Tribally-affiliated syringe services programs in the United States: a brief report

Abstract

Background

Few studies have examined the implementation of syringe services programs (SSPs) that serve Indigenous people who inject drugs in the United States (US). There are 574 Federally-recognized tribes in the US, each characterized by unique traditions, values, and customs. Given the diversity of tribes, better understanding SSP implementation in Native contexts first requires examining the degree to which tribes in the US implemented these programs.

Objective

This research describes the number of SSPs that are affiliated with Federally-recognized tribes in the US.

Methods

From July to September 2022, we conducted an online search of all 574 Federally-recognized tribes to determine how many had affiliated SSPs. We downloaded a list of Federally-recognized tribes from the Bureau of Indian Affairs (BIA) and conducted Boolean searches on Google for the name of each tribe and SSPs. Our searches included several synonyms for SSPs, including “needle exchange,” “syringe exchange,” and “harm reduction.” In instances where “harm reduction programs” were identified, we reviewed website contents to determine if the program was inclusive of a SSP. We considered SSPs to be affiliated with Federally-recognized tribe(s) if they were housed in a tribal health clinic or tribal organization, or via an explicit partnership with a Federally-recognized tribe.

Results

We identified 21 SSPs that were affiliated with Federally-recognized tribes. The majority (85.7%) of SSPs were affiliated with a single tribe. Eight of the SSPs also offered medications for opioid use disorder (MOUD) on-site (e.g., the SSPs operated out of health clinics that offered MOUD).

Conclusions

The results of this study demonstrate that there are at least 21 SSPs that are affiliated with Federally-recognized tribes in the US, with some serving multiple tribes. This research makes a noteworthy contribution to the public health literature given that no systematic exploration of the number of SSPs affiliated with tribes has been conducted. The scale of substance use inequities among Indigenous people underscores the critical importance of communities implementing and managing their own comprehensive harm reduction programs.

Background

Recent epidemiological data document alarming trends in overdose mortality and outbreaks of preventable infectious diseases (e.g., HIV, viral hepatitis) associated with substance use [1–6]. These data underscore the urgency of communities implementing evidence-based prevention and harm reduction initiatives. Although every community in the United States (US) has been affected by the addiction and overdose crisis, American Indian/Alaska Natives (AI/AN) have experienced disproportionate harms [7–11]. In recent years, overdose mortality has surged among AI/AN people [12]. Moreover, AI/AN people experienced the steepest percentage increase in overdose fatality rates from 2021 to 2022 of all demographic groups [12].

Substance use-use related morbidity has also increased as injection drug use (IDU) has become more prevalent [13]. Since 2004, data from the Centers for Disease Control and Prevention show that AI/AN communities have faced the highest rates of acute hepatitis C infection [14]. From 2018 to 2022, HIV diagnoses linked to IDU increased by 71% among AI/AN people in the US [15]. These IDU-associated inequities are driven in part by inadequate access to sterile injection equipment, resulting in high-risk injection practices (e.g., syringe sharing). According to National HIV Behavioral Surveillance data, approximately 30% of AI/AN people who inject drugs (PWID) without HIV reported having recently engaged in receptive syringe sharing [16]. Similarly, a recent study among a sample of reservation-based Indigenous PWID found that 65% reported having reused syringes [17].

There are many drivers of health inequities among Indigenous peoples, including historical traumas, stigmatization, forced cultural assimilation, systemic racism, and colonization [18–21]. Nevertheless, cultural and communal practices have been shown to carry protective effects against substance use harms and negative effects associated with discrimination [22–24]. Despite the many adversities and human rights violations Indigenous people have faced since the colonization of North America, they have consistently demonstrated resilience and perseverance. Given the central role that Indigenous culture plays in promoting health and healing, it is essential that community-level interventions be designed to reflect and honor cultural foundations. Furthermore, efforts to reduce substance use harms among Indigenous peoples should be supported through partnerships with local, state, Federal, and Tribal governments that prioritize the integration of evidence-based strategies with community values and culture. However, public health infrastructure is often inadequate in Native communities due to insufficient funding and settler-colonial governments failing to honor treaty and human rights obligations [25, 26].

