NEXT: description, rationale, and evaluation of a novel internet-based mail-delivered syringe servic

Journal of Substance Use

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/ijsu20

NEXT: description, rationale, and evaluation of a novel internet-based mail-delivered syringe service program

Benjamin T. Hayes, Jamie Favaro, Czarina N. Behrends, Daniel Coello, Andrea Jakubowski

& Aaron D. Fox

To cite this article: Benjamin T. Hayes, Jamie Favaro, Czarina N. Behrends, Daniel Coello, Andrea Jakubowski & Aaron D. Fox (2022): NEXT: description, rationale, and evaluation of a novel internet-based mail-delivered syringe service program, Journal of Substance Use, DOI: 10.1080/14659891.2022.2144500

To link to this article: https://doi.org/10.1080/14659891.2022.2144500

Published online: 11 Nov 2022.

Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=ijsu20

JOURNAL OF SUBSTANCE USE

https://doi.org/10.1080/14659891.2022.2144500

NEXT: description, rationale, and evaluation of a novel internet-based mail-delivered syringe service program

Benjamin

T.

Hayes a , Jamie Favarob, Czarina N. Behrends c , Daniel Coellob, Andrea Jakubowski a , and Aaron D. Fox a

aDivision of General Internal Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA; bNEXT Harm Reduction, New York, NY, USA; cPopulation Health Sciences, Weill Cornell Medicine, New York, NY, USA

ABSTRACT

Background: Despite proven health benefits, harm reduction services provided through in-person syringe services programs (SSPs) and pharmacies are largely unavailable to most people who inject drugs (PWID). Internet-based mail-delivered harm reduction services could overcome barriers to inperson SSPs. This manuscript describes Needle Exchange Technology (NEXT) Harm Reduction, the first formal internet-based mail delivery SSP in the US.

Methods: We examined the trajectory of NEXT’s growth between February 2018 and August 2021. Descriptive statistics were used to characterize program participants. All analysis were run using STATA statistical software.

Results: Over the course of 42 months, 1,669 unique participants enrolled in NEXT. The program distributed 1,648,162 total syringes with a median of 79,449 syringes per month. Most participants ordered multiple times (61%); 31% had more 5 or more orders (upper range = 48 orders). The total number of syringes per month and total number of first-time syringe orders per month increased steadily over time, particularly after the onset of the COVID-19 pandemic.

Conclusions: The online platform and mail-delivery model appears successful in reaching PWID at high risk for harms from IDU. Changes to state laws and additional funding support are needed to make maildelivery harm reduction more widely available throughout the US.

Introduction

Over several decades, the “opioid epidemic” has been linked to increasing overdose deaths, incidence of HCV and outbreaks of HIV in the United States (US) (Alpren et al., 2020; Centers for Disease Control and Prevention, 2020a, 2020c; Peters et al., 2016). From 2004 to 2014 the rate of HCV infection increased 133%, mirroring increases in opioid use disorder (Zibbell et al., 2018). Skin, soft tissue, and endovascular infections are increasingly causes of morbidity and mortality among people who inject drugs (PWID) (Capizzi et al., 2020; Ciccarone et al., 2016; Wurcel et al., 2016). Between 2001 and 2016, opioidrelated deaths increased by 345% (Gomes et al., 2018).

Harm reduction services can prevent infections and over dose deaths among PWID. Access to sterile injection supplies (e.g., syringes, cotton filters, etc.) reduces the sharing of injec tion equipment that can lead to transmission of HIV and HCV (Normand et al., 1995; Wodak & McLeod, 2008). Distributing naloxone, medication used to reverse opioid overdoses, to trained non-medical persons, reduces risk of overdose deaths (McDonald et al., 2017). Leading public health authorities recognize these evidence-based practices as integral to prevent ing morbidity and mortality (Centers for Disease Control and Prevention, 2019; World Health Organization, 2004, 2014).

In the US, these harm reduction services are insufficiently available to meet most PWIDs’ needs. For example, although

ARTICLE HISTORY

Received 28 October 2021

Accepted 30 October 2022

KEYWORDS

Syringe services program; harm reduction; HIV/AIDS; HCV; public health services

69% of syringe services programs (SSPs) are located in cities, half of PWID are estimated to live outside of urban areas (Des Jarlais et al., 2015). Of the 220 US counties most at risk for injection-related outbreaks of HCV and HIV, only 7% had SSPs in 2016 (Van Handel et al., 2016). Estimates for the number of sterile syringes needed to reduce blood-borne pathogen transmission range from 200 to 900 syringes per PWID per year, yet access in the US is closer to 39 sterile syringes per PWID per year (Larney et al., 2017; Nguyen et al., 2014; World Health Organization, 2013).

