In early 2015, Scott County, Indiana, was in the midst of one of the worst drug-related HIV outbreaks in US history. As HIV surged in southeastern Indiana, the county’s response was inhibited due to Indiana’s prohibition of syringe services programs (SSPs). State lawmakers eventually reversed course and legalized a local SSP. The results were remarkable. The county’s drug-related overdose deaths plunged 20 percent in 2019, and its HIV transmission rate plummeted to just a single case in 2020. Research models further suggest that Indiana may have mitigated—and even prevented—its HIV outbreak had it implemented an evidence-based response that included a syringe services program before the county’s transmission rate skyrocketed.
SSPs are community-based prevention programs that provide a range of social, medical, and mental health services—often including, but not limited to the provision of sterile syringes, screening and treatment for infectious diseases and substance use disorders, and naloxone distribution—for individuals who inject drugs. Notwithstanding their positive public health impacts, SSPs have long-faced significant political opposition. SSPs have been under attack this year even in locales with concerning blood-borne infectious disease rates. In April 2021, West Virginia—a state that struggles with high HIV and hepatitis C (HCV) transmission—enacted a law that severely restricts the operation of SSPs. Driven by gentrification and economic development concerns, Atlantic City, New Jersey, followed suit in July by enacting an ordinance that outlaws SSPs within municipal limits and, therefore, will shut down its sole SSP. Perhaps most astonishingly, Scott County recently voted to end its successful program on the grounds of stigma-driven suppositions, including the unfounded contention that SSPs increase the presence of discarded needles and encourage risky drug use. As a Philadelphia Inquirer editorial critical of the Atlantic City ordinance recently asked, “What happened to ‘trust science’?”
These moves to shutter or undermine SSPs are poorly timed and promise to have devastating impacts on underserved communities. According to provisional Centers for Disease Control and Prevention (CDC) data, the United States witnessed more than 93,000 fatal drug overdoses in 2020—the largest number of such deaths the country has ever recorded in a 12-month period. Injection drug use and its associated diseases and injuries, such as HIV, HCV, abscesses, cellulitis, and endocarditis, are also on the rise.
While the overdose crisis is frequently framed as a predominantly White suburban and rural issue, drug fatalities involving Black Americans have soared. In Philadelphia, White overdose deaths decreased by 10 percent while Black overdose deaths increased by 29 percent from 2019 to 2020. In Missouri, Black men are now four times more likely to succumb to an overdose than a White person, and overdose deaths rose among Black men by nearly 70 percent in 2020 in Massachusetts. In fact, Black Americans have suffered the highest increase in the national overdose death rate involving synthetic opioids, such as fentanyl, over the past decade.
The elimination of SSPs is certain to exacerbate a horrific public health crisis and deepen health disparities. Even those once opposed to SSPs agree. Scott County’s decision to close its SSP was over the objections of “[a] parade of law enforcement officials, health workers, and community members.” In a powerful demonstration of bipartisan support, former Trump administration Surgeon General Jerome M. Adams attended a public meeting to plead with Scott County officials to keep the SSP open.
SSPs Are Cost-Effective And Promote Public Health
SSPs improve health outcomes and save lives. When combined with other harm reduction interventions, SSPs are associated with a 50 percent reduction in the spread of HIV and HCV. SSPs decrease unsafe needle sharing by 20–40 percent while providing a critical point of entry into the treatment system, testing, and counseling. In fact, research demonstrates that SSP clients are five times more likely to voluntarily participate in evidenced-based drug treatment and three times more likely to stop using drugs than individuals who lack access to such services. SSPs also keep first responders and the public safe by promoting the safe disposal of used needles.
SSPs are also a wise investment. A recent study estimated that SSPs would yield an annual savings of $234.4 million and $62.4 million, in the cities of Philadelphia and Baltimore, respectively. As summarized by the CDC, “[n]early 30 years of research has shown that comprehensive SSPs are safe, effective, and cost-saving, do not increase illegal drug use or crime, and play an important role in reducing the transmission of viral hepatitis, HIV and other infections.”
Federal Law And Policy
Federal law expressly prohibited the use of federal funds to support SSPs for the better part of three decades. Although Congress temporarily lifted that funding ban in 2010, it was reinstated just two years later. In 2018, Congress enacted a statute that permits the use of Department of Health and Human Services funds to support SSPs under certain circumstances but outlawed the use of those funds to purchase sterile needles “for the purposes of illegal use of drugs by injection.”
However, the federal government has changed course once again. On March 6, 2021, President Joe Biden signed into law the American Rescue Act, which provides nearly $4 billion for substance use disorder and mental health treatment, including the unprecedented allocation of $30 million “to support community-based overdose prevention programs, syringe services programs, and other harm reduction services.” Such funding is exempt from the long-standing federal restriction on the use of federal dollars to purchase syringes. The administration’s dedication to preserving and expanding SSPs is consistent with its first-year drug priorities, including expanding access to evidence-based treatment, enhancing evidence-based harm reduction efforts, and advancing racial equity in drug policy.
Potential Legal Challenges To SSP Prohibitions
Despite the recent aid from the American Rescue Act, several state and local governments will not be swayed. In addition to rejecting evidence-based approaches to the overdose crisis and potentially forfeiting federal financial support, the state and local governments that have enacted or are threatening to enact laws and regulations that eliminate or restrict the operation of SSPs face a significant array of potential legal challenges, ranging from Americans with Disabilities Act (ADA) and Rehabilitation Act claims to state and federal Equal Protection and Due Process Clause violations.
The federal courts first recognized that local laws targeting substance use treatment programs can run afoul of the ADA and Rehabilitation Act more than 20 years ago. This is because those statutes recognize substance use disorder as a disability and not as a moral failing or a crime. Relying on that premise, at least three federal courts of appeal, including the US Court of Appeals for the Third Circuit, which hears appeals from New Jersey federal district court cases, have struck down laws that prohibit the operation of opioid treatment programs that dispense methadone in particular locales as facially discriminatory.
State and local governments face important choices: Ignore the evidence, shutter SSPs, and risk considerable public health harms and budget-sapping lawsuits or follow the science, support and expand SSPs, and save both lives and taxpayer dollars. It is poignant that the American Rescue Act was enacted nearly 50 years to the month when President Richard Nixon launched the “War on Drugs,” explicitly aimed at the Black community and the anti-Vietnam War movement. Vital Strategies Director of Drug Use Initiatives Daliah Heller perhaps said it best: “We expect that [the American Rescue Act] funding will address the disproportionate burden of overdose on Black, Indigenous and communities of color. And we dare to hope that this first significant federal investment in harm reduction is a watershed moment—a sign that our country is ready to reject the punitive, carceral approach to drug use that has led to tens of thousands of deaths each year, and adopt proven harm reduction strategies grounded in health and dignity.”
