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. 2020 Jul 31;135(1 Suppl):128S–137S. doi: 10.1177/0033354920921817

State Laws Governing Syringe Services Programs and Participant Syringe Possession, 2014-2019

Marcelo H Fernández-Viña 1, Nadya E Prood 1, Adam Herpolsheimer 1, Joshua Waimberg 1, Scott Burris 1,✉
Editors: Deron C Burton, Hazel D Dean, Jonathan H Mermin
PMCID: PMC7407055  PMID: 32735195

Abstract

Objective

Law is an important factor in the diffusion of syringe services programs (SSPs). This study measures the current status of, and 5-year change in, state laws governing SSP operations and possession of syringes by participants.

Methods

Legal researchers developed a cross-sectional data set measuring key features of state laws and regulations governing the possession and distribution of syringes across the 50 US states and the District of Columbia in effect on August 1, 2019. We compared these data with previously collected data on laws as of August 1, 2014.

Results

Thirty-nine states (including the District of Columbia) had laws in effect on August 1, 2019, that removed legal impediments to, explicitly authorized, and/or regulated SSPs. Thirty-three states had 1 or more laws consistent with legal possession of syringes by SSP participants under at least some circumstances. Changes from 2014 to 2019 included an increase of 14 states explicitly authorizing SSPs by law and an increase of 12 states with at least 1 provision reducing legal barriers to SSPs. Since 2014, the number of states explicitly authorizing SSPs nearly doubled, and the new states included many rural, southern, or midwestern states that had been identified as having poor access to SSPs, as well as states at high risk for HIV and hepatitis C virus outbreaks. Substantial legal barriers to SSP operation and participant syringe possession remained in >20% of US states.

Conclusion

Legal barriers to effective operation of SSPs have declined but continue to hinder the prevention and reduction of drug-related harm.

Keywords: syringe services programs, legal epidemiology, legal mapping, policy surveillance

Prevention of HIV and viral hepatitis attributable to injection drug use is a public health priority.1 The long-term decline in rates of new HIV infections among persons who inject drugs (PWID) has stalled, as rates of infections have been rising in “hotspots” where high levels of nonmedical prescription opioid use coincide with economic vulnerability, changes in drug markets, and lack of access to medication for treating opioid use disorder.2-4 The number of new hepatitis B virus (HBV) cases has been stable. But the number of new hepatitis C virus (HCV) cases, largely attributable to injection drug use, increased 3.5-fold, from 850 in 2010 to 2967 in 2016.5 Syringe services programs (SSPs), which provide PWID with sterile injection equipment and syringe disposal services, can directly provide or link PWID to services including vaccination, substance use disorder treatment, infectious disease screening, and overdose prevention. SSPs are safe, effective, and cost effective in reducing HIV and HCV transmission.6,7 Studies indicate that SSPs do not increase crime rates or stimulate increased drug use, and they do not encourage new or young drug users.8-10 SSPs can significantly decrease the number of improperly discarded syringes.11 SSPs can also play an important role in overdose prevention and the wider use of preexposure prophylaxis (PrEP) by PWID.12,13

The Centers for Disease Control and Prevention (CDC) recommends SSPs as a component of comprehensive HIV and viral hepatitis prevention programs.14 Guidance from the National HIV/AIDS Strategy has consistently relied on SSPs as a proven intervention for preventing new HIV infections.14-16 Despite these evidence-informed recommendations, SSP coverage in the United States is incomplete and uneven. As of 2018, 317 SSPs were operating in 39 states and the District of Columbia. Five states accounted for 46% of those SSPs: California (n = 43), New Mexico (n = 32), North Carolina (n = 24), New York (n = 23), and Kentucky (n = 23).17 As nonmedical prescription opioid users transition from pills to injection as a more efficient mode of administration, many urban and rural areas at risk of injection-driven disease outbreaks remain without SSPs,2,18,19 and outbreaks continue to occur in unserved communities.20-22

