Testimony from:

Stacey McKenna, Senior Fellow, Integrated Harm Reduction, R Street Institute

In Support of a Needs-Based Approach to Syringe Services (DE SB 52)

April 26, 2023

House Health and Human Development Committee

Chairwoman Minor-Brown and members of the committee,

My name is Stacey McKenna, and I am a senior fellow in Integrated Harm Reduction at the R Street Institute (R Street), a public policy research organization focused on advancing limited, effective government in a number of policy areas, including harm reduction. Harm reduction is an evidence-based, cost-effective and pragmatic approach that mitigates the risks associated with a wide range of behaviors, including injection drug use.[1] As such, we are in favor of DE SB 52. This bill would update an important Delaware harm reduction intervention—syringe services—to align with three decades of research and federal best practices recommendations supporting needs-based distribution of syringes and injection equipment.[2]

In 2018, an estimated 3.7 million people in the United States injected drugs, an activity that is associated with a range of potential health harms, including increased risk for overdose; transmission of infectious diseases such as human immunodeficiency virus (HIV); and injection-related injuries and infections.[3] From a public health perspective, the most certain way to avoid these consequences would be for people to simply abstain from all use of illicit substances. However, abstinence-only policies have proven ineffective at the population level, and even the best cessation and prevention programs leave many people behind.

On the other hand, harm reduction is an evidence-based approach that improves health and saves lives. Operating in the United States since the 1980s, syringe services programs (SSPs) are among the most common, best studied and most diverse harm reduction interventions available.[4] They typically include distribution of injection equipment, provision of overdose prevention education and reversal tools, and serve as an important link between their clients and housing, mental health services and addiction treatment resources.[5]

SSPs have been shown to reduce the incidence of HIV and hepatitis C virus (HCV) by as much as 50 percent, as well as helping clients avoid skin infections, hepatitis B and a range of other health issues.[6] By preventing these expensive-to-treat infectious diseases, SSPs save taxpayers money. In nearly two decades of operation, Delaware’s SSPs have saved countless lives, reduced disease transmission and saved taxpayers more than $107 million in HIV treatment costs alone.[7]

But SSPs are at their most effective when they adapt to local needs.[8] The United States, including Delaware, is grappling with an increasingly toxic illicit drug supply that is exacerbating the health risks of injection drug use. [9] In addition to increasing the risk of overdose drastically, fentanyl drives people to increase their injection frequency—and in turn their risk of acquiring HIV or HCV—because its effects are short-lived compared to other opioids, such as heroin.[10] And xylazine, which has recently become more common in Delaware, increases the likelihood and severity of skin wounds, especially if people reuse needles, even their own.[11]

Therefore, in order for the state to continue to mitigate the harms to individuals and communities effectively, it must update its SSP legislation to keep up with the science. That means shifting programs to providing needles and syringes on a needs-based, rather than one-for-one, basis.

Needs-based syringe distribution improves SSP efficacy in a number of ways. The approach ensures people can access the number of syringes and needles they need, even as the drug market changes, and improves reach to isolated and marginalized people through secondary exchange.[12] Furthermore, needs-based distribution has been shown to encourage—not discourage, as some have worried—client  engagement compared to more restrictive policies.[13] In addition, needs-based SSPs present no greater risk for improper needle disposal than one-for-one counterparts, and safe needle and syringe disposal is already facilitated by Delaware’s current SSP legislation and the operating organizations.[14]

By directing Delaware’s SSPs to employ a needs-based approach to syringe distribution, DE SB 52 is following the science to ensure its harm reduction programs are operating according to best practices. As such, R Street urges your favorable report.

Respectfully submitted,

Stacey McKenna
Senior Fellow, Integrated Harm Reduction
R Street Institute
[email protected]

[1] “Principles of Harm Reduction,” National Harm Reduction Coalition, last accessed June 13, 2022. https://harmreduction.org/about-us/principles-of-harm-reduction.

[2] Centers for Disease Control and Prevention, “Needs-Based Distribution at Syringe Services Programs,” U.S. Department of Health and Human Services, December 2020. https://www.cdc.gov/ssp/docs/CDC-SSP-Fact-Sheet-508.pdf.

[3] Heather Bradley et al., “Estimated Number of People Who Inject Drugs in the United States,” Clinical Infectious Diseases 76:1 (July 6, 2022), pp. 96-102. https://academic.oup.com/cid/article-abstract/76/1/96/6628702?redirectedFrom=fulltext&login=false; “Getting Off Right: A Safety Manual for Injection Drug Users,” National Harm Reduction Coalition, last accessed April 24, 2023. https://harmreduction.org/issues/safer-drug-use/injection-safety-manual/potential-health-injections