The US relies upon “in-person” SSPs to deliver harm reduc tion services, but innovations are needed to expand access. Inperson SSPs, which typically provide services from buildings or mobile vehicles, have the advantage of offering supplies ondemand and creating a comfortable space for PWID. However, stigma, fear of harassment from law enforcement, and geo graphic availability prevent PWID from accessing in-person services (Beletsky et al., 2014; Rivera et al., 2014; Surratt et al., 2020; Williams & Metzger, 2010). Women, young people and racial and ethnic minorities, who have unique and elevated risks from injection drug use (IDU), may avoid in-person SSPs (Canary et al., 2017; Cloud et al., 2019; Collins et al., 2019; Dayton et al., 2020; Des Jarlais et al., 2015, 2017; Lyons et al., 2019; Nerlander et al., 2017; Zibbell et al., 2018). Efforts to overcome these barriers have met resistance from local

CONTACT Benjamin T. Hayes bhayes@montefiore.org Division of General Internal Medicine, Montefiore Medical Center, 3300 Kossuth Ave, Bronx, NY 10467, USA

communities and state or federal government, impeding the opening of new in-person SSPs (Des Jarlais et al., 2013, 2020).

State policy changes to increase access to harm reduction services have been inadequate in the face of growing demand. Many states allow pharmacies to distribute sterile syringes and naloxone without prescriptions (Janulis et al., 2020). Pharmacy distribution has been limited, however, by stigma and objec tions from pharmacists who misunderstand or disagree with legal changes (Chiarello, 2016; Meyerson et al., 2019; Pollini et al., 2015). In-person SSPs have increased in number as state laws have allowed, but syringe distribution has not expanded sufficiently to prevent injection-related harms (Des Jarlais et al., 2015). Thus, new approaches are needed to complement in-person SSPs.

Remote internet-based mail-delivered harm reduction ser vices could reach underserved populations of PWID. For years, harm reduction practitioners have mailed supplies to people who do not attend in-person SSPs, and this approach is ready to be scaled, capitalizing upon internet platforms. This manu script will describe Needle Exchange Technology (NEXT) Harm Reduction, the first formal internet-based mail delivery SSP in the US, present rationale supporting NEXT’s approach, and provide preliminary evidence demonstrating NEXT’s abil ity to distribute harm reduction services.

Examples of remote harm reduction services

Since the 1990s, SSP innovations have included syringe distri bution through mobile vehicles, home deliveries, secondary exchange programs (i.e., SSP participants receive extra injec tion supplies to distribute to others who do not attend inperson), and mail delivery. Mobile vehicles offer services in multiple locations or in areas where establishing in-person centers would be infeasible. Home-delivery, where SSP staff hand deliver supplies to clients at specific locations, can reach people who do not attend in-person services (Behrends et al., 2017). Secondary exchange programs have had some success in reaching PWID who are at particularly high-risk for injectionrelated infectious complications (De et al., 2008; Snead et al., 2003). These methods remain limited, however, by staff sche dules, geographic proximity to an SSP, and available resources. Internet-based mail-delivered harm reduction services obviate the need to physically attend an in-person program to receive supplies. Without support from public health authorities, how ever, these efforts are under-funded and limited in availability.

NEXT model overview

NEXT Harm Reduction provides harm reduction services online and delivers supplies through the mail. Using an internet platform and secure messaging services, NEXT securely and confidentially fulfills harm reduction supply requests, provides harm reduction education, and links participants to local harm reduction services. NEXT could potentially mail supplies to people in any region in the US with internet and mail access. NEXT currently collaborates with public health agencies and local in-person SSPs in several states across the U.S. to deliver sterile injection equipment to regional residents. In delivering naloxone, NEXT has partnered with affiliates in thirty-two

states who help to coordinate and fulfill the naloxone requests within that state. NEXT’s platform is user-friendly and private, and staff members provide education and support to partici pants, which combines the convenience of internet services with personal connection.

Program development and evolution

Prior to NEXT’s formation, other harm reductionists infor mally mailed supplies to PWID and have described these methods to successfully reach isolated and underserved PWID (Szalavitz, 2019). These efforts provided “proof of con cept” and inspired the establishment of NEXT in 2017 by Jamie Favaro, the current director. NEXT was founded in consulta tion with stakeholders who had expertise in drug user health, harm reduction program implementation and state-level pol icy. Core principles include having people with lived experi ence using drugs in positions of leadership and program design; ensuring participant privacy and security; and main taining a personal connection with participants. NEXT’s uniqueness comes from its online platform for confidentially requesting supplies and drug user health information. Established in New York, NEXT was waivered through the New York State Department of Health to distribute sterile injection equipment and registered as a New York State Opioid Overdose Prevention program to deliver naloxone. NEXT has since established partnerships with SSPs throughout the US to provide similar services in other states, currently California, Louisiana, Michigan, Oklahoma, and Nevada.