The law has long been recognized as a factor in the availability of SSPs, although the relationship is complex.23-28 SSPs are not explicitly forbidden in US federal and state law; rather, they have been thought by some persons to be illegal by virtue of laws governing the distribution and possession of drug paraphernalia or syringes that were enacted before SSPs were devised.29 Paraphernalia laws, adopted by most states in the 1970s, were designed to shut down businesses that knowingly catered to users of illegal drugs. The laws typically prohibited the possession and distribution of any object whatsoever with the knowledge that it would be used for the preparation, packaging, or consumption of illegal drugs, and they included syringes in a list of items that could be drug paraphernalia. Although the plain language of these laws could be interpreted to cover SSPs, the fact that they were not intended to limit SSPs or regulate legitimate health services created considerable room for doubt as to their applicability.23 SSPs have operated despite paraphernalia laws in many places, whereas the few court decisions considering the legality of SSPs under drug paraphernalia laws have come to conflicting conclusions.30,31 Syringe prescription laws and miscellaneous pharmacy regulations related to pharmacy purchases have also facilitated syringe access,32-34 but they are excluded from this study apart from a few state laws that regulate syringe distribution and possession in lieu of paraphernalia laws.

Law has also been found to be a barrier to syringe access via the activities of police. Many studies found instances in which crackdowns on drug possession, enforcement of paraphernalia laws, or simply police encounters in the vicinity of SSPs led to reduced access and use.35-37 In some instances, persons who had obtained syringes legally under laws that authorized SSPs were arrested for possession of the residue of illegal drugs in the syringes they were returning for exchange and proper disposal.38,39

An expeditious mechanism to eliminate legal doubt about SSPs and to reduce the frequency and effect of law enforcement behavior that interferes with the operation or use of SSPs is for states to amend their relevant laws. During the course of the HIV epidemic, the states that had prescription requirements largely eliminated or modified them to reduce barriers to SSPs; states amended paraphernalia laws to exclude syringes generally or for purposes related to disease prevention; states affirmatively authorized SSPs and the possession of syringes obtained at SSPs. Studies have shown a steady increase in the number of states that have taken 1 or more such actions.23,24,40 Although removing legal barriers has an obvious and straightforward relationship with the provision of at least some SSP services, empirical research on the relative health or health services effect of various modes of legal ordering of SSPs is limited.28,41

The objective of this study was to map current state law governing SSPs and to identify changes from 2014 to 2019 in provisions that may impair effective operation or use of SSPs. Given the lack of research evaluating the effects of various legal approaches, our study also advances the field by creating an open-source data set for use by researchers.42

Methods

Using scientific legal mapping procedures specified in Anderson et al,43 the research team developed a cross-sectional data set measuring key features of state laws and regulations governing the possession and distribution of syringes across the 50 US states and the District of Columbia in effect on August 1, 2019. In this article, the District of Columbia is included when referring to “states.” Initial scope and inclusion criteria for laws were determined by review of existing data sets of state syringe-related law, previous legal studies, and commentary. The team used Westlaw statute and regulation databases for research, with the following search terms: “(syringe or needle w/20 exchange or distrib!),” “(drug! w/25 residue),” and “(“syringe” or “needle” or “drug paraphernalia” or “hypodermic device” and (“deliver!” or “distribu!”) and not “bovine”) or (("controlled substance" or "drug paraphernalia" or drug!) w/25 possess! w/25 (prohibit!)).” The study included paraphernalia laws and any law or regulation that explicitly authorized or prohibited distribution or possession of syringes. It excluded laws or regulations regulating pharmacy operations, wholesale distribution of syringes, the display or process of retail sale (eg, laws requiring a purchaser to provide identification for purchase), and prescription requirements. When an included statute or regulation appeared in the term search, the team examined the chapter’s table of contents to review any relevant surrounding laws. The team consulted secondary sources to determine that all laws relevant to the data set were collected in this process.

