Establishing and Expanding Harm Reduction Efforts in Marion County, Indiana

Marion County Public Health Department (MCPHD) serves a population of nearly 1 million, primarily in Indianapolis, Indiana, which distributes a high level of vulnerability across socioeconomic status, household characteristics, racial and ethnic minority status, and housing type/transportation by CDC/ATSDR Social Vulnerability Index measures. From 2012 to 2017, Marion County observed a ten-fold increase in acute hepatitis C cases with 95% tied to illicit substance use. While HIV rates in Marion County remained steady, the fate of fellow Hoosiers in Scott County prompted the creation of a novel harm reduction program within Indianapolis . The overarching goal of Safe Syringe Access and Support is to prevent infectious diseases related to injection drug use, period.

Due to tension between the legalization of syringe services in Indiana and continued criminalization of paraphernalia, MCPHD worked closely with Indianapolis Metropolitan Police Department to bridge best harm reduction practices with those that would be well-received by local law enforcement and elected officials. Safe Syringe is thus able to operate under a hybrid needs-based negotiation model, and staff contributes to IMPD's Crisis Intervention Training promoting the use of harm reduction as a referral tool for police officers, probation and parole officers, emergency medical services (EMS), and more in Marion County. The results of a study on police office attitudes related to harm reduction at the launch of the program led to collaboration with Northeastern University to bring new training on Safety and Health Integration in the Enforcement of Laws on Drugs” to Indiana Law Enforcement Academy and officers across the state.

Safe Syringe launched in April 2019 with two mobile locations identified by geographic information related to rates of HIV and hepatitis C, emergency medical response to overdose, and arrests for drug-related crimes. MCPHD offered epidemiologic data and education on the history and impact of harm reduction to local neighborhood associations and community partners prior to providing services in the area. These town hall sessions led to meaningful community partnerships, including faith-based institutions, re-entry and housing programs, and AIDS Services Organizations. While the COVID-19 pandemic slowed the rollout of additional locations, Safe Syringe was able to add service hours at two additional locations in 2021 at two district health offices, including a storefront location which allows syringe and wraparound services (point-of-care testing and immunizations) to be offered 36 hours per week. Once per week, Safe Syringe hosts a mobile health fair at Brookside Community Church including comprehensive STI testing through Bell Flower Clinic and primary care services through Gennesaret Free Clinic., Safe Syringe receives supplemental recovery systems support in partnership with Indiana Addiction Issues Coalition. Lastly, in collaboration with Shalom Community Health Center, Safe Syringe offers monthly non-syringe harm reduction services and point-of-care testing at Indianapolis Public Library.

Indiana law establishes limitations on the legalization of syringe services; organizations must go through their city or county legislative authority and demonstrate a need for services in response to increases in infectious disease rates related to substance use. This lengthy and cumbersome process is a challenge for many organizations, and currently only eight out of ninety-two counties host legalized programs. In recognition that institutional distrust of public health exists in many communities, MCPHD began efforts to extend services to other local nonprofits with existing relationships in marginalized communities. Safe Syringe subcontracted with an ASO in March 2022 to further the reach of harm reduction with PLWHIV and BIPOC; an additional partnership is planned for spring 2023 to expand services among LGBTQ+ communities. Safe Syringe exclusively hires people with lived experience with injection drug use that are dually trained as peer recovery coaches to assist clients with goal setting according to the client's own motivation level.

MCPHD contracted an independent accounting firm to conduct a cost-effectiveness analysis specific to Safe Syringe between 2019-2023 to provide additional evidence to support harm reduction programs in Indiana. While analysis is ongoing and the pandemic confounded many variables, interim results demonstrated two primary impacts in Marion County: (1) a decrease in EMS runs related to overdoses, and (2) a decrease in inpatient costs related to injection drug use.

To date, Safe Syringe's greatest outcome lies in its ability to deliver the overdose-reversing drug directly into the hands of those most likely to need and use it. With the limitations in community outreach during the peak of the pandemic in spring and summer 2020, Safe Syringe partnered with Overdose Lifeline and a local emergency department to deliver harm reduction kits to homes in which 911 was called for overdose; these kits contained ten doses of naloxone, as well as non-syringe harm reduction supplies, a resources pamphlet, and nonperishable food goods.  In response to changes in the prevalence of fentanyl in illicit opioids, Safe Syringe doubled distribution of naloxone from 2019 to 2021 to new clients and continues to replace doses as they are used to reverse overdoses in the community. Safe Syringe provides client-provided syringe waste to the state public health laboratory to screen for drug compounds. In the first year of collection, 88% of tested syringes were found to contain fentanyl compared to just 33% containing heroin.

