Testimony in Support of Amending Hawaii’s Syringe Service Programs’ Distribution System from One-to-One Exchange to Needs Based Distribution

Testimony from:
Stacey McKenna, Resident Senior Fellow, Integrated Harm Reduction, R Street Institute

In SUPPORT of Hawaii Senate Bill 1433, “Relating to Harm Reduction.”

March 14, 2025

House Committee on Health

Chair Takayama and members of the committee:

My name is Stacey McKenna and I am a resident senior fellow in Integrated Harm Reduction at the R Street Institute. R Street is a nonprofit, nonpartisan public policy research organization that conducts policy research and outreach to promote free markets and limited, effective government in many areas, including harm reduction. We recognize that, while total abstinence from risky behaviors works for some people, it is does not work for everybody and therefore will not prevent death or disease transmission at the population level.^[1] Harm reduction is a practical, community-driven and evidence-based approach to public health that helps reduce the risks associated with certain behaviors – including drug use – by empowering individuals with the knowledge and tools to make safer, healthier choices.^[2] This is why SB 1433 is of special interest to us.

In 2022, Hawaii saw 76 new cases of HIV, for an incidence rate of 5.3 per 100,000 residents.^[3] While sexual intercourse remains the primary driver of HIV in the state, injection drug use has become a growing risk factor in recent years: Prior to 2018, only about 14 percent of Hawaiians with HIV reported injection drug use, but in 2022, roughly 19 percent of newly diagnosed people injected drugs.^[4] In addition, although overdose deaths have declined slightly in Hawaii since 2023, the state is seeing an influx of new substances added to the drug supply, causing fluctuations in potency and endangering people who use drugs in new and changing ways.^[5] For example, the addition of xylazine to the fentanyl supply can complicate overdoses and cause debilitating soft tissue injuries.^[6] As new and unknown contaminants enter the supply, the risks will change, and organizations providing health services to people who use drugs will need to adapt quickly.^[7]

SB 1433 would help address both of these issues by allowing Hawaii’s syringe service programs (SSPs) to better meet the specific needs of their participants. SSPs have been operating in the United States and all over the world for more than three decades, and in Hawaii since 1989.^[8] They are proven cornerstones in reducing the potential harm associated with drug use – cutting HIV among participants by as much as 50 percent and distributing life-saving tools such as the overdose reversal medication naloxone and drug checking equipment like fentanyl test strips.^[9] In addition, they promote treatment engagement and improve recovery outcomes.^[10] 

The long-standing presence of SSPs in Hawaii is likely one reason that the state’s HIV and overdose death rates are lower than in much of the United States.^[11] However, to further improve the state’s ability to respond to the ever-evolving risks associated with illicit drug use, it is important to allow harm reduction organizations such as SSPs the flexibility to respond to their local and changing community needs.

Currently, Hawaii’s SSPs must engage in one-for-one distribution of needles, requiring participants to turn in one or more syringes and needles for each one they receive. However, decades of evidence tell us that this is not the best way to prevent disease.^[12] SB 1433 would improve the effectiveness of Hawaii’s SSPs by allowing them to distribute syringes and other injection equipment according to need, rather than restricting them to one-for-one distribution. Needs-based distribution is more effective at preventing HIV and other infectious diseases, as well as deterring soft tissue injuries and subsequent risk of cardiac infections by allowing.^[13] Furthermore, increasing the number of syringes distributed can improve reach to vulnerable individuals and research shows that it does not lead to more syringe litter.^[14] 

In addition, SB 1433 would expand protections for SSP employees, volunteers and participants who are carrying supplies to or from the organizations. Since fear of arrest and prosecution are major reasons that individuals discard their used injection equipment in public would increase the likelihood that people will dispose safely of used equipment.^[15] 

SB 1433 would also expand the reach of SSPs by allowing the organizations to serve at-risk individuals even if they do not inject drugs. This shift is extremely important in the current environment. As the drug supply changes, people who did not historically use opioids are seeing fentanyl in their supply that can increase their overdose risk.^[16] And some people who have historically injected drugs are changing to smoking, a switch that alters but does not eliminate risk for disease and overdose.^[17] Thus, it is more important than ever to provide disease and overdose prevention tools as well as points of connection – many of which lead to referrals to social and mental health services as well as substance use disorder treatment – to any individual who uses drugs.^[18] 

Unfortunately, even when people have access to the best prevention and treatment, some people will continue to use illicit substances. Hawaii’s long-time embrace of harm reduction is certainly part of why the state is doing better than most of the United States when it comes to preventing HIV and overdose deaths. But, too many people are still suffering from the potential harm associated with illicit drug use. This not only leads to individual suffering, but can drain community resources. SB 1433 would allow the state’s already-successful SSPs to expand their services to better align with evidence-based practices and to adapt to the evolving circumstances in their communities. We therefore urge you to vote in favor of SB 1433.