Program description

NEXT provides free harm reduction services that are available at in-person SSPs, including sterile drug-use supplies, naloxone for overdose prevention, and safe disposal equipment, such as sharps containers and devices to clip off needle points. NEXT was designed to expand services for people who are unable to access in-person SSPs, not replace, existing SSPs. In this spirit, NEXT reviews potential participants’ online applications and assesses their ability and willingness to use existing local SSPs. If participants cannot access in-person services (e.g., they are geographically isolated from an SSP or uncomfortable attend ing in-person services), NEXT will determine they are eligible for their mail-delivery services and mail them the requested supplies along with drug use-related health information. Otherwise, NEXT staff will help navigate people to a local SSP.

The NEXT website allows for people to make confidential supply requests, find local SSPs, and access harm reduction information at no cost. NEXT receives and processes all orders through their online platform. In states where NEXT has an instate SSP partner, NEXT informs the partner SSP of incoming orders, and the SSP sends supplies to participants. In states where NEXT has no in-state SSP partner, NEXT staff will directly mail supplies to participants. Participants may request supplies for themselves and other people. NEXT follows state regulations that limit the quantity of syringes that may be distributed for individual use, which typically range from 200 to 400 per month. Participants who wish to distribute supplies to other people, known as “secondary exchange,” may request

as many as 1,500 syringes per month. NEXT will register these participants in their secondary exchange program. NEXT includes personal notes with each shipment to enhance con nection with harm reduction staff.

Most discover the program website through word-ofmouth; however, Reddit and Google searches are also common entry points. The website is available in English and Spanish and integrates both text and video-based education on strate gies for safer drug use and overdose prevention. First-time recipients of naloxone are required to complete an online training. NEXT encourages that all communications occur through encrypted messaging and mail services, such as Signal and Protonmail. Staff members are also available by phone. People who are living homeless or are unstably housed will often use general delivery services at a local US Postal Service branch or will have mail delivered to family or friends.

Legal considerations

Federal law prohibiting the transport of drug paraphernalia through the mail is a legal barrier to mailing injection supplies (“United States Code, 2006 Edition, Supplement 4, Title 21 Drug paraphernalia,” 2010). In the US, equipment used to inject illicit drugs can be purchased and mailed through online marketplaces, however once supplies are paired with safer injection education, those supplies can be criminalized as drug paraphernalia (Burris, 2017). For example, mailing insu lin syringes with harm reduction education could fall under drug paraphernalia laws. As of 2019, 39 states have modified laws to allow for distribution of syringes, however, these allow ances are generally restricted to state-authorized SSPs (Fernández-Viña et al., 2020). Thus, recipients of syringes from non-authorized SSPs are at risk for legal repercussions in states that have not explicitly allowed SSPs and maildelivery. NEXT prioritizes the harm reduction needs of parti cipants, and staff communicate to participants any potential legal risks before mailing supplies. Although NEXT staff have found that most participants are willing to accept these risks, they likely deter some potential participants from ordering supplies.

For naloxone, most states have legal provisions to allow naloxone to be distributed under “non-patient specific pre scriptions.” This allows programs to distribute naloxone to anyone who may experience or witness an opioid overdose. For example, a state health official may issue a “standing order” that applies to all entities in the state, subject to certain direc tives. However, these directives vary state by state and may pose legal barriers to mail-delivery (Breen & Davis, 2019; Davis & Carr, 2017).

Methods

Program evaluation

To examine the trajectory of NEXT’s growth, we character ized all program participants, and evaluated the volume of syringes distributed and first-time syringe orders placed per month. We used data for participants who ordered any harm reduction supplies, including syringes and naloxone, between

February 15 2018 and August 16 2021. Data on sociodemo graphics, health status, and drug use behaviors were collected from a questionnaire completed by all participants who requested injection supplies for individual use at the time they first requested services. Some participants who initially enrolled in the syringe program requested other harm reduc tion supplies and did not ultimately order syringes. Participants enrolled in the secondary exchange program enroll were not included in this sample. Data from the participant questionnaires were self-reported. Data on syr inge orders were provided by NEXT from their program records. Both of these data sets (the questionnaires and program records) were de-identified and could not be merged. Data for naloxone distribution has been previously reported (Yang et al., 2021). Descriptive statistics (i.e., med ian and proportions) were used to characterize program participants. All analysis were run using STATA statistical software.

