Experts say the spike in overdoses and diseases related to sharing needles means it’s time to revoke a longtime ban restricting federal funds for syringe exchanges. But lawmakers in both parties remain resistant to allowing taxpayer dollars to go toward clean needles and syringes for drug use.
Though controversial, syringe service programs have been active since the 1980s. Public health advocates argue that providing clean needles and disposing of old ones can reduce fatalities and limit the spread of infectious diseases for those who use injectable drugs such as heroin.
The programs can also connect people who use drugs to health care they might not ordinarily seek, including education and treatment. The Centers for Disease Control and Prevention, National Institutes of Health and multiple public health departments have touted the programs’ benefits, saying their ability to connect drug users with opioid overdose reversal drugs like naloxone or fentanyl test strips can also reduce drug-related deaths.
But the red tape surrounding what can and cannot receive federal funding has been taxing. Since fiscal 1990, the federal government has effectively banned funding to distribute syringes and needles with a rider attached to annual appropriations bills.
Democrats in both chambers have tried unsuccessfully to strip this long-standing language from Labor-HHS-Education spending bills, most recently during the fiscal 2022 omnibus negotiations.
This year, the push to remove that rider is on again.
President Joe Biden's budget request seeks boosts for syringe programs and other forms of harm reduction, referring to public health policies designed to lessen the negative consequences associated with drug use.
The 2021 COVID-19 relief law also touted $30 million for harm reduction, though that spurred pushback earlier this year. Sen. Marco Rubio, R-Fla., and Rep. David B. McKinley, R-W.Va., introduced bills that would prohibit using federal funds to purchase sterile needles for the programs or purchase or distribute any paraphernalia to use narcotics.
The sensitive nature of the subject has led to a quiet push from lobbyists and lawmakers who don’t want to derail chances to remove restrictions on these programs. But public health experts and those working on the front lines of the drug crisis have been more vocal about their desire to lift the ban while Democrats hold control of both chambers and the White House.
“Traditionally, the federal government has focused on prevention and treatment when it comes to drug activity. But we know that prevention and treatment in and of themselves are not sufficient,” said Maritza Perez, director of federal affairs at the Drug Policy Alliance. “Harm reduction means we meet people where they're at, without judgment.”
Some 334 organizations wrote to Labor-HHS-Education Appropriations leaders in May calling on Congress to remove the syringe funding ban and provide $150 million for the Infectious Diseases and the Opioid Epidemic program to expand access to syringe service programs.
Last week, the American Medical Association released a report recommending that physicians and policymakers support increased access to harm reduction services, including syringe programs.
But pushback remains, with the loudest opposition coming from Republican lawmakers. Still, opponents from both parties, including Sen. Joe Manchin III, D-W.Va., have cited concerns that the programs could increase drug use despite a number of studies indicating otherwise.
“While this is a heartbreaking issue that must be fully addressed by the federal government, using taxpayer funds to buy paraphernalia for those struggling with substance use disorder is not the solution,” Manchin said in February.
Public health advocates are unswayed.
“It’s just theater to pretend that if people knew that the federal government was paying for these syringes at the legal needle exchange, somehow that would be encouraging drug use,” said Scott Burris, a law professor and director of the Center for Public Health Law Research at Temple Law School and an expert in HIV/AIDS policy.
Medical experts say these programs are lifesaving for an already vulnerable population, and promoting the use of new or sterile needles can reduce the spread of infectious diseases.
The CDC estimates that syringe programs can reduce contraction of HIV and hepatitis C by 50 percent. That number jumps to 67 percent when combined with medication-assisted treatment to address opioid use disorder.
But they’ve also become a broader public health tool. Syringe programs have helped distribute COVID-19 vaccines to people living with a substance use disorder, who are at increased risk for severe illness, according to the CDC.
Congress briefly lifted the ban on paying for new or sterile needles in the fiscal 2010 omnibus, but it was reinstated in the fiscal 2012 spending law after Republicans gained control of the House.
Since then, spending laws have altered the scope of the ban, but the ban remains largely intact.
Public perception shifted somewhat after Scott County, Indiana, experienced a large-scale HIV and hepatitis outbreak in 2015 caused primarily by injectable drugs. Then-Gov. Mike Pence opposed syringe service programs, leading experts to criticize his waiting to allow a state-supervised program as a driver of additional cases.
“When that happened, that sort of caught people's attention, and they sort of understood that certain service programs are a critical part to prevention, preventing HIV and hepatitis,” said Emily McCloskey Schreiber, senior director of policy and legislative affairs at the National Alliance of State and Territorial AIDS Directors.
In the aftermath of that outbreak, the fiscal 2016 omnibus carved out a provision specifying that a state or local health department can seek an exemption with the CDC if their jurisdiction is experiencing or at high risk for an outbreak of hepatitis or HIV infections due to intravenous drug use. Those departments receiving an exemption could use funds to pay for staff, testing supplies, naloxone or other non-needle supplies.
Brandon Marshall, an epidemiology professor at the Brown University School of Public Health, said 44 states currently have jurisdictions that qualify under CDC guidelines, highlighting the need for the policy nationwide.
Last year, Scott County commissioners voted to end its syringe program.
Alexander/a Bradley, outreach and community education manager at HIPS, a harm-reduction agency in Washington, D.C., said the layers of restrictions have made it complicated to write grants to seek private funding for the approximately $85,000 needed for needles necessary for the program. HIPS is currently applying for grants for the next fiscal year.
“It is incredibly laborious and stressful for the team because it leaves us kind of not able to fully do our jobs or not able to focus on the work because we're constantly having to do this battle,” said Bradley, who uses they/them pronouns.
Bradley said the ban essentially keeps the agency from paying for “the bread and butter” of what it does.
“It’s truly like pulling-your-hair-out-worthy stuff,” they said.
Brian Hurley, an addiction physician and medical director of substance abuse prevention and control for the Los Angeles County Department of Public Health, said the restrictions are burdensome.
“In my job in the Los Angeles County Department of Public Health, we have to use non-federal local funding for our harm-reduction partners that we could use in other ways if there were less restrictions on the federal money that would be available to support harm-reduction services,” said Hurley, the president-elect of the American Society of Addiction Medicine.
In December, the Office for National Drug Control Policy released a model law for states to expand access to the programs.
No states have yet adopted the model law, but some have taken action to remove restrictions on sterile needles and syringes.
Heather Gray, senior legislative attorney with the Legislative Analysis and Public Policy Association, said Georgia enacted a law in July that would no longer classify a hypodermic needle or syringe as a “drug-related object.” Similar efforts in Kentucky and Maryland are underway, while Vermont's Republican Gov. Phil Scott vetoed legislation in May that would have reduced some requirements on syringe programs.
Twelve states do not have statewide allowances for syringe service programs, according to the NASTAD, but some cities are still able to operate them through local authorizations. State, county and city regulations vary widely, and access can also depend on local investments.
Public health advocates say they’re prepared to persist in order to have the tools they need to properly fight substance use disorder.
“We know policymakers have not exhausted all remedies. Until we have, we must keep advocating for humane, evidence-based responses,” said Bobby Mukkamala, chair of the AMA Substance Use and Pain Care Task Force. “What is becoming painfully evident is that there are limits to what physicians can do.”