The team developed an initial set of legal features to be measured (coding questions) based on background research. Two researchers independently conducted the legal research and coding and resolved all research and coding divergences through group discussion, clarification of coding rules, and reference to secondary sources. The team recorded research steps and coding decisions in a research protocol, available with the data at LawAtlas.org.42 (LawAtlas also provides access to every law covered in this study.) The researchers used data on the law as of August 1, 2014, from earlier data sets created in substantially the same manner and published on LawAtlas with detailed protocols.44,45 (The 2014 data did not include comparable measurements of additional services or possession requirements.)

The team gathered information on the number of states with operating SSPs on August 1, 2019, by using 3 secondary websites that track SSP services: amfAR, NASEN, and the Henry J. Kaiser Foundation.17,46,47 The findings from these sources were verified using state government websites that confirmed the operation of SSPs in the state and SSP websites that confirmed the operation of SSPs in the state.

Results

Of the 50 states and the District of Columbia, 39 states had 1 or more laws in effect on August 1, 2019, that were consistent with the legal operation of SSPs and/or explicitly authorized and regulated SSPs. SSPs were operating in 41 states and the District of Columbia as of August 1, 2019, a gain in 2 states from the Kaiser Foundation’s 2018 report17 (Figure). Thirty-two states explicitly authorized SSPs by law. Minnesota was included in this group, although it had no explicit authorizing legislation, because SSPs are maintained by the state health department, apparently under its general legal authority. The number of states affirmatively authorizing SSPs increased by 14 since August 1, 2014. Many of these states also made other legal changes that reduced barriers to SSPs (Table 1).

Figure.

Figure

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US states that have syringe services programs (SSPs) and state-level laws that explicitly authorize or are consistent with the legal operation of SSPs, August 1, 2019.

Table 1.

Laws clarifying legal status for syringe services programs (SSPs) in the 50 US states and the District of Columbia, 2014 and 2019

Legal Condition August 1, 2014 August 1, 2019
Law explicitly authorizes SSPs California, Colorado, Connecticut, Delaware, District of Columbia, Hawaii, Maine, Maryland, Massachusetts, Minnesota,a Nevada, New Jersey, New Mexico, New York, Rhode Island, Utah, Vermont, Washington California, Colorado, Connecticut, Delaware, District of Columbia, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Minnesota,a Montana, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Rhode Island, Tennessee, Utah, Vermont, Virginia, Washington
No state drug paraphernalia law Alaska Alaska
State law does not prohibit free distribution of syringes Arkansas, Massachusetts, Michigan, Vermont, West Virginia Arkansas, Massachusetts, Michigan, Vermont, West Virginia
Paraphernalia definition explicitly excludes objects used for injecting drugs Nevada, Oregon, Wisconsin Nevada, Oregon, Wisconsin
Paraphernalia definition does not refer to objects used for injecting drugs Connecticut, Indiana, Massachusetts, New Hampshire, Rhode Island, South Carolina Connecticut, Indiana, Massachusetts, New Hampshire, Rhode Island, South Carolina
No state law removing barriers or uncertainty as to SSP legality Alabama, Arizona, Florida, Georgia, Idaho, Illinois, Iowa, Kansas, Kentucky, Louisiana, Mississippi, Missouri, Montana, Nebraska, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Dakota, Tennessee, Texas, Virginia, Wyoming Alabama, Arizona, Iowa, Kansas, Mississippi, Missouri, Nebraska, Oklahoma, Pennsylvania, South Dakota, Texas, Wyoming
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aHas not passed a law authorizing SSPs, but the state government maintained SSPs under its general authority.

Seven states that had not affirmatively authorized SSPs as of August 1, 2019, had legal conditions that allow or reduce legal barriers to SSPs in other ways. Alaska did not have a statewide paraphernalia law, and the paraphernalia laws of Arkansas, Michigan, and West Virginia did not prohibit free distribution of paraphernalia. Oregon and Wisconsin explicitly excluded syringes from the definition of drug paraphernalia. South Carolina’s paraphernalia law did not refer to syringes. The total number of states with at least 1 provision reducing legal barriers to SSPs increased by 12 since 2014. Twelve states had enacted no state legislation to remove legal barriers or uncertainty as of August 1, 2019. However, in at least 1 of those 12 states (Pennsylvania), SSPs operate under local legal authorizations in at least 2 cities (Table 1).

