Below is a compilation of peer-reviewed research about the public health impact of Syringe Service Programs (SSPs) since 2007. SSPs have an extensive evidence base that goes back nearly three decades. Meta-analyses reviewing this body of research are included on this list.
- Year
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Syringe Disposal Outcomes
- Syringe disposal among people who inject drugs before and after the implementation of a syringe services program.
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Syringe disposal among people who inject drugs before and after the implementation of a syringe services program.Year:2019Citation:
Drug & Alcohol Dependence. 202:13-17. doi: 10.1016/j.drugalcdep.2019.04.025.
Study Methods:Visual inspection walkthroughs of randomly selected census blocks in the neighborhoods in the top quartile of narcotics-related arrests were conducted to assess improperly discarded syringes. Syringe location was geocoded in ArcGIS. Adult PWID pre-SSP (n = 448) and post-SSP (n = 482) implementation were recruited for a survey using respondent-driven sampling in Miami. A Poisson regression model was used to determine the adjusted relative risk (aRR) of improper syringe disposal pre- and post-SSP.
Gap in evidence addressed:Due to the increase in people who use opioids in the US, there has been a steady increase in injection drug use. Without access to safe syringe disposal locations, people who inject drugs (PWID) have few options other than improper disposal, including in public places. In 2016, Florida's first legal Syringe Services Program (SSP) was established in Miami. This study aims to compare syringe disposal practices among PWID before and after the implementation of an SSP.
Key Findings:A total of 191 syringes/1000 blocks were found post-implementation versus 371/1000 blocks pre-implementation, representing a 49% decrease after SSP implementation. In the surveys, 70% reported any improper syringe disposal post-SSP implementation versus 97% pre-SSP implementation. PWID in the post-implementation survey had 39% lower adjusted relative risk (aRR = 0.613; 95% CI = 0.546, 0.689) of improper syringe disposal as compared to pre-implementation. There was a significant decrease in the number of improperly discarded syringes in public in Miami after the implementation of an SSP. Providing PWID with proper disposal venues such as an SSP could decrease public disposal in other communities
- Syringe disposal among people who inject drugs in Los Angeles: the role of sterile syringe source.
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Syringe disposal among people who inject drugs in Los Angeles: the role of sterile syringe source.Year:2014Citation:International Journal of Drug Policy 25(5):905-10. doi: 10.1016/j.drugpo.2014.05.008.Study Methods:
A cross-sectional sample of PWID (N=412) was recruited and administered a structured questionnaire between July 2011 and April 2013. Descriptive analyses investigated syringe access and disposal practices among participants. Multivariate logistic regression analysis identified adjusted associations between syringe source (syringe exchange program [SEP] or pharmacy) and improper syringe disposal.
Gap in evidence addressed:Few recent studies have investigated the prevalence of improperly discarded syringes in community settings by people who inject drugs (PWID). We examined whether syringe source was associated with the act of improper syringe disposal and amount of syringes improperly disposed of among PWID in Los Angeles, California.
Key Findings:Most participants were male (69%), homeless (62%) and low-income earners (64%). The majority (87%) of the sample received syringes from a SEP in the past six months, with 26% having received syringes from pharmacies and 36% from unauthorised sources (e.g., friend, drug dealer). Of more than 30,000 used syringes reportedly disposed of by participants during the past 30 days, 17% were disposed of improperly. Two percent of participants disposed of any used syringes at pharmacies, compared to 68% who used SEPs for syringe disposal. Having received sterile syringes from a SEP was independently associated with lower odds of improper syringe disposal; however, purchasing sterile syringes from pharmacies was associated with significantly higher odds of improper syringe disposal. In a city with both SEPs and pharmacies as syringe source and disposal options for PWID, these findings suggest that while pharmacies are selling syringes, they are not as readily involved in safe syringe disposal. Given limits on SEP availability and the large geographic size of Los Angeles County, augmenting current SEP services and providing other community disposal sites, including pharmacy disposal, processes could reduce improper syringe disposal among PWID in Los Angeles.
- A comparison of syringe disposal practices among injection drug users in a city with versus a city without needle and syringe programs
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A comparison of syringe disposal practices among injection drug users in a city with versus a city without needle and syringe programsYear:2012Citation:
Drug and Alcohol Dependence 123(1-3): 255-259. https://doi.org/10.1016/j.drugalcdep.2011.12.001
Study Methods:We conducted visual inspection walkthroughs in a random sample of the top-quartile of drug-affected neighborhoods in San Francisco, California (a city with NSPs) and Miami, Florida (a city without NSPs). We also conducted quantitative interviews with adult IDUs in San Francisco (N=602) and Miami (N=448).
