Centers for Disease Control and Prevention: Summary of Information on The Safety and Effectiveness of Syringe Services Programs (SSPs)
Background
The nation is currently experiencing an opioid crisis involving the misuse of prescription opioid pain relievers as well as heroin and fentanyl.1,2 The increase in substance use has resulted in concomitant increases in injection drug use across the country.3 This has caused not only large increases in overdose deaths,4 but also tens of thousands of viral hepatitis infections annually5 and is threatening recent progress made in HIV prevention.6 The most effective way for individuals who inject drugs to avoid the negative consequences of injection drug use is to stop injecting.7,8 However, many people are unable or unwilling to do so, or they have little or no access to effective treatment. Approximately 775,000 Americans report having injected a drug in the past year.9 In 2017, 14% of high school students reported using opioids without a prescription and 1.5% reported having ever injected drugs.10
Syringe services programs (SSPs) are proven and effective community-based prevention programs that can provide a range of services, including access to and disposal of sterile syringes and injection equipment, vaccination, testing, and linkage to infectious disease care and substance use treatment. 8, 11 SSPs reach people who inject drugs, an often hidden and marginalized population. Nearly 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.11,12Research shows that new users of SSPs are five times more likely to enter drug treatment and about three times more likely to stop using drugs than those who don’t use the programs.13 SSPs that provide naloxone also help decrease opioid overdose deaths. SSPs protect the public and first responders by facilitating the safe disposal of used needles and syringes.
Appropriations language from Congress in fiscal years 2016-2018 permits use of funds from the Department of Health and Human Services (HHS), under certain circumstances, to support SSPs with the exception that funds may not be used to purchase needles or syringes.14 State, local, tribal, or territorial health departments must first consult with CDC and provide evidence that their jurisdiction is experiencing or at risk for significant increases in hepatitis infections or an HIV outbreak due to injection drug use.15 CDC has developed guidance and consults with state, local, or tribal and territorial health departments on determining if they have adequately demonstrated need according to federal law. Decisions about use of SSPs to prevent disease transmission and support the health and engagement of people who inject drugs are made at the state and local level.
Prevention of Infectious Diseases
Viral hepatitis, HIV, and other blood-borne pathogens can spread through injection drug use if people use needles, syringes, or other injection materials that were previously used by someone who had one of these infections. Injecting drugs can also lead to other serious health problems, such as skin infections, abscesses and endocarditis. The best way to reduce the risk of acquiring and transmitting disease through injection drug use is to stop injecting drugs. For people who do not stop injecting drugs, using sterile injection equipment for each injection can reduce the risk of infection and prevent outbreaks.
During the last decade, the United States has seen an increase in injection drug use — primarily the injection of opioids. Outbreaks of hepatitis C, hepatitis B and HIV infections have been correlated with these injection patterns and trends.16,17The majority of new hepatitis C virus (HCV) infections are due to injection drug use, and the nation has seen a 3.5-fold increase in reported cases of HCV from 2010 to 2016, reaching a 15- year high.5 New HCV virus infections are increasing most rapidly among young people, with the greatest incidence among individuals under 30.
Until recently, CDC had observed a steady decline since the mid-1990s in HIV diagnoses attributable to injection drug use. However, recent data show progress has stalled. Notably, new HIV infections among white people who inject drugs, the group most affected by the expanding opioid epidemic, increased 10% from 2014 to 2015.18 The estimated lifetime cost of treating one person living with HIV is near $450,000.19 Hospitalization in the US due to substance- use related infections alone costs over $700 million annually.20 In the United States, the estimated cost of providing health care services for people living with chronic HCV infection is $15 billion annually.21 SSPs can help reduce these healthcare costs by preventing viral hepatitis, HIV, endocarditis and other infections.