[4] S.G. Sherman and D. Purchase, “Point Defiance: a case study of the United States’ first public needle exchange in Tacoma, Washington,” International Journal of Drug Policy 12:1 (April 1, 2001), pp. 45-57. https://pubmed.ncbi.nlm.nih.gov/11275503/#:~:text=The%20first%20publicly%20funded%20needle,%2C%20Washington%2C%20in%20August%201988; Substance Abuse and Mental Health Services Administration, “Harm Reduction,” U.S. Department of Health and Human Services, Aug. 16, 2022. https://www.samhsa.gov/find-help/harm-reduction; Don C. Des Jarlais, “Harm reduction in the USA: the research perspective and an archive to David Purchase,” Harm Reduction Journal 14:51 (July 26, 2017). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5530540

[5] Centers for Disease Control and Prevention, “Syringe Services Programs (SSPs) Fact Sheet,” U.S. Department of Health and Human Services, May 23, 2019. https://www.cdc.gov/ssp/syringe-services-programs-factsheet.html#:~:text=SSPs%20are%20associated%20with%20an,in%20HIV%20and%20HCV%20incidence.&text=When%20combined%20with%20medications%20that,reduced%20by%20over%20two%2Dthirds.

[6] Centers for Disease Control and Prevention. https://www.cdc.gov/ssp/syringe-services-programs-factsheet.html#:~:text=SSPs%20are%20associated%20with%20an,in%20HIV%20and%20HCV%20incidence.&text=When%20combined%20with%20medications%20that,reduced%20by%20over%20two%2Dthirds; Cameron Bushling et al., “Syringe services programs in the Bluegrass: Evidence of population health benefits using Kentucky Medicaid data,” The Journal of Rural Health 38:3 (Sept. 19, 2021), pp. 620-629. https://onlinelibrary.wiley.com/doi/epdf/10.1111/jrh.12623.

[7] “Delaware’s syringe services program is saving lives and taxpayer dollars,” Cape Gazette, Dec. 4, 2019. https://www.capegazette.com/article/delaware%E2%80%99s-syringe-services-program-saving-lives-and-taxpayer-dollars/193313.

[8] Centers for Disease Control and Prevention. https://www.cdc.gov/ssp/syringe-services-programs-factsheet.html#:~:text=SSPs%20are%20associated%20with%20an,in%20HIV%20and%20HCV%20incidence.&text=When%20combined%20with%20medications%20that,reduced%20by%20over%20two%2Dthirds; Bushling et al. https://onlinelibrary.wiley.com/doi/epdf/10.1111/jrh.12623; Emanuel Krebs et al., “The impact of localized implementation: determining the cost-effectiveness of HIV prevention and care interventions across six U.S. cities,” AIDS 34:3 (March 1, 2020), pp. 447-458. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7046093.

[9] Rob Petree, “Fentanyl accounts for majority of overdose deaths in Delaware,” 47 ABC WMDT, Aug. 30, 2022. https://www.wmdt.com/2022/08/fentanyl-accounts-for-majority-of-overdose-deaths-in-delaware.

[10] Barrot H. Lambdin et al., “Associations between perceived illicit fentanyl use and infectious disease risks among people who inject drugs,” International Journal of Drug Policy 74 (December 2019), pp. 299-304. https://www.sciencedirect.com/science/article/abs/pii/S0955395919302786.

[11] Paul Kiefer, “Delaware public health officials offer grim update on overdose figures and xylazine impacts,” Delaware Public Media, Jan. 18, 2023. https://www.delawarepublic.org/science-health-tech/2023-01-18/delaware-public-health-officials-offer-grim-update-on-overdose-figures-and-xylazine-impacts; “Harm Reduction Issues: Xylazine,” National Harm Reduction Coalition, last accessed April 24, 2023. https://harmreduction.org/issues/xylazine.  

[12] Centers for Disease Control and Prevention. https://www.cdc.gov/ssp/docs/CDC-SSP-Fact-Sheet-508.pdf.

[13] Susan G. Sherman et al., “Consequences of a restrictive syringe exchange policy on utilisation patterns of a syringe exchange program in Baltimore, Maryland: Implications for HIV risk,” Drug and Alcohol Review 34:6 (April 28, 2015), pp. 637-644. https://onlinelibrary.wiley.com/doi/abs/10.1111/dar.12276; Sam Haut, “Needle giveaway change easily passes senate,” Town Square Live, April 6, 2023. https://townsquaredelaware.com/senate-votes-to-allow-change-in-needle-program; Tasha Turner-Bicknell, “Implementing best-practice with a local syringe service program: Needs-based syringe distribution,” Public Health Nursing 38:1 (January 2021), pp. 85-92. https://pubmed.ncbi.nlm.nih.gov/33084122.

[14] Ricky N. Bluthenthal et al., “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 89:2-3 (July 10, 2007), pp. 214-222. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2562866; Luc de Montigny et al., “Assessing a drop box programme: A spatial analysis of discarded needles,” International Journal of Drug Policy 21:3 (May 2010), pp. 208-214. https://www.sciencedirect.com/science/article/pii/S0955395909001108