Syringe services programs (SSPs) are an evidence-based strategy rooted in harm reduction and aim to meet people “where they are at” without requiring substance use cessation [27–34]. These programs provide people who use drugs with low-threshold access to a variety of risk-reduction supplies, including sterile injection equipment and naloxone [28, 31, 32, 34–36]. They may offer referrals for drug treatment and housing services [31]. SSPs were first implemented in the US in the 1980s in response to the AIDS crisis [34]. In 2022, there were more than 600 operational SSPs in the US [37]. Most urban counties had at least one SSP while only 6.7% of rural counties had operational programs [37]. No parallel lines of study have examined the degree to which American Indian tribes have implemented SSPs.

Extensive public health literature documents the public health benefits of SSPs [31]. For example, SSP implementation has been associated with lower odds of syringe sharing and reductions in IDU-associated HIV diagnoses, resulting in significant cost savings via averted treatment costs and improved quality of life [38–41]. PWID who access SSP services are five times more likely to enter substance use treatment and approximately three times more likely to stop using substances [42]. SSPs also support the safe disposal of injection equipment [31, 32]. Notably, research has shown that SSPs are not linked to increases in drug use, criminal activity, or public syringe litter [31, 32].

While existing SSP-related literature is informative, very little of this work has focused on SSP implementation in Indigenous communities in the US. For example, studies have documented that Indigenous PWID report difficulties accessing SSP services [43, 44] Among the international literature, only limited study has focused on SSPs that serve Indigenous PWID, and these data are not directly translatable to the US given complex relationships between Indigenous peoples and local, state, and Federal entities [45–50]. Further, there are 574 Federally-recognized tribes in the US, each characterized by unique traditions, values, and customs. Given the diversity of tribes, better understanding SSP implementation in Native contexts first requires examining the degree to which tribes implemented these programs. Unfortunately, no systematic study has been conducted to identify tribally-affiliated SSPs. As a first step in this line of inquiry, this research explores the number of SSPs that are affiliated with Federally-recognized tribes in the US.

Methods

From July to September 2022, we conducted an online search of all 574 Federally-recognized tribes to determine how many had affiliated SSPs. We downloaded a list of Federally-recognized tribes from the Bureau of Indian Affairs (BIA) [51]. We then conducted Boolean searches on Google for the name of each tribe and SSPs [52]. In conducting these searches, we used both formal and informal names of tribes (when applicable) to ensure robustness. Our searches also included several synonyms for SSPs, including “needle exchange,” “syringe exchange,” and “harm reduction.” In instances where “harm reduction programs” were identified, we reviewed website contents to determine if the program was inclusive of a SSP. We considered SSPs to be affiliated with Federally-recognized tribe(s) if they were housed in a tribal health clinic or tribal organization, or via an explicit partnership with a Federally-recognized tribe.

No SSPs or tribes were contacted as part of this research. Given that this research only used publicly accessible data, it did not constitute human subjects research and Institutional Review Board approval was not required. Nevertheless, we undertook steps to ensure our work was respectful of Tribal Nations. First, the co-authors of this manuscript include several individuals (CA, PK, SD, and FJ) who operate SSPs that serve Indigenous peoples. Our co-authors also include several individuals who have experiences pertaining to the provision of harm reduction services in Native contexts; as a result, they are acutely aware of the potential ramifications of unwanted attention to their work (e.g., stigmatization of substance use). Further, we did not name any tribe or affiliated SSP as naming requires careful consideration of potential downstream effects (e.g., unwanted attention to tribes and/or affiliated SSPs) and the explicit permission of tribes.