According to a qualitative survey conducted among Safe Syringe participants in 2021, the primary reason clients return to the Safe Syringe program (excluding syringes) is the nonjudgmental, welcoming atmosphere promoted by the staff. Since its introduction in 2019, Safe Syringe has served nearly 2,700 unique clients at approximately 13,000 visits. Nearly 1.3 million syringes and over 33,000 doses of naloxone have been distributed among people who inject drugs, and 1,899 lives have been saved with naloxone provided through this program. For more information on Safe Syringe Access and Support through Marion County Public Health Department, please visit www.marionhealth.org /safesyringe and follow the program on Facebook.

The Center for Health Policy at Indiana University's Fairbanks School of Public Health estimates that between 0.2 and 1.6 percent (1,903 and 15,220 persons, respectively) of Marion County's population (951,257 persons in 2017) has injected drugs at least once in their lifetime. The strategic plans for Safe Syringe outlined in 2018 set the goal of reaching 20 percent of people who inject drugs in Marion County by the end of the third year of operation. Using a moderate estimate that 0.8 percent of Marion County's population currently engages in injection drug use (IDU), Safe Syringe hoped to reach 1,522 unique clients by April 2022. This goal was reached six months early in September 2021. As of January 1, 2023, Safe Syringe has served 2,687 unique clients – 35 percent of the projected target population and 142 percent of the minimum estimated target population.

It is difficult to isolate a defined target population because the opioid crisis affects all demographics and geographic locations. MCPHD anticipated most SSAS clients to be primarily low-income, non-Hispanic white adults between the ages of 18-44 years based on the demographics of acute HCV cases and drug overdoses. Since Safe Syringe launched in 2019 in response to an increasing incidence in acute hepatitis C related to injection drug use, the demographics of acute hepatitis C cases were utilized to predict the target population. Sixty-eight percent of acute HCV cases reported in 2017 were white, 14 percent African American, and 5.6 percent Hispanic/Latino. Eighty-three percent of cases were between the ages of 18 and 44 years (range 18 to 67 years). Females were diagnosed with acute HCV at a slightly higher rate than males.

Clients often lack essential human necessities such as food, transportation, shelter, and health insurance, which create significant barriers to recovery. Many also have trauma associated with their substance use disorder (SUD), such as abuse, violence, and/or adverse childhood experiences and/or underlying psychological issues/mental health conditions. Countless individuals with SUD hail from families with a history of intergenerational addiction.

Safe Syringe joined a multi-pronged effort by Health and Hospital Corporation (HHC) of Marion County to address the drug epidemic. Prior to Safe Syringe, MCPHD served PWID through a variety of existing programming. Substance Use Outreach Services provides naloxone training and distribution to the public and connects PWUD with recovery services, including a small stipend to cover the cost of treatment each year. MCPHD's Ryan White/HIV Services provides a coordinated response to ending the HIV epidemic through oversight of agencies serving PLWH/A. Eskenazi Health, the hospital and Federally Qualified Health Center branch of HHC, includes Project POINT, a peer recovery coach-led emergency department initiative, and Sandra Eskenazi Mental Health Center, an opioid treatment and behavioral health center. Indianapolis Emergency Medical Services collaborates with Indianapolis Metropolitan Police Department to offer a Mobile Crisis Assistance Team in response to behavioral health, substance use, and medical emergencies in effort to divert arrests. Lastly, Sandra Eskenazi Mental Health Center collaborates with Marion County Sheriff's Office to divert substance use-related arrests to the Assessment and Intervention Center, a free transitional housing unit that serves any Marion County resident, regardless of justice involvement, and includes 24/7 intakes, withdrawal management, peer-led recovery, and warm referrals for additional treatment and recovery housing.

The missing prong of this coordinated effort to address substance use disorder in Marion County was harm reduction – providing services to people in active and chaotic drug use without the requirement of treatment or justice involvement. Safe Syringe offers nonjudgmental, noncoercive syringe services, in addition to peer recovery coaching, point-of-care testing, and immunizations. Clients are provided with the necessary number of syringes, sharps containers, and non-syringe harm reduction supplies for 100% coverage of every injection before their next anticipated visit; supplies are provided in a backpack in addition to a resources card and six doses of naloxone. Nearly two-thirds of Safe Syringe clients are unstably housed, with 20% disclosing they are completely without shelter. Safe Syringe is able to provide clients with blankets, as well as warm socks, hats, and gloves, and also offers a community closet thanks to generous donations from local faith-based institutions and individuals. Safe Syringe staff respects clients as autonomous individuals and the experts in their own lives; all wraparound services are provided at client request.

