reduct J. 2022 May 28;19(1):55. doi: 10.1186/s12954-022-00639-z. PMID: 35643444; PMCID: PMC9145109.
6. Behrends CN, Gutkind S, Winkelstein E, Wright M, Dolatshahi J, Welch A, Paone D, Kunins HV, Schackman BR. Costs of opioid overdose education and naloxone distribution in New York City. Subst Abus. 2022;43(1):692-698. doi: 10.1080/08897077.2021.1986877. Epub 2021 Oct 19. PMID: 34666633; PMCID: PMC9048167.
7. Park JN, Frankel S, Morris M, Dieni O, Fahey-Morrison L, Luta M, Hunt D, Long J, Sherman SG. Evaluation of fentanyl test strip distribution in two Mid-Atlantic syringe services programs. Int J Drug Policy. 2021 Aug;94:103196. doi: 10.1016/j.drugpo.2021.103196. Epub 2021 Mar 10. PMID: 33713964.
8. Suarez E , Jr, Bartholomew TS, Plesons M, Ciraldo K, Ostrer L, Serota DP, Chueng TA, Frederick M, Onugha J, Tookes HE. Adaptation of the Tele-Harm Reduction intervention to promote initiation and retention in buprenorphine treatment among people who inject drugs: a retrospective cohort study. Ann Med. 2023 Dec;55(1):733-743. doi: 10.1080/07853890.2023.2182908. PMID: 36856571; PMCID: PMC9980015.
9. Scaramutti C, Hervera B, Rivera Y, Chueng TA, Forrest DW, Suarez E Jr, Serota DP, Alkamli H, Ciraldo K, Bartholomew TS, Tookes HE. Improving access to HIV care among people who inject drugs through tele-harm reduction: a qualitative analysis of perceived discrimination and stigma. Harm Reduct J. 2024 Feb 23;21(1):50. doi: 10.1186/s12954-024-00961-8. PMID: 38396017; PMCID: PMC10893685.
10. Marx MA, Crape B, Brookmeyer RS, Junge B, Latkin C, Vlahov D, Strathdee SA. Trends in crime and the introduction of a needle exchange program. Am J Public Health. 2000 Dec;90(12):1933-6. doi: 10.2105/ajph.90.12.1933. PMID: 11111271; PMCID: PMC1446444.
11. 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 Nov 1;28(3):282-8. doi: 10.1097/00042560-200111010-00014. PMID: 11694838.
12. Myer AJ, Belisle L. Highs and lows: an interrupted time-series evaluation of the impact of North America’s only supervised injection facility on crime. Journal of Drug Issues. 2018;48(1), 36-49. https://doi.org/10.1177/0022042617727513
13. Fitzgerald J, Burgess M, Snowball L. Trends in property and illicit drug crime around the medically supervised injecting centre in Kings Cross: an update. NSW Bureau of Crime Statistics and Research. 2010 Oct 8; accessed on November 13, 2024: apo-nid22857.pdf
14. 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 Mar 1;220:108521. doi: 10.1016/j.drugalcdep.2021.108521. Epub 2021 Jan 11. PMID: 33485010.
15. Chalfin A, Del Pozo B, Mitre-Becerril D. Overdose Prevention Centers, Crime, and Disorder in New York City. JAMA Netw Open. 2023 Nov 1;6(11):e2342228. doi: 10.1001/jamanetworkopen.2023.42228. PMID: 37955901; PMCID: PMC10644216.
16. 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 Jul 10;89(2-3):214-22. doi: 10.1016/j.drugalcdep.2006.12.035. Epub 2007 Feb 5. PMID: 17280802 PMCID: PMC2562866.
17. Tookes HE, Kral AH, Wenger LD, Cardenas GA, Martinez AN, Sherman RL, Pereyra M, Forrest DW, LaLota M, Metsch LR. A comparison of syringe disposal practices among injection drug users in a city with versus a city without needle and syringe programs. Drug Alcohol Depend. 2012 Jun 1;123(1-3):255-9. doi: 10.1016/j.drugalcdep.2011.12.001. Epub 2011 Dec 29. PMID: 22209091; PMCID: PMC3358593.
18. Quinn B, Chu D, Wenger L, Bluthenthal RN, Kral AH. Syringe disposal among people who inject drugs in Los Angeles: the role of sterile syringe source. Int J Drug Policy. 2014 Sep;25(5):905-10. doi: 10.1016/j.drugpo.2014.05.008. Epub 2014 May 21. PMID: 24930425.
19. Gonsalves GS, Crawford FW. Dynamics of the HIV outbreak and response in Scott County, IN, USA, 2011-15: a modelling study. Lancet HIV. 2018 Oct;5(10):e569-e577. doi: 10.1016/S2352-3018(18)30176-0. Epub 2018 Sep 13. PMID: 30220531; PMCID: PMC6192548.
20. Nguyen TQ, Weir BW, Des Jarlais DC, Pinkerton SD, Holtgrave DR. Syringe exchange in the United States: a national level economic evaluation of hypothetical increases in investment. AIDS Behav. 2014 Nov;18(11):2144-55. doi: 10.1007/s10461-014-0789-9. PMID: 24824043; PMCID: PMC4211599.
21. Allen ST, Grieb SM, Glick JL, White RH, Puryear T, Smith KC, Weir BW, Sherman SG. Applications of research evidence during processes to acquire approvals for syringe services program implementation in rural counties in Kentucky. Ann Med. 2022 Dec;54(1):404-412. doi: 10.1080/07853890.2022.2028001. PMID: 35098828; PMCID: PMC8812801.