SSPs are a tool that can help reduce transmission of viral hepatitis, HIV, and other blood-borne infections. SSPs are associated with an approximately 50% reduction in HIV and HCV incidence.11 When combined with medications that treat opioid dependence (also known as medication-assisted treatment) HIV and HCV transmission is reduced by more than two-thirds.22,23
Linkage to Substance Use Treatment, Naloxone, and Other Healthcare Services
Syringe services programs serve as a bridge to other health services including, HCV and HIV diagnosis and treatment and MAT for substance use.24 The majority of SSPs offer referrals to MAT,25 and people who inject drugs who regularly use an SSP are more than five times as likely to enter treatment for a substance use disorder and nearly three times as likely to report reducing or discontinuing injection as those who have never used an SSP.13,26,27 SSPs facilitate entry into treatment for substance use disorders by people who inject drugs.26,28 People who use SSPs show high readiness to reduce or stop their drug use.29 There is also evidence that people who inject drugs who work with a nurse at an SSP or other community-based venue are more likely to access primary care than those who don’t,36 also increasing access to MAT.30 Many comprehensive community-based SSPs offer a range of preventative services including vaccination, infectious disease testing, and linkage to healthcare services.
Syringe services programs can reduce overdose deaths by teaching people who inject drugs how to prevent and respond to a drug overdose, providing them training on how to use naloxone, a medication used to reverse overdose, and providing naloxone to them. Many SSPs provide “overdose prevention kits” containing naloxone to people who inject drugs.31,32 SSPs have partnered with law enforcement, providing naloxone to local police departments to help them keep their communities safer.33
Public Safety
Syringe services programs can benefit communities and public safety by reducing needlestick injuries and overdose deaths, without increasing illegal injection of drugs or criminal activity. Studies show that SSPs protect first responders and the public by providing safe needle disposal and reducing community presence of needles.34–38 As many as one in every three officers may be stuck by a used needle during his or her career.39 Needle stick injuries are among the most concerning and stressful events experienced by law officers.40,41 A study compared the prevalence of improperly disposed of syringes and self-reported disposal practices in a city with SSPs (San Francisco) to a city without SSPs (Miami) and found eight times as many improperly disposed of syringes in Miami, the city without SSPs.34 People who inject drugs in San Francisco also reported higher rates of safe disposal practices than those in Miami. Data from CDC’s National HIV Behavioral Surveillance system in 2015 showed that the more syringes distributed at SSPs per people who inject drugs in a geographic region, the more likely people who inject drugs in that region were to report safe disposal of used syringes.42
Evidence demonstrates that SSPs do not increase illegal drug use or crime.43,44 Studies in Baltimore44 and New York City43have found no difference in crime rates between areas with and areas without SSPs. In Baltimore, trends in arrests were examined before and after a SSP was opened and found that there was not a significant increase in crime rates. The study in New York City assessed whether proximity to an SSP was associated with experiencing violence in an inner city neighborhood and found no association.
SSP Implementation
Not all SSPs are alike. Programs differ in size, scope, geographic location, and delivery venue (e.g., mobile vs. fixed sites). Community acceptance and legality also impact program success. Prior to establishing an SSP, it is important for public health agencies (or others) to assess the needs of potential clients, their families, key stakeholders, law enforcement, and the community at large.
The decision to incorporate SSPs as part of a comprehensive prevention program is made at the state and local level. Laws vary by state and can either increase or reduce access to SSPs. CDC created a guidance document to aid state and local health departments in managing HIV and hepatitis C outbreaks among people who inject drugs, which provides best practices to consider when establishing an SSP.45 Conducting a needs assessment prior to the establishment of an SSP, developing evaluation tools, and careful planning of the operational tasks can increase the chances the SSP will be successful in a community.
HHS guidance states that SSPs should be part of a comprehensive service program that includes, as appropriate,46
Provision of sterile needles, syringes, and other drug preparation equipment (purchased with non-federal funds) and disposal services.
Education and counseling to reduce sexual, injection and overdose risks.
Provision of condoms to reduce risk of sexual transmission of viral hepatitis, HIV or other sexually transmitted diseases.
Provision of HIV, viral hepatitis, STD and tuberculosis screening.
Provision of naloxone to reverse opioid overdoses.
Referral and linkage to HIV, viral hepatitis, STD, and TB prevention, treatment, and care services, including antiretroviral therapy for HCV and HIV, pre-exposure prophylaxis (PrEP), post-exposure prophylaxis (PEP), prevention of mother-to-child transmission, and partner services.
Referral and linkage to hepatitis A virus (HAV) and hepatitis B virus vaccination.
