Safer Smoking Supplies and Syringe Service/Harm Reduction Programs in the US

"Research has shown a shifting trend from injecting toward smoking opioids since 2020, especially along the West Coast (Kral et al., 2021, Parent et al., 2021, Kingston et al., 2022, Megerian et al., 2024, Eger et al., 2024, Tanz et al., 2024). Some SSPs [Syringe Service Programs were providing smoking supplies prior to this shift, while others more recently implemented safer smoking supply distribution to meet emerging needs and maintain participant engagement. However, access to and distribution of safer smoking supplies remain controversial, especially the distribution of smoking pipes. U.S. federal law prohibits the use of federal funds to purchase safer smoking supplies (Centers for Disease Control and Prevention, 2024c, US Department of Health and Human Services, 2016). The introduction of safer smoking supplies by SSPs was met with considerable public opposition, including the Cutting Rampant Access to Crack Kits (CRACK) Act by Senator Marco Rubio (R-FL) and the Preventing Illicit Paraphernalia for Exchange Systems (PIPES) Act by Senators Rubio and Manchin (D-WV) (Rubio, 2022a, Rubio, 2022b). This public opposition culminated in the Biden administration revising its policies and disallowing SSPs from using federal funding for harm reduction to procure smoking supplies (Becerra and Gupta, 2022). In contrast to the public response to prescription opioid use primarily among White people (Netherland and Hansen, 2017), the political opposition against the distribution of smoking pipes appears to be a negative externality of the racially motivated War on Drugs, which has primarily targeted Black and Brown communities in the U.S. for the past 50 years (Cohen et al., 2022). The federal ban and political opposition have forced SSPs that are distributing safer smoking supplies to patch together different funding sources—individual donations, private funding, state grants, etc.—to support implementation. SSP funding levels already do not meet minimum benchmarks, and insufficient funding threatens the implementation of evidence-based interventions (Facente et al., 2024, Akiba et al., 2024). Our findings highlight how critical it is to financially support SSPs to implement safer drug use supplies in the evolving political context and shifting drug use patterns.

"SSPs classified as DPHs [Departments of Public Health], HCOs [Health Care Organizations], or other distributed pipes for smoking less often than SSPs classified as CBOs [Community Based Organizations]. Recent research found CBO SSPs provided a greater number of syringes, naloxone doses, fentanyl test strips, and buprenorphine compared to DPH SSPs (Ray et al., 2024). Given the federal ban on purchasing pipes, DPH SSPs may experience greater legal and financial obstacles for pipe distribution compared to CBO SSPs. Furthermore, CBO SSPs tend to adopt innovative approaches more quickly than DPHs or HCOs (Wenger et al., 2021), including mail-based harm reduction supplies, low-barrier buprenorphine, vaccinations during the COVID-19 pandemic, and delivering HIV pre-exposure prophylaxis (PrEP) (Wenger et al., 2021, Aronowitz et al., 2021, Behrends et al., 2022, Hood et al., 2020, Heidari et al., 2024, Bartholomew et al., 2022). We also found differences in pipe distribution across Census divisions, with SSPs in the Pacific having the highest proportion of pipe distribution. This finding may reflect how SSPs responded to the shift to smoking fentanyl along the West coast as well as more political and legal support for harm reduction services compared to other U.S. regions. For instance, safer smoking supply distribution by SSPs is legal in California and Washington.(Office of AIDS, n.d.; Wash. Rev. Code § 69.50.4121., 2023)"