Background
Nearly 107,000 people died from an overdose in the United States in 2023.Reference Garnett and Miniño 1 While overdose deaths declined overall in 2024, the fatal overdose rate is rising among Black and Native Americans, and overdose remains a leading cause of injury and death.Reference Spencer 2 Most drug-related harm involves opioids, but stimulant-related harms are rapidly increasing. Infectious disease transmission is also rising, particularly among people who inject drugs. 3 Many of these harms are preventable. Because law in the United States often criminalizes and stigmatizes people who use drugs (PWUD), it is both a barrier to reducing harm and a structural driver of that harm.
Over the last decade, both the US federal government and the states have increasingly adopted evidence-based harm reduction policies and practices to stem the tide of drug-related injury and death, including passing laws to reduce barriers to accessing naloxone and drug-checking equipment.Reference Davis 4 Unfortunately, that adoption often came at the price of reducing the spirit of harm reduction to a set of interventions, such as distributing naloxone or providing fentanyl test strips. These practices promote the well-being of PWUD and advance public health, but they alone do not constitute “harm reduction.” Harm reduction is not a collection of policies or practices but rather a framework of guiding principles based on dignity, respect, and self-determination, seeking to reduce the harms associated with drug use. 5
One key public health intervention — rooted in the spirit of harm reduction and championed by harm reductionists — is syringe services programs (SSPs). Over the past 30 years, SSPs have evolved from shoestring underground operations run by dedicated activists to — in some places — full-scope harm reduction programs that distribute syringes and other injection equipment, safer smoking supplies, and drug-checking equipment in addition to being social hubs that connect people to health care, housing, and treatment in a stigma-free environment.Reference Martin 6 SSPs are safe, effective, cost-saving, and do not increase crime or encourage drug use.Reference Bernard 7 They are also crucial access points for naloxone and important links to recovery care.Reference Seal 8
Unfortunately, most states have enacted laws that criminalize the possession or distribution of some or all of these life-saving tools, hindering the ability of SSPs to provide safer drug use supplies and connect people to other services.Reference Davis, Carr and Samuels 9 Over time, most states have modified these laws to permit SSPs to operate in some fashion. In some states this takes the form of exempting SSP operators and participants from paraphernalia laws, the removal of syringes from the definition of paraphernalia, or the full or partial repeal of paraphernalia laws. In many states, however, state law creates specific, limited carveouts for SSPs, which are permitted to operate only with a number of restrictions. These restrictions limit their reach and impose harm on PWUD and their communities.
While some SSPs do operate underground where syringe distribution is prohibited, a supportive legal environment is critical to community acceptance; acquiring funding from state, federal, and private sources; and ensuring protection from arrest and criminal prosecution for SSP employees, volunteers, and participants. This article presents data on state laws that, while ostensibly permitting SSP operation, do so in a fashion that limits their utility as comprehensive public health interventions. The article also suggests ways to improve these laws, particularly with regard to soliciting and meaningfully incorporating the needs and views of people who do — or would — access SSPs and related services.
Methods
Three trained public health attorneys systematically searched the Westlaw Edge legal database for all statutes and regulations (hereafter referred to as “laws”) in each state and the District of Columbia (hereafter referred to as “states”) for all laws that permit the operation of SSPs or govern their operation. This was done by using keyword searches for the terms “syringe,” “inject!,” “needle,” and “hypodermic,” as well as “needle exchange,” “syringe exchange,” “syringe services,” and “harm reduction.” The version of each responsive law in effect as of July 1, 2025 was downloaded for review. The parameters of laws that govern SSP operation, including requirements or limitations on SSP operation (such as whether state law requires that SSPs be approved by a government entity or restricts the number of syringes that they may distribute) were systematically coded. All laws were independently coded by three trained attorneys with expertise in drug policy. Discrepancies were rare and resolved by consensus. Data is on file with the authors.