Results

We identified 21 SSPs that were affiliated with Federally-recognized tribes. The majority (85.7%) of SSPs were affiliated with a single tribe. Among SSPs affiliated with multiple tribes, one was based in a clinic that served persons from four Federally-recognized tribes and two programs operated out of tribal health consortia (i.e., organizations that provided healthcare services to persons from many different tribes). Eight of the SSPs also offered medications for opioid use disorder (MOUD) on-site (e.g., the SSPs operated out of health clinics that offered comprehensive healthcare services).

Discussion

The results of this study demonstrate that there are at least 21 SSPs that are affiliated with Federally-recognized tribes, with some serving multiple tribes. This research makes a noteworthy contribution to the public health literature given that no systematic exploration of the number of SSPs affiliated with tribes has been conducted. Further, the scale of substance use inequities among Indigenous people underscores the critical importance of communities implementing and managing their own comprehensive harm reduction programs that are anchored in local culture. Indeed, there is a movement toward Indigenizing harm reduction initiatives such that they not only meet people where they are at but also reconnect people to culture and work toward undoing the harms of colonization [53].

The low volume of tribally-affiliated SSPs may reflect the need for Indigenous people to combine SSPs, which most often reflect harm reduction and allopathic “western” approaches to health and well-being, with traditional Indigenous approaches for healing. Harm reduction aims to minimize adverse health, social, and legal consequences of substance use and does not require abstinence [29, 30]. Allopathic “western” approaches are generally individualistic and biologic in nature and encompass pharmacologic treatments for health conditions [54–56]. In contrast, traditional Indigenous approaches are holistic and seek to meet the emotional, physical, spiritual, and mental health needs of people who seek care. Traditional Indigenous approaches are heterogeneously defined across Indigenous communities, but may include healing ceremonies, use of medicinal plants, song and dance, smudging and purification, storytelling, talking circles, and engaging with Elders [23, 54–61]. Notably, Indigenous PWID may have goals that transcend all three approaches to health and well-being. For example, they may continue to use substances, potentially calling for harm reduction services, while also accessing MOUD (i.e., allopathic “western” services) and wanting to participate in traditional Indigenous ceremonies to meet their spiritual and mental health needs. As a result, the implementation of SSPs centered on holistically addressing the needs of Indigenous PWID may result in enhanced access to life-sustaining and health-promoting resources.

In some instances, tribally-affiliated SSPs have adopted program models that differ from other tribal programs. For example, in efforts to reduce barriers to service, some tribal SSPs do not require proof of tribal enrollment and serve a mixed-status population to ensure that their programs effectively reach PWID in the broader community [64]. Tribal SSPs may also emphasize outreach to incarcerated community members, as AI/AN are over-incarcerated in many states and incarceration is a major risk factor for drug overdose and other harms [62].

Integrating multiple approaches to health and wellbeing at SSPs that serve Indigenous people may carry unique challenges. For example, traditional Indigenous and allopathic “western” approaches reflect different belief systems [55, 63]. Further, allopathic “western” practitioners can be skeptical of traditional Indigenous approaches and discount their value [63]. Harm reduction also has tensions with traditional Indigenous and allopathic “western” approaches [64, 65]. For instance, some feel that harm reduction is in conflict with the goals of allopathic “western” approaches to drug dependence (e.g., MOUD), since abstinence is not necessarily the goal of harm reduction [65–67]. At the same time, the integration of harm reduction and traditional Indigenous approaches to healing can be challenging as some teachings emphasize abstaining from psychotropic substances as a prerequisite for engaging in certain cultural and spiritual practices associated with healing [47, 68].