Results Participant description

Over the course of 42 months, 1,669 unique participants enrolled in NEXT and 1,594 unique participants received injection supplies. 75 participants did not receive injection supplies (64 ordered naloxone only, 9 ordered other harm reduction supplies, and 2 made no orders during the study period). Of the 1,669 participants enrolled in NEXT, the med ian age was 36 years and participants were mostly women (54%) and non-Hispanic white (94%) (see Table 1). Most participants were stably housed (61%) and uninsured (53%). Less than half of participants were parenting (38%). Self-reported infection with HCV was common (30%), while HIV was not (<1%). Methamphetamine was the most common drug used in the past 30 days (72%), followed by heroin (63%), benzodiazepines (34%), and opioid analgesics (31%). Only 20 participants (1%) reported that they knowingly used fentanyl.A substantial percentage of participants reported having overdosed in the prior year (30%), and most had wit nessed an overdose (74%).

Program measures

During the study period, the program distributed 1,648,162 total syringes with a median of 79,449 syringes per month. From February 15 2018 through August 16 2021, the median number of total orders per month was 312 (interquartile (IQ) range: 134–423) and first-time syringes orders per month was 65 (IQ range: 31–92). Most participants ordered multiple times (61%); 31% had more 5 or more orders (upper range = 48 orders). The median number of syringes requested for each individual order was 269.2 (IQ range: 237.1–277.1), while the median number of syringes ordered for first time orders was 140 (IQ range: 102–200). Both the total number of syringes per month (see Figure 1) and total number of first-time syringe orders per month (see Figure 2) showed an increasing trend over time.

Table 1. Baseline sociodemographic characteristics among par ticipants enrolling in syringe services program at NEXT, an online mail-delivery SSP (N = 1,669)*.

Characteristic

n (%)

Age, median (IQR), mean (95% CI) 36 (30,45) Gender (cis-women/men) (n = 1,448)* cis-women 779 (53.8) cis-men 605 (42)

Genderqueer or transgender 64 (4.1) LGBQ (yes) 520 (31.1) Latinx (yes) ** 62 (3.7)

Race (n = 1,441)* white

1,351 (93.8) AA, Black 26 (1.8) NA, AN 29 (2.0) Other (API, no ID) 35 (2.4) Parenting (yes) (n = 1,441)* 542 (37.5)

Housing

Stably housed

1,021 (61.2) Homeless or unstably housed 648 (38.8) Health Insurance (yes) (n = 1,441)* 676 (46.8)

Chronic disease

HCV 499 (29.9) HIV 12 (0.72)

Current Drug Use (yes)

Heroin 1,044 (62.6) Opioid analgesics 512 (30.7) Benzodiazepines 569 (34.1) Methamphetamines 1,209 (72.4)

Overdose (OD), past year (yes) OD (n = 1,441)* 432 (30.0) Witnessed OD (n = 1,441)* 1,067 (74.1)

IQR= interquartile range; CI=confidence intervals; LGBQ= Lesbian, gay, bisexual, or questioning; AA= African American; NA= Native American; AN=Alaskan Native; API=Asian or Pacific Islander; ID=identification.

*Total number of respondents indicated for each measure only if missing responses.

**Includes Hispanic, Latina, and Latino. March 2020

Figure 1. Total syringe orders per month from February 15, 2018 to August 16, 2021.

Discussion

Lessons learned

The program leadership emphasizes several lessons learned: (1) The online platform and mail-delivery model appears successful in reaching PWID at high risk for IDU-related harms. Participants reported high rates of HCV infection, overdose, and witnessing overdoses. (2) NEXT also reaches women and younger adults who are at high risk for complications of IDU but face obstacles to traditional in-person SSPs (Canary et al., 2017; Dayton et al., 2020; Nerlander et al., 2017). For example, a 2016–2017 national survey found that only 34% of SSP participants were women, thus NEXT’s high proportion of women is encouraging (Behrends et al., 2018). (3) Demand for NEXT services has rapidly escalated since its inception. This escalation coincided with the onset of COVID-19 (see Figures 1 and 2), when many PWID were impacted by home-isolation orders and in-person SSPs reduced their capacity (Glick et al., 2020). The increasing demand for NEXT may have been boosted by this altered landscape of service delivery, however the trend suggests broadening interest in this model. Future work will determine whether NEXT sustains high demand for services post-COVID. (4) NEXT has received high volume requests from regions that lack waivers for mail-delivered sterile injection equipment (data not shown). NEXT hopes to collaborate with health departments in these regions to increase harm reduction service access in these areas. (5) NEXT has found that personal connection with participants sustains ongoing utili zation and increases new referrals to the program.