Laws that explicitly authorize SSPs may also define rules, conditions, or procedures for program operation. Nine states required local government approval in 2019, an increase of 6 since 2014. Three states required local law enforcement consultation in 2019, which was 1 more than in 2014. Two states required both local government approval and law enforcement consultation. Four states required that SSP participants only receive the same number of syringes that they return (“one-for-one exchange”); 3 states that had this requirement in 2014 had removed it by 2019, and 1 state added this requirement. The laws in Delaware and Florida in 2019 specified that syringes received from an SSP may not be redistributed, which may operate as a prohibition of secondary exchange, in which SSP participants obtain large quantities of needles to distribute to PWID who have not obtained syringes from the SSPs themselves. In 2014, Delaware was the only state that had that provision (Table 2).

Table 2.

Additional legal requirements for operating a syringe services program (SSP) in the 50 US states and the District of Columbia, 2014 and 2019

Legal Requirement August 1, 2014 August 1, 2019
Local government approval Colorado, Massachusetts, New Jersey California, Colorado, Florida, Indiana, Kentucky, Louisiana, Maryland, Massachusetts, New Jersey
Local law enforcement approval California, Colorado California, Colorado, Ohio
One-for-one exchangea Connecticut, Delaware, Hawaii, Maryland, Maine, New Mexico Delaware, Florida, Hawaii, Maine
No redistributionb Delaware Delaware, Florida
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aSSP participants are limited to 1 new syringe for each syringe returned.

bSyringes distributed at an SSP may not legally be redistributed by the recipient.

Laws authorizing SSPs may define additional health or social services that an SSP must offer on-site or via referral (Table 3). In our study, “referral” includes providing information on where to obtain services and direct linkage to care. Georgia (with 7 required services), Virginia (with 4 required services), and Colorado, Delaware, Maine, New Jersey, North Carolina, Ohio, and Tennessee (with 3 required services each) had enacted the largest number of required services to be provided on-site. Georgia was also a leader in explicitly requiring SSPs to provide referrals, with 5 required services. California required referrals for 7 services, and Maryland required referrals for 5 services. Nine states that authorized SSPs explicitly did not require any additional services to be provided on-site, and 10 states did not require any additional services to be provided through referral. The absence of a requirement is not a prohibition of a service or referral.

Table 3.

Services explicitly required to be provided on-site or by referral at syringe services programs (SSPs) explicitly authorized by state or District of Columbia law, 2019