Referral and linkage to and provision of substance use disorder treatment, including MAT for opioid use disorder, which combines drug therapy (e.g., methadone, buprenorphine, or naltrexone) with counseling and behavioral therapy.
Referral to medical care, mental health services, and other support services.
Emerging Issues
In addition to the concerning increases in hepatitis and HIV rates, CDC has also identified additional emerging infectious disease risks related to injection drug use, including increases in methicillin-resistant Staphylococcus aureus (MRSA) infection rates, which increased 124% between 2011 and 2016 among people who inject drugs.47 In addition, people who inject drugs are 16 times as likely as other people to develop invasive MRSA infections.
Rates of endocarditis, a life-threatening infection of the heart valves that can occur in people who inject drugs, has also increased. For example, in North Carolina alone, the rate of hospital discharge diagnoses for endocarditis related to drug dependence increased more than 12-fold from 2010 to 2015, with unadjusted hospital costs increasing from $1.1 million in 2010 to over $22 million in 2015.48 Identifying and responding to these emerging infectious disease threats is critical to alleviate the subsequent harms of opioid misuse and abuse. These infections have been linked to frequency of injecting and to syringe sharing.49 SSPs may help reduce bacterial infections by providing sterile injection equipment and linkage to substance use treatment.
SOURCES
Zibbell, J. E., Asher, A. K., Patel, R. C., Kupronis, B., Iqbal, K., Ward, J. W., & Holtzman, D. (2018). Increases in Acute Hepatitis C Virus Infection Related to a Growing Opioid Epidemic and Associated Injection Drug Use, United States, 2004 to 2014. Am J Public Health, 108(2), 175-181. doi:10.2105/ ajph.2017.304132
Centers for Disease Control and Prevention. (2018). Drug overdose death data.
Centers for Disease Control. (2018). Surveillance for Viral Hepatitis — United States, 2016.
Centers for Disease Control and Prevention. (2016). Vital signs: HIV and injection drug use pdf icon[PDF – 2.4 MB, 4 pages].
MacArthur, G. J., Minozzi, S., Martin, N., Vickerman, P., Deren, S., Bruneau, J., . . . Hickman, M. (2012). Opiate substitution treatment and HIV transmission in people who inject drugs: systematic review and meta- analysis. Bmj, 345, e5945. doi:10.1136/bmj.e5945
Martin, N. K., Hickman, M., Hutchinson, S. J., Goldberg, D. J., & Vickerman, P. (2013). Combination interventions to prevent HCV transmission among people who inject drugs: modeling the impact of antiviral treatment, needle and syringe programs, and opiate substitution therapy. Clin Infect Dis, 57 Suppl 2, S39-45. doi:10.1093/cid/cit29
Lansky, A., Finlayson, T., Johnson, C., Holtzman, D., Wejnert, C., Mitsch, A., … Crepaz, N. (2014). Estimating the number of persons who inject drugs in the United States by meta-analysis to calculate national rates of HIV and hepatitis C virus infectionsexternal icon. PLoS ONE, 9(5), e97596.
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention: Division of Adolescent and School Health Centers for Disease Control and Prevention. Youth Risk Behavior Survey Data Summary & Trends Report 2007-2017.
Aspinall, E. J., Nambiar, D., Goldberg, D. J., Hickman, M., Weir, A., Van Velzen, E., . . . Hutchinson, S. J. (2014). 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, 43(1), 235- 248. doi:10.1093/ije/dyt243
Bernard, C. L., Owens, D. K., Goldhaber-Fiebert, J. D., & Brandeau, M. L. (2017). Estimation of the cost-effectiveness of HIV prevention portfolios for people who inject drugs in the United States: A model-based analysis. PLoS Med, 14(5). doi:10.1371/journal.pmed.1002312
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”, Journal of Substance Abuse Treatment, 2000; 19:247–252.
Department of Defense and Labor, Health and Human Services, and Education Appropriations Act, 2019 (P.L. 115-245)
Centers for Disease Control and Prevention. (2018). Syringe service program determination of need.
Comer M, Matthias J, Nicholson G, Asher A, Holmberg S, Wilson C. Notes from the field: Increase in acute hepatitis B infections — Pasco County, Florida, 2011–2016. MMWR Morb Mortal Wkly Rep 2018;67:230–231.