Gap in evidence addressed:The United States (U.S.) approved use of federal funds for needle and syringe programs (NSPs) in December 2009. This study compares syringe disposal practices in a U.S. city with NSPs to a U.S. city without NSPs by examining the prevalence of improperly discarded syringes in public places and the self-reported syringe disposal practices of injection drug users (IDUs) in the two cities.
Key Findings:In the visual inspections, we found 44 syringes/1000 census blocks in San Francisco, and 371 syringes/1000 census blocks in Miami. Survey results showed that in San Francisco 13% of syringes IDUs reported using in the 30 days preceding the study interviews were disposed of improperly versus 95% of syringes by IDUs in Miami. In multivariable logistic regression analysis, IDUs in Miami had over 34 times the adjusted odds of public syringe disposal relative to IDUs in San Francisco (adjusted odds ratio=34.2, 95% CI=21.92, 53.47). We found eight-fold more improperly disposed syringes on walkthroughs in the city without NSPs compared to the city with NSPs, which was corroborated by survey data. NSPs may help IDUs dispose of their syringes safely in cities with large numbers of IDUs.
- Assessing a drop box programme: A spatial analysis of discarded needles
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Assessing a drop box programme: A spatial analysis of discarded needlesYear:2010Citation:
International Journal of Drug Policy 21(3):208-14. doi: 10.1016/j.drugpo.2009.07.003.
Study Methods:Using a dataset containing the locations of 7274 discarded needles and syringes collected monthly in the non-park open spaces of a 2.5 km2 neighbourhood of Montreal, Canada for a period of five years, we compared levels of discards before and after the installation of 12 drop boxes. We used quasi-Poisson regression to test the effects of drop boxes on monthly counts of collected discards for areas within a walking distance of 25, 50, 100 and 200m of a drop box. We adjusted for known time-dependent covariates linearly and unknown time-dependent covariates using a smoothing function.
Gap in evidence addressed:Distributing sterile injection equipment to injection drug users is one of few proven ways of lowering the transmission rate of blood borne viruses. Distribution of equipment has also been linked to increased needle discarding, which is a public health risk for both injectors and their host communities. Drop boxes (anonymous and public-access sharps containers) are a promising and increasingly popular means of reducing unsafe disposal, yet there is little empirical research to support or guide their implementation.
Key Findings:We found strong evidence of reduced discarding following the installation of drop boxes; drop boxes were associated with reductions of up to 98% (95% CI: 72 100%) and significant reductions for areas up to 200m from a drop box. Reductions were inversely proportional to walking distance from drop boxes. No measure of weather or use of needle exchange programmes (NEPs) had a consistent relationship with discard counts. Our research suggests that IDUs changed their needle-disposal behaviour in response to increased safe disposal options. In addition to being relatively low-threshold, economical and rapid, drop boxes appear to be a highly effective intervention to reduce discarded needles.
- Higher syringe coverage is associated with lower odds of HIV risk and does not increase unsafe syringe disposal among syringe exchange program clients
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Higher syringe coverage is associated with lower odds of HIV risk and does not increase unsafe syringe disposal among syringe exchange program clientsYear:2007Citation:
Drug and Alcohol Dependence 89(2-3) doi: 10.1016/j.drugalcdep.2006.12.035
Study Methods:HIV risk assessments with 1577 injection drug users (IDUs) recruited from 24 SEPs in California between 2001 and 2003. Individual syringe coverage was calculated as a proportion of syringes retained from SEP visits to total number of injections in the last 30 days.
Gap in evidence addressed:To determine if adequate syringe coverage --"one shot for one syringe"--among syringe exchange program (SEP) clients is associated with injection-related HIV risk behaviors and syringe disposal.
Key Findings:Participants were divided into four groups based on syringe coverage: <50%, 50-99%, 100-149%, and 150% or more. In multivariate logistic regression, SEP clients with less than 50% syringe coverage had significantly higher odds of reporting receptive syringe sharing in the last 30 days (adjusted odds ratio [AOR]=2.3; 95% confidence interval [CI]=1.4, 3.6) and those with 150% or more coverage had lower odds of reporting receptive syringe sharing (AOR=0.5; 95%CI=0.3, 0.8) as compared to SEP clients with adequate syringe coverage of 100-149%. Similar associations were observed for other main outcomes of distributive syringe sharing and syringe re-use. No differences in safe syringe disposal were observed by syringe coverage. Individual syringe coverage is strongly associated with safer injection behaviors without impacting syringe disposal among SEP clients. Syringe coverage is a useful measure for determining if IDUs are obtaining sufficient syringes to lower HIV risk.