Service On Site (n = 32 States)
No. (%) of States That Explicitly Authorize SSPs		 State(s) Referral (n = 32 States)
No. (%) of States That Explicitly Authorize SSPs		 States(s)
Drug abuse treatment services 6 (18.8) District of Columbia, Georgia, Maine, New Jersey, Tennessee, Virginia 22 (68.8) California, Colorado, Connecticut, Delaware, District of Columbia, Florida, Georgia, Hawaii, Idaho, Indiana, Maine, Maryland, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Rhode Island, Tennessee, Utah
HIV screening 5 (15.6) Colorado, Delaware, Georgia, Ohio, Rhode Island 13 (40.6) California, District of Columbia, Florida, Georgia, Idaho, Maine, Maryland, New Hampshire, New Jersey, New York, North Dakota, Rhode Island, Utah
Hepatitis screening 3 (9.4) Colorado, Georgia, Ohio 11 (34.4) California, Florida, Georgia, Idaho, Maine, Maryland, New Hampshire, New Jersey, North Dakota, Rhode Island, Utah
Tuberculosis screening 1 (3.1) Georgia 2 (6.3) Georgia, New York
Sexually transmitted infections screening 1 (3.1) Georgia 5 (15.6) California, Georgia, Maryland, New York, North Dakota
Housing services 0 None 1 (3.1) California
Educational services 22 (68.8) Colorado, Connecticut, Delaware, District of Columbia, Florida, Georgia, Hawaii, Idaho, Indiana, Maine, Maryland, New Jersey, New Mexico, Nevada, New York, North Carolina, North Dakota, Ohio, Rhode Island, Tennessee, Utah, Virginia 3 (9.4) California, New Jersey, Rhode Island
Naloxone services 3 (9.4) Georgia, North Carolina, Virginia 5 (15.6) Florida, Idaho, Maryland, Tennessee, Utah
Syringe disposal services 13 (40.6) Connecticut, Delaware, Florida, Indiana, Maine, Minnesota, North Carolina, Nevada, New Jersey, New York, North Dakota, Tennessee, Virginia 2 (6.3) California, New York
No mandated services 9 (28.1) California, Illinois, Kentucky, Louisiana, Massachusetts, Montana, New Hampshire, Vermont, Washington 10 (31.3) Illinois, Kentucky, Louisiana, Massachusetts, Minnesota, Montana, Nevada, Vermont, Virginia, Washington
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The health effect of SSPs depends not just on the distribution of sterile syringes but also on their possession and use by PWID. Laws that decriminalize the distribution of syringes do not necessarily authorize possession, which are separate crimes. Thirty-three states had 1 or more laws in effect on August 1, 2019, that were consistent with legal possession of syringes by SSP participants under at least some circumstances (Table 4).

Table 4.

Laws governing possession of syringes by participants of syringe services programs (SSPs) in the 50 US states and the District of Columbia, 2019

Legal Condition States
Law explicitly authorizes SSPs and exempts participants from state’s possession of drug paraphernalia or syringe laws. California, Colorado, Connecticut,a Delaware, District of Columbia, Florida, Hawaii, Illinois,a Massachusetts,a Maine,b Maryland, New Hampshire,b New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Tennessee, Washingtonc
Does not have a paraphernalia law. Alaska
Law does not prohibit simple possession of paraphernalia or syringes. Michigan, New Hampshire, Oregon, Rhode Island, Vermont, West Virginia, Wyoming
Paraphernalia law explicitly excludes objects used for injecting drugs. Nevada, Oregon, Wisconsin
The definition of drug paraphernalia does not refer to objects used for injecting drugs. Connecticut, Indiana, Massachusetts, New Hampshire, Rhode Island, South Carolina
Possession allowed if syringe is unused and in a sealed sterile package. Utah
Paraphernalia law provides immunity for persons who disclose possession of syringes to police officers prior to search. Colorado, Kentucky, North Carolina, Tennessee
No exemptions from paraphernalia law applicable to SSP participants. Alabama, Arkansas,d Arizona, Georgia,d Idaho,d Iowa, Kansas, Louisiana,d Minnesota,d Mississippi, Missouri, Montana,d Nebraska, Oklahoma, Pennsylvania, South Dakota, Texas, Virginiad
Law exempts residue in used syringe from crime of drug possession. Colorado, Kentucky, Maine, Maryland, Nevada, New Hampshire, New Jersey, New York, North Carolina, Tennessee
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aSSP law has been interpreted in case law to authorize possession by participants.38,48,49

bIt is an affirmative defense that the syringes were obtained from an SSP.

cOnly applies to persons aged >18 years.

dState has authorized SSPs or otherwise eliminated or reduced legal barriers to SSPs.

Twenty states that affirmatively authorized SSPs had provisions exempting SSP participants from syringe or paraphernalia possession crimes. This number includes 3 states (Connecticut, Illinois, and Massachusetts) in which the authorization has been read into the law by courts. Eight states do not prohibit simple possession of drug paraphernalia (ie, possession without the intent to sell or distribute). Laws that explicitly exclude syringes from the definition of illegal paraphernalia, present in 3 states, operate to reduce legal questions about consumer possession in the same manner as they do for syringe distribution. Six states did not reference syringes, hypodermic instruments, or objects used for injecting drugs in their paraphernalia laws. Utah had an exception for unused syringes in a sealed sterile package. Four states provided immunity for persons who disclose possession of syringes to police officers before search. Eighteen states, including 7 states that had laws that authorize or reduce legal barriers to SSPs, had no laws that remove or reduce syringe possession–related legal jeopardy for SSP participants. Ten states had explicitly limited arrests or prosecutions based on the possession of illegal drug residue in used syringes.