Results
While 40 states allow SSP operations in some form, many state laws limit the operation of SSPs in various ways. Most notably, 23 states permit SSPs to legally operate only if they receive prior authorization from local or state government officials. Of these, 15 require state authorization (Connecticut, Delaware, District of Columbia, Georgia, Hawaii, Maine, New Jersey, New Mexico, New York, North Dakota, Oklahoma, Rhode Island, Tennessee, Vermont, Virginia), 4 require local authorization (Florida, Kentucky, Louisiana, Ohio), 1 generally requires local authorization with exceptions for programs with experience or health facilities licensed or certified by the state (Colorado), 2 states require either state or local authorization (California, Indiana), and 2 require state and local authorization (Maryland, West Virginia). Further, 3 additional states (Illinois, North Carolina, Utah) require some sort of registration or process prior to SSP operation, even if they do not explicitly require programs to be “authorized.”
Obtaining the required authorization is often difficult, particularly for community-based programs and in areas of the country that are hostile to harm reduction. This means that, even in states that theoretically permit SSPs to operate, the number of programs may be limited and subject to the whims of local elected officials, rather than public health experts.
Requiring operation of a 1:1 syringe exchange model, whereby participants receive only the number of syringes they return, is another concern.Reference Dennis 10 Two states require that SSPs only operate on a 1:1 syringe exchange model. Florida requires this outright, whereas Arizona’s law requires that “[t]he number of needles and hypodermic syringes disposed of through a program shall be at least equivalent to the number of needles and hypodermic syringes distributed through the program.” 11 Two other states (Tennessee and West Virginia) require that SSPs “strive for” or “have the goal of” 1:1 exchange. 12 Additionally, Maine requires programs to “adhere to” a 1:1 distribution policy but allows programs to bend this rule in instances where the participant “cannot offer a used syringe to be exchanged.” 13
This does not reflect public health best practices, as it can increase the spread of infectious disease.Reference Turner-Bicknell 14 It also increases the risk of criminal liability in the majority of states in which the possession of drug residue in used syringes could result in a drug possession charge. It likely also increases the risk of needlestick injury, since it forces individuals to keep syringes instead of immediately safely disposing of them. Needs-based syringe distribution models have been shown to not increase unsafe needle disposal in communities.Reference Bluthenthal 15 Further, PWUD often collect safer use supplies for their community, which may have a fluctuating need and can’t be dependent on exactly how many syringes were used since the last time the SSP was visited.
State SSP laws often contain other restrictions that are not rooted in evidence or harm reduction principles and may make operation harder for SSPs. For example, in many states, the law places restrictions on locations in which SSPs can legally operate. Three states (Georgia, New Hampshire, Tennessee) impose restrictions on how far an SSP must be from schools, parks, or both. In several states, the law explicitly states that an SSP is only allowed to operate in the authorizing jurisdiction — although it’s likely that any law that requires local authorization would also imply operations only in that locality. Other restrictions include requiring approval from the local health officer in each county where the program operates, if more than one (Maryland), or requiring that each location that the SSP operates be separately state licensed (West Virginia).
Further, SSP laws in nine states restrict how funding can be acquired or used. This ranges from banning any state, county, or municipal funding to be used to operate the SSP (Florida) to forbidding the use of any public or state funds for the purchase of syringes either at all or under some circumstances (Indiana, North Dakota, Oklahoma, Tennessee, Virginia). New Hampshire requires programs to be self-funded but allows the state to disburse federal funds to SSPs, as well as state funds in some instances, and Ohio’s law makes the cost of an SSP the responsibility of the authorizing board of health. In New York, the requirements for a program’s operation are lessened if they do not receive funds from the Department of Health. 16
Beyond these specific restrictions, other components of state SSP statutes that can interfere with an SSP’s ability to provide community care were identified. For example, no state SSP laws specifically preempt local laws that prohibit or restrict SSP operation. This has led to litigation over local control in some states. In 2024, the Pueblo, Colorado city council passed a ban on SSPs that would forbid syringe exchange and distribution from several SSPs in the city. The American Civil Liberties Union sued the city, and the court determined that because the state has a strong interest in promoting the public health, the ordinance was a matter of statewide concern and resulted in an operational conflict with state law. The state law required SSPs to provide clean syringes, and the court found that an SSP “cannot operate a clean needle exchange program without the ability to exchange needles,” so the local ordinance was therefore preempted. 17 However, the ruling may have been different if the local ordinance had only restricted SSP operations, as the state statute contains no language expressly preempting local control. This leaves open the possibility that other SSPs in Colorado could face local restrictions that could hinder their operations. Localities in several other states have also banned or severely limited SSPs, even when their operation was legal under state law.