Challenges

Legal uncertainties, funding, and reaching racial and ethnic minorities challenge NEXT’s sustainability and growth. (1)

NEXT receives numerous requests from people in states with legal barriers to distributing harm reduction supplies by mail. For example, some regulations require that SSPs provide spe cified on-site services, such as HIV and HCV testing or dis tribute syringes only at an approved site (Fernández-Viña et al., 2020). Mailing supplies to these areas could pose legal risks to participants and to NEXT. Legislators could overcome these barriers by changing state laws, such as exempting syringes from paraphernalia laws, removing restrictions on syringe dis tribution, and clarifying and broadening standing-order direc tives for naloxone. State entities can issue explicit approval for mail-distribution of these supplies, as was done by the gover nor of Maine in 2020 (Mills, 2020). (2) NEXT is funded through grants and donations, but has struggled to afford enough supplies and staff to meet the escalating demand. In 2016, Congress eased the ban that prevented federal funds from being used for SSPs, although there remain restrictions on some federal money being used to purchase syringes (Centers for Disease Control and Prevention, 2020b). Other successful in-person SSPs often receive public funding through contracts with health departments. In states where NEXT has partnered with local SSPs, funds can be used to compensate NEXT for capacity building and technology infrastructure. If more health departments made waiver and funding provisions for maildelivered harm reduction supplies, then the NEXT model could be more rapidly scaled. (3) The program has not found success in reaching non-urban racial and ethnic minorities. Participant data reported here lacked representation because most applications from racial and ethnic minorities are in urban areas where applicants can be referred to in-person services. NEXT plans to explore reasons for lower engagement among non-urban persons of color and is considering adapting its outreach methods to advertise outside of online forums.

Figure 2. Number of first-time orders per month from February 15, 2018 to August 16, 2021.

Next steps

In addition to addressing the challenges above, NEXT has developed their own encrypted web-based “app” to centralize requests for supplies and communication with harm reduction staff. This app also gives NEXT oversight of security and con fidentiality, which may be reassuring for participants who are concerned about the safety of third-party software. NEXT plans to share this app with programs seeking to replicate their services. This dissemination will help scale up services and make mail-delivery harm reduction more widely available.

Conclusions

Despite their proven health benefits to PWID, harm reduction services are largely unavailable to many people at risk for drugrelated harms. The components essential to NEXT’s operations –internet-based platforms for requesting supplies and maildelivery – are widely available throughout the US. These innova tions have allowed the program to rapidly reach PWID. Leveraging existing networks of PWID with limited grant fund ing, NEXT has directly served roughly 1700 participants, deliver ing over 1,600,000 syringes, and has likely served far more PWID through secondary exchange. Having developed an innovative program that complements and collaborates with local SSPs, NEXT has set the stage to expand and replicate this program throughout the US.

Acknowledgement

We would like to thank Tracey Helton for her leadership in pioneering mail delivery harm reduction services in the United States.

Disclosure statement

Jamie Favaro is the founder of NEXT Harm Reduction, a non-profit organization whose work is highlighted in the article. The other authors have no potential conflicts of interest to disclose.

Funding

This research was supported by the National Institute of Allergy and Infectious Diseases CFAR Grant P30AI124414. Dr. Fox is supported by the National Institutes of Health under Grant R01DA044878.

ORCID

Benjamin T. Hayes http://orcid.org/0000-0002-4282-6869

Czarina N. Behrends http://orcid.org/0000-0003-3885-088X

Andrea Jakubowski http://orcid.org/0000-0001-5651-5589

Aaron D. Fox http://orcid.org/0000-0002-6904-4795

References

Alpren, C., Dawson, E. L., John, B., Cranston, K., Panneer, N., Fukuda, H. D., Roosevelt, K., Klevens, R. M., Bryant, J., Peters, P. J., Lyss, S. B., Switzer, W. M., Burrage, A., Murray, A., Agnew-Brune, C., Stiles, T., McClung, P., Campbell, E. M., Breen, C., Buchacz, K., & Lyss, S. B. (2020). Opioid use fueling HIV Transmission in an Urban setting: An outbreak of HIV infection among people who inject drugs —Massachusetts, 2015–2018. American Journal of Public Health, 110 (1), 37–44. https://doi.org/10.2105/ajph.2019.305366

Behrends, C. N., Li, C. S., & Gibson, D. R. (2017). Decreased odds of injection risk behavior associated with direct versus indirect use of syringe exchange: Evidence from two California cities. Substance Use & Misuse, 52(9), 1151–1159. https://doi.org/10.1080/10826084.2017.1299182

Behrends, C. N., Nugent, A. V., Des Jarlais, D. C., Frimpong, J. A., Perlman, D. C., & Schackman, B. R. (2018). Availability of HIV and HCV on-site testing and treatment at syringe service programs in the United States. Journal of Acquired Immune Deficiency Syndromes, 79 (2), e76–78. https://doi.org/10.1097/qai.0000000000001792

Beletsky, L., Heller, D., Jenness, S. M., Neaigus, A., Gelpi-Acosta, C., & Hagan, H. (2014). Syringe access, syringe sharing, and police encoun ters among people who inject drugs in New York city: A community-level perspective. The International Journal on Drug Policy, 25(1), 105–111. https://doi.org/10.1016/j.drugpo.2013.06.005 Breen, S., & Davis, C. (2019). Characteristics of statewide naloxone dis tribution mechanisms The Network for Public Helath Law. Retrieved January 18, from https://www.networkforphl.org/wp-content/uploads/ 2020/08/50-State-Survey-Characteristics-of-Statewide-NaloxoneDistribution-Mechanisms.pdf