Thank you for your time and consideration.

All the best,

Stacey McKenna, PhD
Resident Senior Fellow, Integrated Harm Reduction
R Street Institute
(970) 443-8063
smckenna@rstreet.org 

[1] “Principles of Harm Reduction,” National Harm Reduction Coalition, accessed Feb. 26, 2025. https://harmreduction.org/about-us/principles-of-harm-reduction.

[2] Ibid.

[3] Josh Green and Kenneth S. Fink, “Hawaii HIV/AIDS Surveillance 2022 Annual Report,” Hawaii State Department of Health, June 30, 2023. https://health.hawaii.gov/harmreduction/files/2023/12/HIV-2023-surveillance-annual-report_20231220.pdf.

[4] Ibid.

[5] National Center for Health Statistics, Provisional Drug Overdose Death Counts, March 5, 2025. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm; Lynn Kawano, “In alarming trend, Hawaii saw multiple overdose deaths in 2023 involving horse tranquilizer,” Hawaii News Now, Jan. 23, 2024. https://www.hawaiinewsnow.com/2024/01/04/alarming-trend-hawaii-saw-multiple-overdose-deaths-2023-involving-horse-tranquilizer; Stacey McKenna, “What Policymakers Should Know About the Illegal Drug Supply,” R Street Institute Analysis, Feb. 20, 2025. https://www.rstreet.org/commentary/what-policymakers-should-know-about-the-illegal-drug-supply.

[6] McKenna, https://www.rstreet.org/commentary/what-policymakers-should-know-about-the-illegal-drug-supply.

[7] Ibid.

[8] Hawai’i State Department of Health, “Syringe Service Programs (SSPs),” Syringe Service Programs (SSPs), Harm Reduction Services Branch, Accessed March 12, 2025. https://health.hawaii.gov/harmreduction/syringe-service-programs/#:~:text=In 1992, the state legislature,and to refer PWID to.

[9] “Syringe Services Programs (SSPs),” Centers for Disease Control and Prevention, Accessed March 12, 2025. https://www.cdc.gov/syringe-services-programs/php/index.html?CDC_AAref_Val=https://www.cdc.gov/ssp/docs/cdc-ssp-fact-sheet-508.pdf.

[10] Ibid.

[11] Hawai’i State Department of Health, “HIV & AIDS,” Learn About Diseases, Harm Reduction Services Branch, Accessed March 12, 2025. https://health.hawaii.gov/harmreduction/learn-about-diseases/sexually-transmitted-infections/hiv-aids/#:~:text=Data & Statistics, Reporting in Hawai’i&text=The prevalence rate (calculated per,that of females (33.0); “Mental Health in Hawaii,” Kaiser Family Foundation, Accessed March 12, 2025. https://www.kff.org/statedata/mental-health-and-substance-use-state-fact-sheets/hawaii.

[12] Chelsea Boyd, “Effective Practices for Syringe Services Programs,” R Street Institute Explainer, March 5, 2025. https://www.rstreet.org/research/effective-practices-for-syringe-services-programs.

[13] Chelsea Boyd, “Effective Practices for Syringe Services Programs,” R Street Institute Explainer, March 5, 2025. https://www.rstreet.org/research/effective-practices-for-syringe-services-programs.

[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 (Feb. 5, 2007), pp. 214-222. https://pmc.ncbi.nlm.nih.gov/articles/PMC2562866.

[15] Carol Y. Franco et al., “’We’re actually more of a likely ally than an unlikely ally’: relationships between syringe services programs and law enforcement,” Harm Reduction Journal, (Aug. 4, 2021). https://pmc.ncbi.nlm.nih.gov/articles/PMC8336277.

[16] Karla D. Wagner et al., “Prevalence of fentanyl in methamphetamine and cocaine samples collected by community-based drug checking service,” Drug and Alcohol Dependence, 252 (Nov. 1, 2023). https://www.sciencedirect.com/science/article/pii/S0376871623012231.

[17] Victoria Colliver, “Smoking Fentanyl, Rising in SF, Is a Deadly New Risk for Overdose,” UCSF News, May 22, 2024. https://www.ucsf.edu/news/2024/05/427651/smoking-fentanyl-rising-sf-deadly-new-risk-overdose.

[18] Stacey McKenna, “Why Harm Reduction Organizations Distribute Safer (Drug) Smoking Supplies,” R Street Institute Analysis, June 26, 2024. https://www.rstreet.org/commentary/why-harm-reductionists-distribute-safer-drug-smoking-supplies.