- Safe Syringe Disposal is Related to Safe Syringe Access among HIV-positive Injection Drug Users
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Safe Syringe Disposal is Related to Safe Syringe Access among HIV-positive Injection Drug UsersYear:2007Citation:
AIDS and Behavior 11(5):652-62. doi: 10.1007/s10461-006-9171-x
Study Methods:We evaluated the effect of syringe acquisition on syringe disposal among HIV-positive injection drug users (IDUs) in Baltimore, New York City, and San Francisco (N=680; mean age 42 years, 62% male, 59% African-American, 21% Hispanic, 12% White).
Gap in evidence addressed:An additional reason to focus on proper syringe disposal is that removal of syringes from circulation may itself be an important component of prevention of blood-borne disease transmission. HIV-1 may persist in syringes for up to 4 weeks (Abdala, Stephens, Griffith, & Heimer,1999) and greater duration of syringe circulation is associated with increased HIV risk behaviors (Kaplan & Heimer,1994). When few opportunities exist to dispose of syringes properly, they may remain in circulation for longer periods of time, elevating the risk of disease transmission.
Key Findings:Independent predictors of safe disposal were acquiring syringes through a safe source and ever visiting a syringe exchange program. Weaker predictors included living in San Francisco, living in the area longer, less frequent binge drinking, injecting with an HIV+ partner, peer norms supporting safe injection, and self-empowerment. Independent predictors of safe "handling"-both acquiring and disposing of syringes safely-also included being from New York and being older. HIV-positive IDUs who obtain syringes from a safe source are more likely to safely dispose; peer norms contribute to both acquisition and disposal. Our data have implications for interventions to improve the health of injectors and of the general public. Like diabetics, IDUs likely dispose of syringes by the most convenient means, suggesting that safe disposal messages and readily accessible syringe disposal units in public places would advance safe disposal practices. Interventions to improve disposal should include expanding sites of safe syringe acquisition while enhancing disposal messages, alternatives, and convenience.
- Author
- Title
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Publication Topic: Syringe Disposal Outcomes
Year Citation Study Methods Gap in evidence addressed Key Findings A comparison of syringe disposal practices among injection drug users in a city with versus a city without needle and syringe programs (2012) Tookes, Kral, Wenger Cardenas, Martinez, Sherman, Pereyra, Forrest, LaLot, Metscha, 2012 Drug and Alcohol Dependence 123(1-3): 255-259. https://doi.org/10.1016/j.drugalcdep.2011.12.001
We conducted visual inspection walkthroughs in a random sample of the top-quartile of drug-affected neighborhoods in San Francisco, California (a city with NSPs) and Miami, Florida (a city without NSPs). We also conducted quantitative interviews with adult IDUs in San Francisco (N=602) and Miami (N=448).
The United States (U.S.) approved use of federal funds for needle and syringe programs (NSPs) in December 2009. This study compares syringe disposal practices in a U.S. city with NSPs to a U.S. city without NSPs by examining the prevalence of improperly discarded syringes in public places and the self-reported syringe disposal practices of injection drug users (IDUs) in the two cities.
In the visual inspections, we found 44 syringes/1000 census blocks in San Francisco, and 371 syringes/1000 census blocks in Miami. Survey results showed that in San Francisco 13% of syringes IDUs reported using in the 30 days preceding the study interviews were disposed of improperly versus 95% of syringes by IDUs in Miami. In multivariable logistic regression analysis, IDUs in Miami had over 34 times the adjusted odds of public syringe disposal relative to IDUs in San Francisco (adjusted odds ratio=34.2, 95% CI=21.92, 53.47). We found eight-fold more improperly disposed syringes on walkthroughs in the city without NSPs compared to the city with NSPs, which was corroborated by survey data. NSPs may help IDUs dispose of their syringes safely in cities with large numbers of IDUs.
Assessing a drop box programme: A spatial analysis of discarded needles (2010) de Montigny, Vernez, Moudon, Leigh, Kim, 2010 International Journal of Drug Policy 21(3):208-14. doi: 10.1016/j.drugpo.2009.07.003.