Discussion

Thirty-two states had explicitly authorized SSPs as of August 1, 2019, and 39 states overall had taken at least 1 action to address legal concerns about SSPs. Since 2014, the number of states explicitly authorizing SSPs nearly doubled, and the new states included many rural, southern, or midwestern states that had been identified as having poor access to SSPs and being at high risk for HIV and HCV outbreaks. Both the trend and the number are encouraging, but neither is sufficient nor consistent with the legal action in other areas of drug user health. It is noteworthy that in the 5-year period beginning May 15, 2012, 45 states and the District of Columbia passed laws authorizing lay administration of naloxone, the standard antidote to opioid overdose.50 Twelve states still have no clear statewide legal basis for SSPs. Legal commentators have long suggested that the most expeditious and unambiguous way to remove legal concerns from the public health work of SSPs is to deregulate syringes entirely, so that no criminal law applies to their possession or distribution.51

Although explicit authorization certainly enables SSPs, it does not in itself provide the funding and coordination necessary to maintain the service and integrate it in a network of care. Provisions authorizing SSPs in some states include requirements that may reduce effectiveness or increase costs. Although community support is highly desirable, if not essential, to the successful long-term operation of SSPs, requiring local government approval as a legal condition for operation can enable opponents to block the opening of an SSP and make it more difficult for an SSP to win the community’s trust through effective operation over time. It has proven to be a harmful barrier in important instances.20,52-55

The requirement of one-for-one exchange, accompanied in 2 states by a prohibition of redistribution, is rare but problematic. At least 1 study reported that SSPs that allowed participants to exchange 1 syringe for more than 1 syringe had a reduction in the reuse of syringes among the PWID population compared with SSPs that used one-for-one exchange.41 Evidence suggests that secondary exchange reaches users who are unwilling or unable to come to an SSP themselves and can be a mechanism to distribute syringes in distant communities that are not served by SSPs.56,57 Research on SSPs, risk behaviors, and HIV/HCV service provision in nonurban areas remains far too limited.58,59

SSPs are a valuable community access point for health information, housing assistance, drug abuse treatment, and infectious disease screening services. Although comprehensive on-site service provision is an ideal model for addressing drug use,60 HIV, HCV, and other conditions, laws requiring these services may create a barrier by requiring SSPs to support a broad and potentially resource-intensive range of services, especially if funding for the mandate is not provided. Allowing SSPs to refer participants to existing off-site services, and allowing them the flexibility to adjust available services to current participant needs, is more practical than one-size-fits-all statutory requirements. No state laws reference providing SSP users with access to or referral to PrEP.

For SSPs to work optimally, participants must have confidence that they will not encounter police interference48 or face penalties based on their acquisition or return of syringes.38 Our study found problematic inconsistencies and limitations in the law of SSP-participant syringe possession. Seven states that have authorized SSPs or otherwise reduced barriers to distribution continue to lack protection for possession. It is not clear whether this omission was intentional or an oversight. In Georgia, for example, the SSP law exempts employees but not participants, whereas in Minnesota the law allowing possession is confined to syringes obtained from pharmacies. Regardless of the cause, failure to clearly protect possession leaves SSP participants at legal risk.