Harris AM, Iqbal K, Schillie S, et al. Increases in acute hepatitis B virus infections — Kentucky, Tennessee, and West Virginia, 2006–2013. MMWR Morb Mortal Wkly Rep 2016;65:47–50.
Centers for Disease Control and Prevention. HIV Surveillance Report, 2016; vol. 28. Published November 2017. Accessed 7/30/2018.
Farnham PG et al. Updates of lifetime costs of care and quality of life estimates for HIV-infected persons in the United States: Late versus early diagnosis and entry into care. JAIDS 2013; 64: 183-189. Estimates updated to 2017
Ronan, M., & Herzig, S. (2016). Hospitalizations related to opioid abuse/ dependence and associated serious infections increased sharply, 2002–12external icon. Health Affairs, 35(5), 832-837.
Chahal, H. S., Marseille, E. A., Tice, J. A., Pearson, S. D., Ollendorf, D. A., Fox, R. K., et al. (2016, January). Cost-effectiveness of early treatment of hepatitis C virus genotype 1 by stage of liver fibrosis in a U.S. treatment-naive populationexternal icon. The Journal of the American Medical Association, 176(1), 65–73. Retrieved October 25, 2017.
Platt L, Minozzi S, Reed J, Vickerman P, Hagan H, French C, Jordan A, Degenhardt L, Hope V, Hutchinson S, Maher L, Palmateer N, Taylor A, Bruneau J, Hickman M. Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject drugs. Cochrane Database of Systematic Reviews 2017, Issue 9. Art. No.: CD012021. DOI: 10.1002/14651858.CD012021.pub2
Fernandes, R. M., Cary, M., Duarte, G., Jesus, G., Alarcao, J., Torre, C., … Carneiro, A. V. (2017). Effectiveness of needle and syringe programmes in people who inject drugs – An overview of systematic reviews. BMC Public Health, 17(1), 309. doi:10.1186/s12889-017-4210-2
HIV and Injection Drug Use: Syringe Services Programs for HIV Prevention. (2016). CDC Vital Signs.
Des Jarlais D., Nugent A., Solberg A. Syringe service programs for persons who inject drugs in urban, suburban, and rural areas — United States, 2013 MMWR Morb Mortal Wkly Rep 2015;64: 1337-1341
Strathdee, S.A., Celentano, D.D., Shah, N., Lyles, C., Stambolis, V.A., Macal, G., Nelson, K., Vlahov, D., “Needle-exchange attendance and health care utilization promote entry into detoxification”, J Urban Health 1999; 76(4):448-60.
Heimer, R. (1998). Can syringe exchange serve as a conduit to substance abuse treatment? Journal of Substance Abuse Treatment 15:183–191.
Bluthenthal, R.N., Gogineni, A. Longshore, D., Stein, M. (2001). Factors associated with readiness to change drug use among needle-exchange users. Drug & Alcohol Dependence 62:225-230.
Artenie, Andreea & Jutras-Aswad, D & Roy, É & Zang, G & Bamvita, J-M & Lévesque, Annie & Bruneau, J. (2015). Visits to primary care physicians among persons who inject drugs at high risk of hepatitis C virus infection: Room for improvement. Journal of Viral Hepatitis. 22. 10.1111/jvh.12393.
Chou R, Korthuis PT, Weimer M, et al. Medication-Assisted Treatment Models of Care for Opioid Use Disorder in Primary Care Settingsexternal icon. Rockville (MD): Agency for Healthcare Research and Quality (US); 2016 Dec. (Technical Briefs, No. 28.)
Seal, KH, Thawley R, Gee L, Bamberger J, Kral AH, Ciccarone D, Edlin BR (2005). “Naloxone distribution and cardiopulmonary resuscitation training for injection drug users to prevent heroin overdose death: A pilot intervention study”, Journal of Urban Health: Bulletin of the New York Academy of Medicine, 2005; 82(2):, 303–311.
Leece PN, Hopkins S, Marshall C, Orkin A, Gassanov MA, Shahin RM, “Development and implementation of an opioid overdose prevention and response program in Toronto, Ontario”, Canadian Journal of Public Health, 2013;104(3):e200-4.