Two states’ SSP laws (Indiana and Oklahoma) contain a “sunset provision” — a date by which the carve-outs for SSPs to legally operate will be repealed if further amendments are not passed. Services provided by SSPs are life-sustaining: cutting off that access simply due to the law expiring can make life more chaotic for PWUD and make drug use more harmful. Programs may be hesitant to scale up, e.g. providing new services or products, if they do not know whether they will be legal to operate if and when the law sunsets.
Vague language in SSP authorization laws can be detrimental to harm reduction efforts as well. For example, some SSP statutes contain language allowing the provision of syringes as well as “other harm reduction supplies” or words to that effect. In Idaho, the state SSP authorization statute provided that an SSP could acquire “materials necessary” for the operation of the program. When Idaho programs began to see a shift in the drug use preferences of their participants, they began to distribute pipes for inhalation of drugs, as well as syringes, which led to a raid by Boise police and the seizure of safer smoking supplies. Though no one was ever arrested or charged with a crime, this police action directly led to the state legislature repealing the state’s authorization statute — the first and only time such a law has ever been repealed.
Discussion
Ostensibly designed to increase access to syringes and other harm reduction supplies, the state laws identified in this article can cause harm to PWUD, their families, and their communities.
These laws are categorically unnecessary. States should simply identify and remove laws that prohibit the possession and distribution of paraphernalia instead of creating complicated schemes that permit SSPs to operate only in limited situations, and should fully fund SSPs and other proven harm reduction initiatives. Given that these laws do exist, they should be informed by the experiences and desires of the people SSPs are designed to serve — people who use drugs.Reference Klein 18
SSPs and other programs that provide harm reduction services are stronger when they have input from the people who use the programs. People who use drugs can provide critical insights into the programs and policies that affect them and should be involved in their development and implementation. In addition, SSPs are essential partners in soliciting input from PWUD, and have a strong understanding of the policy and program landscape. Input from PWUD and SSP participants can be gathered in a variety of ways, both formal and informal. In Washington State, the University of Washington Addictions, Drug & Alcohol Institute (UW ADAI) partners with SSPs and state and local health departments to develop and administer surveys and qualitative interviews with SSP participants.
These surveys and interviews aim to learn more about the health of people who use drugs, and their preferences for services and programs; provide SSPs with data to inform their own programs and services in their local area; and inform state-level programs, policies, and services for PWUD.
SSPs provide input on questions and can adapt or add questions specifically for their program. Site-specific survey results are only shared with the corresponding program, and the SSP owns their data. This helps foster connections locally and ensures that the SSP has control over how their data are used. UW ADAI shares statewide summary data via meetings with SSPs, state and local government agencies, and through written reports and journal articles.
These surveys have produced a number of important findings, including that harm reduction helps improve the lives and protect the health of SSP participants, most participants surveyed want to reduce or stop their drug use, there are high levels of interest in mental and physical health care being provided at SSPs, and PWUD want holistic, low-barrier care.Reference Kingston 19
At the local level, Washington state SSPs have used these data to show the benefits that PWUD see from an SSP and support continued funding, to expand the services they provide to their participants, and to help humanize the public perception of PWUD. Specific examples of program expansion supported by survey data include the provision of safer smoking supplies, coordination with a local jail to increase naloxone distribution on release, and the addition of innovative, low-barrier health and substance use services at SSPs.Reference Kingston 20
At the state level, the survey and interviews have supported the continued funding of SSPs. They have also contributed to the development of the Health Hubs model in Washington state, where programs combine harm reduction services with health care, access to medications for opioid use disorder, and other substance use disorder treatment services.