Although integrating multiple approaches to health can be challenging, there are numerous SSPs that successfully did so. For example, the SSP at the Indigenous Peoples Task Force (located in Minneapolis, Minnesota) integrates harm reduction (e.g., access to sterile injection equipment and naloxone, safer use counseling and education), allopathic “western” (e.g., MOUD referrals, HIV/STI testing and prevention services), and traditional Indigenous (e.g., ceremonial fires, alters with asemaa, cedar, and sage for client use) approaches [69]. The Indigenous Peoples Task Force also provides healthy meals that feature foods from traditional diets before colonization (e.g., wild rice, corn, berries, and buffalo or fish). Additionally, the Indigenous Peoples Task Force provides SSP clients with opportunities to visit with Elders. Future work should be conducted to learn from SSPs that center the voices of Indigenous people and holistically meet the needs of Native PWID.

Research has shown that SSPs tailored to Native PWID are able to provide public health services in ways that address unmet needs for multiple approaches to health and wellbeing. For example, the Gwayakobimaadiziwin Bad River Harm Reduction (a community center that operates a SSP on the Bad River Band of Lake Superior Chippewa reservation) conducted a qualitative exploration of their SSP operations and community needs among Indigenous PWID in 2019 [68]. Among their findings, Indigenous PWID reported being confronted with multiple barriers to accessing healthcare. Participants reported that healthcare providers did not understand the difficulties they experienced attending scheduled appointments due to housing instability and limited access to transportation and phone services. Participants also reported that they felt distanced from opportunities for traditional healing due to requirements for abstinence. These findings informed how the SSP subsequently adapted operations to align with cultural practices and worked to improve the provision of traditional Indigenous, allopathic “western,” and harm reduction services to Indigenous PWID [68]. Currently, the Gwayakobimaadiziwin Bad River Harm Reduction has an open-door policy for PWID, providing a comfortable space to access to harm reduction supplies (e.g., sterile injection equipment, naloxone), personal wellness needs (e.g., shower, laundry service, safe sleeping areas, food, phones, phone cards and bus passes) and support for accessing higher-level heathcare (e.g., peer support, rides to appointments, MOUD and in-patient treatment referrals, HIV/STI prevention and testing services). The program also provides PWID with access to Native medicines and opportunities to participate in Ojibwe healing ceremonies, and all aspects of service delivery are grounded in the seven teachings of the Ojibwe. This program has parallels to other tribally-affiliated SSPs that offer access to traditional medicines, sobriety feasts, referrals to spiritual leaders to conduct ceremonies, and harvests of medicinal herbs.

Although existing public health literature has gaps, there are clear indicators of Indigenous communities wanting enhanced access to SSP services. For example, a 2025 study conducted in a northern Midwest American Indian community found that 56% of people who had recently used drugs were willing to use an SSP if it were available [70]. In that Indigenous community, willingness to use an SSP was associated with recent methamphetamine use, having experienced or witnessed an overdose, having friends or family who use drugs, and younger age [70]. These findings have parallels to a qualitative study conducted among Indigenous PWID in which participants voiced positive attitudes and perceptions about SSP services, but noted that programs were difficult to access [43]. Another study conducted in rural Montana among Indigenous PWID found that 98% expressed interest in utilizing a harm reduction program [17]. Our findings, in conjunction with the literature, provide compelling evidence of the need for communities working to advance the public health of Indigenous PWID via enhanced access to SSPs.