Burris, S. (2017). Syringe distribution laws http://lawatlas.org/datasets/syr inge-policies-laws-regulating-non-retail-distribution-of-drug-parapherna Canary, L., Hariri, S., Campbell, C., Young, R., Whitcomb, J., Kaufman, H., & Vellozzi, C. (2017). Geographic disparities in access to syringe services programs among young persons with hepatitis C virus infection in the United States. Clinical Infectious Diseases, 65 (3), 514–517. https://doi.org/10.1093/cid/cix333

Capizzi, J., Leahy, J., Wheelock, H., Garcia, J., Strnad, L., Sikka, M., Englander, H., Thomas, A., Korthuis, P. T., & Menza, T. W. (2020). Population-based trends in hospitalizations due to injection drug use-related serious bacterial infections, Oregon, 2008 to 2018. Plos One, 15(11), e0242165. https://doi.org/10.1371/journal.pone.0242165

Centers for Disease Control and Prevention. (2019). Summary of informa tion on the safety and effectiveness of syringe services programs (SSPs). Retrieved December 10, from https://www.cdc.gov/ssp/syringeservices-programs-summary.html

Centers for Disease Control and Prevention. (2020a). The drug overdose epidemic: Behind the numbers Retrieved December 10, from https:// www.cdc.gov/drugoverdose/data/index.html

Centers for Disease Control and Prevention. (2020b). Syringe Services Programs, Determination of Need. Retrieved December 20, from https://www.cdc.gov/ssp/determination-of-need-for-ssp.html

Centers for Disease Control and Prevention. (2020c). Viral Hepatitis Surveillance – United States, 2018. Retrieved December 15, from https://www.cdc.gov/hepatitis/statistics/SurveillanceRpts.htm

Chiarello, E. (2016). Nonprescription syringe sales: Resistant pharmacists’ attitudes and practices. Drug and Alcohol Dependence, 166, 45–50. https://doi.org/10.1016/j.drugalcdep.2016.06.023

Ciccarone, D., Unick, G. J., Cohen, J. K., Mars, S. G., & Rosenblum, D. (2016). Nationwide increase in hospitalizations for heroin-related soft tissue infections: Associations with structural market conditions. Drug and Alcohol Dependence, 163, 126–133. https://doi.org/10.1016/j.dru galcdep.2016.04.009

Cloud, D. H., Ibragimov, U., Prood, N., Young, A. M., & Cooper, H. L. (2019). Rural risk environments for hepatitis c among young adults in appalachian kentucky. International Journal of Drug Policy, 72, 47–54. https://doi.org/10.1016/j.drugpo.2019.05.006

Collins, A. B., Bardwell, G., McNeil, R., & Boyd, J. (2019). Gender and the overdose crisis in North America: Moving past gender-neutral approaches in the public health response. The International Journal on Drug Policy, 69, 43–45. https://doi.org/10.1016/j.drugpo.2019.05.002

Davis, C., & Carr, D. (2017). State legal innovations to encourage naloxone dispensing. Journal of Pharmacy Association, 57(2s), S180–s184. https://doi.org/10.1016/j.japh.2016.11.007

Dayton, L., Tobin, K., Falade Nwulia, O., Davey-Rothwell, M., Al-Tayyib, A., Saleem, H., & Latkin, C. (2020). Racial disparities in overdose prevention among people who inject drugs. Journal of Urban health Bulletin of the New York Academy of Medicine, 97(6), 823–830. doi:10. 1007/s11524-020-00439-5.

De, P., Cox, J., Boivin, J.-F., Platt, R. W., & Jolly, A. M. (2008). Social network-related risk factors for bloodborne virus infections among

injection drug users receiving syringes through secondary exchange. Journal of Urban Health, 85(1), 77–89. https://doi.org/10.1007/s11524007-9225-z

Des Jarlais, D. C., Arasteh, K., McKnight, C., Feelemyer, J., Tross, S., Perlman, D., Friedman, S., & Campbell, A. (2017). Racial/Ethnic dis parities at the end of an HIV epidemic: Persons who inject drugs in New York city, 2011–2015. American Journal of Public Health, 107(7), 1157–1163. https://doi.org/10.2105/AJPH.2017.303787

Des Jarlais, D. C., Feelemyer, J., LaKosky, P., Szymanowski, K., & Arasteh, K. (2020). Expansion of syringe service programs in the United States, 2015-2018. American Journal of Public Health, 110(4), 517–519. https://doi.org/10.2105/ajph.2019.305515