Without timely input from PWUD, even well-meaning policymakers can find themselves behind the times in an ever-changing illicit drug market. For example, between 2020 and 2025, laws making it legal to provide and possess fentanyl test strips (FTS) proliferated throughout the United States, and even the federal government began to promote their use.Reference Davis 21 However, in many places these laws were enacted long after fentanyl had flooded the local drug supply. By 2021–22, PWUD were already using FTS less frequently than they had in the years prior.Reference Zibbell 22 Needs assessments and other coordination with on-the-ground programs could have informed policymakers that a broader decriminalization of drug checking equipment may have been a wiser policy choice, as comprehensive drug checking can play a crucial role in harm reduction services.Reference Moran 23
Another example of this legality lag is distribution of pipes and other safer smoking supplies from SSPs. Distribution of these objects is prohibited in 37 states, while PWUD have increasingly been turning to smoking, rather than injecting, drugs.Reference Davis 24 It is critical to keep up with changes in local drug use practices, as adapting to the needs of participants increases engagement with SSPs, allowing more opportunities for programs to offer support.Reference Chung 25
It can often be difficult for PWUD to make their voices heard when there is no outreach to their communities. Coalition building within the harm reduction movement can amplify those voices. Community-based SSPs and other harm reduction organizations are often involved in mutual aid or other coalitions, which can be very helpful and flexible in responding to immediate needs. However, public health departments and health policymakers can and should support and fund these community coalitions to provide a platform for advocacy for harm reductionists, as well as to assist in the implementation of public health interventions.
For example, the California Syringe Exchange Program (CASEP) coalition is an organizing group of SSPs that have used their collective power to fight for state funding for SSPs in California. 26 This funding has been “game-changing” for PWUD and for programs.Reference Lambdin 27 CASEP continues to work for SSPs in California, providing technical assistance, advocacy space, and mutual support for programs — and the state invests in CASEP through the state harm reduction budget, enabling programs to do more for more people. Community-based organizations are more effective than government-run organizations in the delivery of services to PWUD.Reference Ray 28 Supplying state funding to community-based SSPs allows states to have a larger impact on the community of people who use drugs than public health departments could do alone.Reference Fischer 29
Having PWUD in the room when decisions are being made about the services provided to them is the most direct way of creating policy that is reflective of the drug-using community’s needs. When Rhode Island policymakers began writing regulations to carry out the groundbreaking state law allowing the operation of overdose prevention centers (OPCs), they included members of the team from Project Weber/RENEW, which would be the first organization to open an explicitly state-legal OPC in the United States. Those team members advocated for the inclusion of safer smoking areas within the facilities. They were more in touch with the community of people who would be using the OPC and knew that without access to inhalation areas, many in the Black and brown community of Providence would be unlikely to use the facility, as they generally preferred smoking. People with lived and living experience of using drugs were able to guide the establishment of the nation’s first state-legal OPC into a location that would be engaging with as many PWUD as possible.Reference Castro 30
Engaging with PWUD in these ways can lead to policies that truly represent what PWUD need — “nothing about us, without us.”Reference Jürgens 31 Such engagement should be undertaken early in the policymaking process and should help guide both the policymaking and implementation process. 32 This could include participation as simple as answering survey questions to ongoing participation such as holding leadership positions within implementation teams — and the individuals and organizations involved in this policy-making process should be compensated equitably and ethically for their input and effort.Reference Szlyk 33 When contributing their knowledge to the policy process, PWUD are giving not just their time but their life experience, and deserve fair payment.
Conclusion
Despite overwhelming evidence that access to safer use supplies reduces harm to PWUD and their communities, laws in many states impose barriers to evidence-based and PWUD-informed interventions. People who use drugs are often the best informed about their needs and should be concretely involved in both policymaking and implementation.
Building off the input and leadership of people who use drugs, whether through surveys, coalition building, or direct guidance, policymakers can make changes that will increase community health. Given the extensive evidence that access to safer use supplies reduces harm to PWUD and the communities in which they live, policymakers should remove those barriers by repealing drug paraphernalia criminalization laws, as Minnesota did in 2023.Reference Davis 34 If unwilling to take that step, policymakers should seek advice from PWUD on how to modify existing law to improve the health, safety, and dignity of people who use drugs.
Open access