Many states have authorized possession of syringes in a conditional manner, in which the authorization depends on the source of the syringe or even the willingness of the possessor to inform police of possession. Ohio’s provision, for example, applies only to possession within 1000 feet of the SSP and only if the participant can show documentation of active participation. Conditional laws create ambiguity about the legality of any particular syringe; this ambiguity can be protective if users and law enforcement assume that syringes are protected, but it can be harmful if the law creates a real or perceived burden of proof for the possessor. The most straightforward way to create confidence in the legality of syringe possession—and to support pharmacy sales along with SSPs—is to remove any legal prohibition. Protection against prosecution based on drug residue in used syringes is also important, both because it reduces legal barriers to proper disposal and because, realistically, drug users may need to use their own syringe more than once to avoid sharing. In several instances, police responded to a change in the law on syringe possession by stepping up enforcement based on residue.38,39,48,49 Residue legislation exists as a response to increased law enforcement for drug residue and serves as a protection against prosecution for drug residue left in used syringes. Overall, law continues to provide less than clear and sweeping protection for PWID who try to preserve their own health and others’ health by obtaining, using, and properly disposing of sterile syringes.

The publicly available data set created in this study is cross-sectional. Although longitudinal data will be necessary to allow inferences of causation, even research identifying correlations among SSP laws, services, and PWID health outcomes will address important gaps in the literature. Research is needed on important issues, including the effects of various legal strategies, such as removing syringes from paraphernalia laws vs creating exceptions for SSP users, or affirmatively authorizing SSPs vs removing legal barriers; the effect of operational mandates on SSP operations and participants’ health outcomes; the effect of local approval requirements on the availability and accessibility of SSPs; and the effect of various SSP-related legal reforms on law enforcement activity and user injection behavior.

Limitations

This study had several limitations. First, there is no necessary connection between laws that authorize or remove legal barriers to SSPs and the operation of SSPs. Because paraphernalia laws were intentionally drafted broadly, omission of terms such as “injection” or “syringe” is not a guarantee that courts or law enforcement officials will interpret the laws to include syringes. Therefore, this study captures state laws governing SSP operations, but the presence of laws that authorize or remove legal barriers to SSPs does not guarantee operation of SSPs. Second, this study did not address other laws relevant to syringe access, such as pharmacy sale regulations and Medicaid payment rules.28 Pharmacy sale of syringes is another way that syringes can be accessed, and capturing data on pharmacy sale regulations could provide a more complete picture of laws that facilitate syringe access. Medicaid payment rules related to access to HCV treatment for PWID can work in combination with SSP laws to reduce HCV transmission. Therefore, this study focused exclusively on state laws governing SSP operations and possession of syringes by SSP participants, which are part of the broader landscape of syringe access and disease prevention laws. Lastly, this study did not address county or municipal-level laws relevant to syringe access. County and municipal-level laws have allowed SSPs to operate in states where no state legislation exists to remove legal barriers or uncertainty related to the operation of SSPs. Therefore, capturing county and municipal-level laws relevant to SSP operation would provide a more comprehensive view of laws that authorize or remove legal barriers to SSPs and the operation of SSPs.

Conclusion

PWID are at serious risk for HIV and viral hepatitis, and lack of access to sterile syringes for each injection increases their risk of contracting these diseases. Persons in areas not served by SSPs have preventable risk, as demonstrated by repeated outbreaks. SSPs have consistently been recommended by the federal government and public health experts as an effective means of reducing HIV and HCV transmission. Nonetheless, adoption of the intervention is far less than complete in the United States, and almost no research directly examines the effect of various legal strategies on SSP operation or impact. Nearly 40 years after the epidemic of HIV among PWID was first detected, and despite decades of accumulating evidence of the safety and effectiveness of SSPs, the absence of legal bases to allow for the operation of SSPs continues to be a major barrier to accessing SSPs and related harm-reduction services. Although our study found a general trend toward expansion of legal bases for SSPs across jurisdictions, 12 states still provide no legal basis for SSPs to operate, and the legality of syringe possession remains ambiguous in many places.

Footnotes

Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: Research for this article was supported by funding from Trust for America’s Health and the Robert Wood Johnson Foundation. The views expressed in this article do not necessarily reflect the views of either funding organization.

ORCID iD

Scott Burris https://orcid.org/0000-0002-6013-5842

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