Des Jarlais, D. C., Nugent, A., Solberg, A., Feelemyer, J., Mermin, J., & Holtzman, D. (2015). Syringe service programs for persons who inject drugs in Urban, Suburban, and Rural Areas - United States, 2013. MMWR Morbidity and Mortality Weekly Report, 64(48), 1337–1341. https://doi.org/10.15585/mmwr.mm6448a3

Des Jarlais, D. C., Pinkerton, S., Hagan, H., Guardino, V., Feelemyer, J., Cooper, H., Hatzatkis, A., & Uuskula, A. (2013). 30 years on selected issues in the prevention of HIV among persons who inject drugs. Advances in Preventive Medicine, 2013 https://doi.org/10.1155/2013/346372

Fernández-Viña, M. H., Prood, N. E., Herpolsheimer, A., Waimberg, J., & Burris, S. (2020). State laws governing syringe services programs and participant syringe possession, 2014-2019. Public Health Reports, 135 (1_suppl), 128s–137s. https://doi.org/10.1177/0033354920921817

Glick, S. N., Prohaska, S. M., LaKosky, P. A., Juarez, A. M., Corcorran, M. A., & Des Jarlais, D. C. (2020). The Impact of COVID-19 on syringe services programs in the United States. AIDS and Behavior, 24(9), 2466–2468. https://doi.org/10.1007/s10461-020-02886-2

Gomes, T., Tadrous, M., Mamdani, M. M., Paterson, J. M., & Juurlink, D. N. (2018). The burden of opioid-related mortality in the United States. JAMA Network Open, 1(2), e180217. https://doi.org/10. 1001/jamanetworkopen.2018.0217

Janulis, P., Montgomery, B. W., & Anthony, J. C. (2020). Estimated effect of US state syringe sale policy on source of last-used injection equipment. The International Journal on Drug Policy, 76, 102625. https://doi.org/10.1016/j.drugpo.2019.102625

Larney, S., Peacock, A., Leung, J., Colledge, S., Hickman, M., Vickerman, P., Grebely, J., Dumchev, K. V., Griffiths, P., Hines, L., Cunningham, E. B., Mattick, R. P., Lynskey, M., Marsden, J., Strang, J., & Degenhardt, L. (2017). Global, regional, and country-level coverage of interventions to prevent and manage HIV and hepatitis C among people who inject drugs: A systematic review. Lancet Glob Health, 5 (12), e1208–1220. https://doi.org/10.1016/s2214-109x(17)30373-x

Lyons, R. M., Yule, A. M., Schiff, D., Bagley, S. M., & Wilens, T. E. (2019). Risk factors for drug overdose in young people: A systematic review of the literature. Journal of Child and Adolescent Psychopharmacology, 29 (7), 487–497. https://doi.org/10.1089/cap.2019.0013

McDonald, R., Campbell, N. D., & Strang, J. (2017). Twenty years of take-home naloxone for the prevention of overdose deaths from heroin and other opioids-Conception and maturation. Drug and Alcohol Dependence, 178, 176–187. https://doi.org/10.1016/j.drugalcdep.2017.05.001

Meyerson, B. E., Lawrence, C. A., Cope, S. D., Levin, S., Thomas, C., Eldridge, L. A., Coles, H. B., Vadiei, N., & Kennedy, A. (2019). I could take the judgment if you could just provide the service: Non-prescription syringe purchase experience at Arizona pharmacies, 2018. Harm Reduction Journal, 16(1), 57. https://doi.org/10.1186/s12954-019-0327-1

Mills, J. T. (2020). Executive order 27: An order regarding state certified hypodermic apparatus exchange programs https://www.maine.gov/gov ernor/mills/official_documents

National Research Council (US) and Institute of Medicine (US) Panel on Needle Exchange and Bleach Distribution Programs. (1995). Preventing HIV transmission: The role of sterile needles and bleach (J. Normand, D. Vlahov, & L. E. Moses, Eds.) National Academies Press (US). https:// doi.org/10.17226/4975

Nerlander, L. M., Hess, K. L., Rose, C. E., Sionean, C., Thorson, A., Broz, D., & Paz-Bailey, G. (2017). Exchange sex and HIV infection among women who inject drugs-20 US cities, 2009. Journal of Acquired Immune Deficiency Syndromes, 75(Suppl 3), S333–s340. https://doi.org/ 10.1097/qai.0000000000001408

Nguyen, T. Q., Weir, B. W., Des Jarlais, D. C., Pinkerton, S. D., & Holtgrave, D. R. (2014). Syringe exchange in the United States: A national level economic evaluation of hypothetical increases in investment. AIDS and Behavior, 18(11), 2144–2155. https://doi.org/10. 1007/s10461-014-0789-9