Despite extensive evidence documenting the public health benefits of SSP implementation, domestic policies and funding priorities remain challenges. Broadly speaking, reservation-based public health services are severely underfunded. In part, this reflects a failure of the US government to honor treaties [25, 26]. Further, there are unique policy implications for tribes as they navigate the complex interplay between federal, state, and tribal regulations. Tribal Nations face challenges navigating sovereignty and overlapping legal systems that impact implementation of SSPs. Although federal guidelines permit SSPs, some states may still criminalize syringe possession, restrict access to naloxone, or impose limitations on point-of-contact or CLIA-waived rapid screening for HIV, HCV, or STIs. Public Law 83-280 (PL 280) limits tribal sovereignty by granting certain states criminal jurisdiction over tribal lands which oftentimes undermines tribal authority in enforcement of tribal laws and authority to govern public health initiatives, such as SSPs. These additional legal barriers significantly impact the implementation of SSPs in tribal communities by creating additional limitations and confusion over jurisdiction. Another example, under Public Law 93-638, the Indian Self-Determination and Education Assistance Act, some tribes rely entirely on the Indian Health Service for healthcare, limiting their ability to implement certain harm reduction strategies due to federal policy. Other tribes have assumed more direct control of their healthcare in which they must also comply with relevant state laws, which further shapes service delivery and access to care. These deficiencies of the US government paired with the lasting effects of colonization and historic traumas act independently and synergistically to drive health outcomes among Indigenous people. Reversing the inertia of the status quo requires systems level changes throughout the US and broader support for holistic service delivery to Indigenous PWID, including via SSPs. The influx of opioid settlement funding for states and counties provides a unique opportunity to right past wrongs through funding partnerships to eliminate drug-related disparities among AI/AN populations.

This research has several limitations that warrant consideration. First, our search strategy focused on identifying SSPs that were affiliated with Federally-recognized tribes. As a result, our findings likely underestimate the true number of SSPs that serve Indigenous people, particularly given that several tribes are not recognized by the US Federal Government. Additionally, our search strategy may not have accounted for Indigenous language terms related to SSPs, harm reduction, or specific traditional healing practices. Another limitation is that our search strategy did not lend itself to the identification of SSPs that served Indigenous people, but were not affiliated with a specific tribe or tribes; for instance, the SSP at the Indigenous Peoples Task Force primarily serves Indigenous people, but is not affiliated with a specific tribe. Another limitation is that tribes may not publicize their SSPs due to concerns about privacy or attracting unwanted attention (e.g., “not in my backyard” opposition). Further, they may have limited capacity to serve people who are not affiliated with the tribe. Another limitation is that we were unable to ascertain the volume of PWID the tribally-affiliated SSPs served and their associated geographic catchment areas. Future work exploring the reach of these programs may enhance our understanding of whether tribally-affiliated SSPs are accessed at greater rates than programs operating in predominantly “western” contexts. Finally, we did not contact tribes to solicit information about whether they had operational SSPs. While doing so might have helped identify additional SSPs without accessible information on the internet, it would have potentially conflicted with one or multiple tribes’ or tribal governments’ expectations for appropriate outreach. Federal and Constitutional protections for this sort of inquiry may be accepted by US tribes generally, but each tribe maintains systems to exercise self-governance and self-determination, which may include unique protections and protocols for engagement with outside researchers. Despite these limitations, this research enhances our understanding of tribally-affiliated SSPs in the US.

In conclusion, this research reports the number of tribally-affiliated SSPs in the US identified through a comprehensive search of publicly available sources. We found evidence of 21 SSPs affiliated with Federally-recognized tribes. Given the scale of substance use inequities, additional work is needed to better understand how to support tribal communities implement SSPs that are tailored to local contexts and priorities. Additional funding should be allocated by local, state, and Federal governments to support tribally-led initiatives to implement tailored harm reduction initiatives, including SSPs.

Abbreviations

AI/AN

American Indian/Alaska native

SSP

Syringe services programs

PWID

People who inject Drugs

HIV

Human immunodeficiency virus

MOUD

Medications for opioid use disorder

CDC

Centers for disease control and prevention

IDU

Injection drug use

Author contributions

STA, EK, MW were involved in the conception of the study. EK led the online searches. All authors were involved in the interpretation of the findings. All authors were involved in drafting the manuscript. All authors reviewed and approved the final manuscript and agree to be held accountable for all aspects of the work.

Funding

STA and MW are supported by the Bloomberg American Health Initiative at Johns Hopkins University. Research reported in this publication was supported by the National Institute On Drug Abuse of the National Institutes of Health under Award Number P50DA058619. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

This research did not constitute human subjects research and only utilized publicly accessible data.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.