Safer Solutions: The Misplaced Fear of Needle Exchanges

As humans, our thought processes are complicated—including those that bring us to the wrong conclusions. In this introductory series for our biweekly Safer Solutions newsletter, we’ve talked about how common types of risk misperception can lead us in the wrong direction. So far we’ve looked at how people overestimate the risk of unlikely outcomes in methadone and opioid use, expose themselves to risk via an “it won’t happen to me” mindset regarding sexual health, and miscalculate risk due to misinformation about nicotine. Each of these misperceptions can lead policymakers to block or restrict access to tools that save lives, make communities safer, and save tax dollars.

So what happens when all of these misperceptions come together? Thanks for asking, because it’s time to talk about syringe services programs (SSPs).

SSPs, sometimes referred to as “needle exchanges,” emerged in the 1980s to prevent the spread of HIV and hepatitis C among people who inject drugs. SSPs recognize that people who are physically dependent on drugs are not able to “just quit,” and they understand that shared needles create real health risks for individuals and communities. Needle sharing is one of the riskiest behaviors for HIV transmission as well as the primary way in which hepatitis C spreads.

SSPs are an undeniable public health success story. They are associated with up to a 50 percent reduction in HIV and hepatitis C transmission and savings of $6 to $7 for every dollar spent on HIV treatment alone. SSP participants are also five times more likely to enter treatment and three times more likely to stop using drugs altogether.

So why, in the face of so much positive evidence, do SSPs face so much pushback from policymakers? In short, a confluence of all three types of risk misperception is at play.

1. Over-weighting the Risks of Unlikely Events

While some maintain that SSPs “enable” or “condone” drug use, there is no evidence to support their claim. People use SSPs because they are already using drugs, and SSPs often achieve the opposite outcome by successfully linking people to treatment.

2. Basing Arguments on Persistent Misinformation

In 2024, Nebraska’s governor vetoed a bipartisan bill that would have allowed cities in the state to authorize the operation of SSPs. In his veto letter, the governor said that SSPs “only contribute to a negligible reduction in HIV infections” and that they create risk via “improperly disposed needles.” In fact, a study cited in the veto letter found that a new SSP can reduce HIV rates by as much as 18.2 percent. Multiple studies have also found that SSPs do not increase syringe litter and may even contribute to fewer improperly discarded syringes.

3. Falling Prey to the “It Won’t Happen to Me” Mentality

While intravenous drug use, HIV, and hepatitis C might seem far removed from the everyday lives of many lawmakers and community members, they can (and do) affect people from all walks of life—including those who mistakenly believe they are in monogamous relationships.

While these diseases are no longer fatal if properly treated, HIV requires lifelong medical management, and untreated hepatitis C can lead to permanent liver damage. People living with HIV have “substantially fewer healthy years,” developing health problems an average of 16 years earlier than people without HIV. In 2018, about 16,000 people died from hepatitis C-related causes in the United States.

These conditions impact us all via their draw on public budgets. Hepatitis C has an annual economic impact of more than $10 billion, while HIV’s domestic economic burden is estimated at $36.4 billion per year. Medicaid and Medicare are the largest sources of coverage for people living with HIV, and enrollment has grown as people with HIV are living longer.

The resistance to SSPs driven by this complex bundle of misperceptions has real policy consequences, including state laws to severely restrict the operation of SSPs (e.g., in West Virginia), statewide and municipal bans on SSPs (e.g., in Idaho; Pueblo, Colorado; and El Dorado County, California), and vetoes of bipartisan efforts to authorize the operation of SSPs (e.g., in Nebraska). A new database showing how states spent more than $6 billion in opioid settlement funding indicates that they committed an average of just 2 percent of their opioid settlement funds to SSPs in 2022 and 2023.

Too many lawmakers and members of the public erroneously believe that SSPs are dangerous and unnecessary—a toxic combination that blocks people from accessing these life- and money-saving programs. This puts all of us at risk.