Childs, R. Law Enforcement and Naloxone Utilization in the United States [PDF – 1 MB, 24 pages]external icon.
Tookes HE, Kral AH, Wenger LD, Cardenas GA, Martinez AN, Sherman RL, Pereyra M, Forrest DW, Laota 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 and Alcohol Dependence, 2012 ;123(1-3):255-9
Riley ED, Kral AH, Stopka TJ, Garfein RS, Reuckhaus P, Bluthenthal RN, “Access to sterile syringes through San Francisco pharmacies and the association with HIV risk behavior among injection drug users”, Journal of Urban Health, 2010; 87(4):534-42
Klein SJ, Candelas AR, Cooper JG, Badillo WE, Tesoriero JM, Battles HB, Plavin HA, “Increasing safe syringe collection sites in New York State”, Public Health Reports, 2008; 123(4):433-40.
de Montigny L, Vernez Moudon A, Leigh B, Kim SY, “Assessing a drop box programme: a spatial analysis of discarded needles”, International Journal of Drug Policy, 2010; 21(3):208-14.Doherty MC, Junge B, Rathouz P, Garfein RS, Riley E, Vlahov D, “The effect of a needle exchange program on numbers of discarded needles: a 2-year follow-up”, American Journal of Public Health. 2000 Jun; 90(6):936-9.
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 and Alcohol Dependence, 2007; 89(2-3):214-22
Lorentz, J., Hill, L., & Samimi, B. (2000). Occupational Needlestick Injuriesexternal icon. American Journal of Preventive Medicine, 18(2), 146-150.
Cepeda, J. A., Beletsky, L., Sawyer, A., Serio-Chapman, C., Smelyanskaya, M., Han, J., Sherman, S. G. (2017). Occupational Safety in the Age of the Opioid Crisis: Needleexternal icon. Journal of Urban Health, 94(1), 100-103.
Davis, C., Johnston, J., de Saxe Zerden, L., Clark, K., Castillo, T., & Childs, R. (2014). Attitudes of North Carolina law enforcement officers toward syringeexternal icon. Drug and Alcohol Dependence, (144), 265-269.
Centers for Disease Control and Prevention. HIV Infection, Risk, Prevention, and Testing Behaviors among Persons Who Inject Drugs—National HIV Behavioral Surveillance: Injection Drug Use, 20 U.S. Cities, 2015. HIV Surveillance Special Report 18. Revised edition. Published May 2018. Accessed 7/30/2018.
Galea, S., Ahern, J., Fuller, C., Freudenberg, N., & Vlahov, D. (2001). Needle exchange programs and experience of violence in an inner city neighborhood. Journal of Acquired Immune Deficiency Syndromes, (28), 282-288.
Marx, M. A., Crape, B., Brookmeyer, R. S., Junge, B., Latkin, C., Vlahov, D., & Strathdee, S. A. (2000). Trends in crime and the introduction of a needle exchange program. American Journal of Public Health, 90(12), 1933–1936.
Centers for Disease Control and Prevention. Managing HIV and hepatitis C outbreaks among people who inject drugs—A guide for state and local health departments pdf icon[PDF – 2 MB, 102 pages]. March 2018.
Department of Health and Human Services Implementation Guidance to Support Certain Components of Syringe Services Programs, 2016. (2016, March). Department of Health and Human Services.
Jackson KA, Bohm MK, Brooks JT, et al. Invasive Methicillin-Resistant Staphylococcus aureus Infections Among Persons Who Inject Drugs — Six Sites, 2005–2016. MMWR Morb Mortal Wkly Rep 2018; 67:625–628.
Fleischauer, A. T., Ruhl, L., Rhea, S., & Barnes, E. (2017). Hospitalizations for Endocarditis and Associated Health Care Costs Among Persons with Diagnosed Drug Dependence – North Carolina, 2010-2015. MMWR Morb Mortal Wkly Rep, 66(22), 569-573. doi:10.15585/mmwr.mm6622a1
Dahlman, D., Hakansson, A., Kral, A., Wenger, L., Ball, E., & Novak, S. (2017). Behavioral characteristics and injection practices associated with skin and soft tissue infections among people who inject drugs: A community-based observational studyexternal icon. Substance Abuse, 38(1), 105-112.