Using a dataset containing the locations of 7274 discarded needles and syringes collected monthly in the non-park open spaces of a 2.5 km2 neighbourhood of Montreal, Canada for a period of five years, we compared levels of discards before and after the installation of 12 drop boxes. We used quasi-Poisson regression to test the effects of drop boxes on monthly counts of collected discards for areas within a walking distance of 25, 50, 100 and 200m of a drop box. We adjusted for known time-dependent covariates linearly and unknown time-dependent covariates using a smoothing function.
Distributing sterile injection equipment to injection drug users is one of few proven ways of lowering the transmission rate of blood borne viruses. Distribution of equipment has also been linked to increased needle discarding, which is a public health risk for both injectors and their host communities. Drop boxes (anonymous and public-access sharps containers) are a promising and increasingly popular means of reducing unsafe disposal, yet there is little empirical research to support or guide their implementation.
We found strong evidence of reduced discarding following the installation of drop boxes; drop boxes were associated with reductions of up to 98% (95% CI: 72 100%) and significant reductions for areas up to 200m from a drop box. Reductions were inversely proportional to walking distance from drop boxes. No measure of weather or use of needle exchange programmes (NEPs) had a consistent relationship with discard counts. Our research suggests that IDUs changed their needle-disposal behaviour in response to increased safe disposal options. In addition to being relatively low-threshold, economical and rapid, drop boxes appear to be a highly effective intervention to reduce discarded needles.
Higher syringe coverage is associated with lower odds of HIV risk and does not increase unsafe syringe disposal among syringe exchange program clients (2007) Bluthenthal, Anderson, Flynn, Kral, 2007 Drug and Alcohol Dependence 89(2-3) doi: 10.1016/j.drugalcdep.2006.12.035
HIV risk assessments with 1577 injection drug users (IDUs) recruited from 24 SEPs in California between 2001 and 2003. Individual syringe coverage was calculated as a proportion of syringes retained from SEP visits to total number of injections in the last 30 days.
To determine if adequate syringe coverage --"one shot for one syringe"--among syringe exchange program (SEP) clients is associated with injection-related HIV risk behaviors and syringe disposal.
Participants were divided into four groups based on syringe coverage: <50%, 50-99%, 100-149%, and 150% or more. In multivariate logistic regression, SEP clients with less than 50% syringe coverage had significantly higher odds of reporting receptive syringe sharing in the last 30 days (adjusted odds ratio [AOR]=2.3; 95% confidence interval [CI]=1.4, 3.6) and those with 150% or more coverage had lower odds of reporting receptive syringe sharing (AOR=0.5; 95%CI=0.3, 0.8) as compared to SEP clients with adequate syringe coverage of 100-149%. Similar associations were observed for other main outcomes of distributive syringe sharing and syringe re-use. No differences in safe syringe disposal were observed by syringe coverage. Individual syringe coverage is strongly associated with safer injection behaviors without impacting syringe disposal among SEP clients. Syringe coverage is a useful measure for determining if IDUs are obtaining sufficient syringes to lower HIV risk.
Safe Syringe Disposal is Related to Safe Syringe Access among HIV-positive Injection Drug Users (2007) Coffin, Latka, Latkin, Wu, Purcell, Metsch, Gomez, Gourevitch, 2007 AIDS and Behavior 11(5):652-62. doi: 10.1007/s10461-006-9171-x
We evaluated the effect of syringe acquisition on syringe disposal among HIV-positive injection drug users (IDUs) in Baltimore, New York City, and San Francisco (N=680; mean age 42 years, 62% male, 59% African-American, 21% Hispanic, 12% White).
An additional reason to focus on proper syringe disposal is that removal of syringes from circulation may itself be an important component of prevention of blood-borne disease transmission. HIV-1 may persist in syringes for up to 4 weeks (Abdala, Stephens, Griffith, & Heimer,1999) and greater duration of syringe circulation is associated with increased HIV risk behaviors (Kaplan & Heimer,1994). When few opportunities exist to dispose of syringes properly, they may remain in circulation for longer periods of time, elevating the risk of disease transmission.