Peters, P. J., Pontones, P., Hoover, K. W., Patel, M. R., Galang, R. R., Shields, J., Blosser, S. J., Spiller, M. W., Combs, B., Switzer, W. M., Conrad, C., Gentry, J., Khudyakov, Y., Waterhouse, D., Owen, S. M., Chapman, E., Roseberry, J. C., McCants, V., Weidle, P. J., Duwve, J. M., & Conrad, C. (2016). HIV infection linked to injection use of oxymor phone in Indiana, 2014–2015. The New England Journal of Medicine, 375(3), 229–239. https://doi.org/10.1056/NEJMoa1515195

Pollini, R. A., Rudolph, A. E., & Case, P. (2015). Nonprescription syringe sales: A missed opportunity for HIV prevention in California. Journal of the American Pharmacists Association, 55(1), 31–40. https://doi.org/ 10.1331/JAPhA.2015.14148

Rivera, A. V., DeCuir, J., Crawford, N. D., Amesty, S., & Lewis, C. F. (2014). Internalized stigma and sterile syringe use among people who inject drugs in New York city, 2010-2012. Drug and Alcohol Dependence, 144, 259–264. https://doi.org/10.1016/j.drugalcdep.2014.09.778

Snead, J., Downing, M., Lorvick, J., Garcia, B., Thawley, R., Kegeles, S., & Edlin, B. R. (2003). Secondary syringe exchange among injection drug users. Journal of Urban Health, 80(2), 330–348. https://doi.org/10.1093/ jurban/jtg035

Surratt, H. L., Cowley, A. M., Gulley, J., Lockard, A. S., Otachi, J., Rains, R., & Williams, T. R. (2020). Syringe service program use among people who inject drugs in Appalachian Kentucky. American Journal of Public Health, 110(1), 34–36. https://doi.org/10.2105/ajph.2019.305333

Szalavitz, M. (2019, March 1). How one group is expanding access to overdose-reversal drugs through the mail. Vice Magazine https://www. vice.com/en/article/gyamdy/naloxone-narcan-by-mail United States Code. (2010). 2006 Edition, Supplement 4, Title 21 Drug paraphernalia.

Van Handel, M. M., Rose, C. E., Hallisey, E. J., Kolling, J. L., Zibbell, J. E., Lewis, B., Bohm, M. K., Jones, C. M., Flanagan, B. E., Siddiqi, A. E., Iqbal, K., Dent, A. L., Mermin, J. H., McCray, E., Ward, J. W., & Brooks, J. T. (2016). County-level vulnerability assessment for rapid dis semination of HIV or HCV infections among persons who inject drugs, United States. Journal of Acquired Immune Deficiency Syndromes, 73(3), 323–331. https://doi.org/10.1097/qai.0000000000001098

Williams, C. T., & Metzger, D. S. (2010). Race and distance effects on regular syringe exchange program use and injection risks: A geobehavioral analysis. American Journal of Public Health, 100(6), 1068–1074. https://doi.org/10.2105/AJPH.2008.158337

Wodak, A., & McLeod, L. (2008). The role of harm reduction in control ling HIV among injecting drug users. Aids, 2(Suppl 2), S81–92. https:// doi.org/10.1097/01.aids.0000327439.20914.33

World Health Organization. (2004). Effectiveness of sterile needle and syringe programming in reducing HIV/AIDS among injecting drug users (9241591641) https://www.who.int/hiv/pub/prev_care/effective nesssterileneedle.pdf

World Health Organization. (2013). WHO, UNODC, UNAIDS technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users – 2012 revision https://www. who.int/hiv/pub/idu/targets_universal_access/en/

World Health Organization. (2014). Community management of opioid overdose (9241548819) https://apps.who.int/iris/bitstream/handle/ 10665/137462/9789241548816_eng.pdf

Wurcel, A. G., Anderson, J. E., Chui, K. K., Skinner, S., Knox, T. A., Snydman, D. R., & Stopka, T. J. (2016). Increasing infectious endocar ditis admissions among young people who inject drugs. Open Forum Infectious Diseases, 3(3), ofw157. https://doi.org/10.1093/ofid/ofw157 Yang, C., Favaro, J., & Meacham, M. C. (2021). NEXT harm reduction: An online, mail-based naloxone distribution and harm-reduction program. American Journal of Public Health, 111(4), 667–671. https:// doi.org/10.2105/ajph.2020.306124

Zibbell, J. E., Asher, A. K., Patel, R. C., Kupronis, B., Iqbal, K., Ward, J. W., & Holtzman, D. (2018). Increases in acute hepatitis C virus infection related to a growing opioid epidemic and associated injection drug use, United States, 2004 to 2014. American Journal of Public Health, 108(2), 175–181. https://doi.org/10.2105/AJPH.2017.304132