Independent predictors of safe disposal were acquiring syringes through a safe source and ever visiting a syringe exchange program. Weaker predictors included living in San Francisco, living in the area longer, less frequent binge drinking, injecting with an HIV+ partner, peer norms supporting safe injection, and self-empowerment. Independent predictors of safe "handling"-both acquiring and disposing of syringes safely-also included being from New York and being older. HIV-positive IDUs who obtain syringes from a safe source are more likely to safely dispose; peer norms contribute to both acquisition and disposal. Our data have implications for interventions to improve the health of injectors and of the general public. Like diabetics, IDUs likely dispose of syringes by the most convenient means, suggesting that safe disposal messages and readily accessible syringe disposal units in public places would advance safe disposal practices. Interventions to improve disposal should include expanding sites of safe syringe acquisition while enhancing disposal messages, alternatives, and convenience.
Syringe disposal among people who inject drugs before and after the implementation of a syringe services program. (2019) Levine, Bartholomew, Rea-Wilson, Onugha, Arriola, Cardenas, Forrest, Kral, Metsch, Spencer, Tookes, 2019 Drug & Alcohol Dependence. 202:13-17. doi: 10.1016/j.drugalcdep.2019.04.025.
Visual inspection walkthroughs of randomly selected census blocks in the neighborhoods in the top quartile of narcotics-related arrests were conducted to assess improperly discarded syringes. Syringe location was geocoded in ArcGIS. Adult PWID pre-SSP (n = 448) and post-SSP (n = 482) implementation were recruited for a survey using respondent-driven sampling in Miami. A Poisson regression model was used to determine the adjusted relative risk (aRR) of improper syringe disposal pre- and post-SSP.
Due to the increase in people who use opioids in the US, there has been a steady increase in injection drug use. Without access to safe syringe disposal locations, people who inject drugs (PWID) have few options other than improper disposal, including in public places. In 2016, Florida's first legal Syringe Services Program (SSP) was established in Miami. This study aims to compare syringe disposal practices among PWID before and after the implementation of an SSP.
A total of 191 syringes/1000 blocks were found post-implementation versus 371/1000 blocks pre-implementation, representing a 49% decrease after SSP implementation. In the surveys, 70% reported any improper syringe disposal post-SSP implementation versus 97% pre-SSP implementation. PWID in the post-implementation survey had 39% lower adjusted relative risk (aRR = 0.613; 95% CI = 0.546, 0.689) of improper syringe disposal as compared to pre-implementation. There was a significant decrease in the number of improperly discarded syringes in public in Miami after the implementation of an SSP. Providing PWID with proper disposal venues such as an SSP could decrease public disposal in other communities
Syringe disposal among people who inject drugs in Los Angeles: the role of sterile syringe source. (2014) Quinn, Chu, Wenger, Bluthenthal, Kral 2014 International Journal of Drug Policy 25(5):905-10. doi: 10.1016/j.drugpo.2014.05.008. A cross-sectional sample of PWID (N=412) was recruited and administered a structured questionnaire between July 2011 and April 2013. Descriptive analyses investigated syringe access and disposal practices among participants. Multivariate logistic regression analysis identified adjusted associations between syringe source (syringe exchange program [SEP] or pharmacy) and improper syringe disposal.
Few recent studies have investigated the prevalence of improperly discarded syringes in community settings by people who inject drugs (PWID). We examined whether syringe source was associated with the act of improper syringe disposal and amount of syringes improperly disposed of among PWID in Los Angeles, California.
Most participants were male (69%), homeless (62%) and low-income earners (64%). The majority (87%) of the sample received syringes from a SEP in the past six months, with 26% having received syringes from pharmacies and 36% from unauthorised sources (e.g., friend, drug dealer). Of more than 30,000 used syringes reportedly disposed of by participants during the past 30 days, 17% were disposed of improperly. Two percent of participants disposed of any used syringes at pharmacies, compared to 68% who used SEPs for syringe disposal. Having received sterile syringes from a SEP was independently associated with lower odds of improper syringe disposal; however, purchasing sterile syringes from pharmacies was associated with significantly higher odds of improper syringe disposal. In a city with both SEPs and pharmacies as syringe source and disposal options for PWID, these findings suggest that while pharmacies are selling syringes, they are not as readily involved in safe syringe disposal. Given limits on SEP availability and the large geographic size of Los Angeles County, augmenting current SEP services and providing other community disposal sites, including pharmacy disposal, processes could reduce improper syringe disposal among PWID in Los Angeles.
If you have questions or notice errors in this list, please contact Tim Candela, Drug User Health Coordinator: tim.candela@doh.wa.gov.