Comprehensive syringe services programs (SSPs) have operated in the United States since 1988. However, syringe services were not legalized in Indiana until 2015 following the notorious HIV outbreak in Scott County, Indiana. Indiana code requires cities or counties to authorize SSPs through their executive/legislative body in response to increases in HIV and/or HCV; authorized programs must be renewed on a one-to-two-year basis. In a mostly rural, conservative state, this is a heavy ask for most counties operating on small local health department budgets with limited staff and pertinent community resources. As of 2023, there are only eight legal SSPs operating in Indiana, a state composed of 92 counties. Marion County was the first city to ever receive unanimous support from its legislative body in 2018 – a feat that has been repeated at biannual renewals in 2020 and 2022.

The procedures of Safe Syringe were built from established models of SSPs across the United States, including, but not limited to: World Health Organization's Guide to Starting and Managing Needle and Syringe Programmes, Department of Health and Human Services' Guide to Support Certain Components of SSPs, National Alliance of State and Territorial AIDS Directors' SSP Development and Implementation Guidelines for State and Local Health Departments, San Francisco's UFO Model Intervention Replication Manual, Harm Reduction Coalition's Guide to Developing and Managing SAPs, and the New Mexico Department of Health's Hepatitis and Harm Reduction Certification Specialist Manual.

Safe Syringe was formally approved by the Indianapolis-Marion County City-County Council in June 2018 with the commitment to rely solely on grant funding for the first three years of operation. The timeline for launching operations was therefore dependent on securing funding, which could not be done on a grand scale without the legal authority for MCPHD to operate a syringe services program (SSP). Safe Syringe was awarded an US Department of Justice Comprehensive Opioid-Abuse Programs grant in October 2018, which covered the cost of staffing and infrastructure for the program. Tobacco Settlement Funds were used to purchase and outfit a box truck for mobile service delivery. Small grants were awarded from the Health Foundation of Greater Indianapolis, a local nonprofit, as well as the Indiana Department of Health (IDOH) for initial start up materials. Finally, the Richard M Fairbanks Foundation, a local philanthropy, provided a generous gift of $1.45 million for syringes and a cost-effectiveness analysis.

MCPHD operated under Incident Command Structure to seek legal authority to operate an SSP, as well as to design the program and begin operations. The Incident Commander, a nurse epidemiologist from Infectious Disease, was hired as the program manager in December 2019. The program's first peer recovery coach was hired in February 2019, and a second coach was hired in July 2019.

Leading up to the program's launch, MCPHD focused on building both community and law enforcement trust. MCPHD hosted a series of town halls for neighborhood associations, community centers, faith-based institutions, and more in early 2019. Neighborhood associations specific to areas of high drug use provided support and approval for the program to operate within their districts, and two community locations were established for mobile delivery of service: Brookside Community Church and the Damien Center. Brookside Church is an active faith-based community on Indianapolis' East Side, serving the community both through housing and re-entry initiatives. Damien Center is Indiana's oldest and largest AIDS Service Organization, serving PLWH/A on Indianapolis' near Eastside with both support and healthcare services. Both partnerships offered unique benefits to Safe Syringe's promotion within the community.

Indianapolis Metropolitan Police Department (IMPD) hosts six district offices, each with three shifts of approximately 50 officers. Safe Syringe's program manager traveled to each office for each shift in the month of March 2019 to provide harm reduction education to officers during their 25 minute roll call. Prior to the training, MCPHD hosted a focus group of IMPD officers to assist with the development of Safe Syringe's practices and procedures surrounding syringe exchange to develop a favorable model that would balance evidence-based practices with methods that would encourage officer discretion concerning unlawful possession of a syringe charges. Officer education was developed in collaboration with IMPD's Deputy Chief of Training, Policy and Oversight and Dr. Bradley Ray's research team at the Indiana University Center for Health and Justice Research. Officers completed a brief survey following the training, which Dr. Ray's team analyzed and disseminated in summer 2019: Police officer attitudes towards syringe services programming. Safe Syringe continued to collaborate with IMPD and other community organizations through participation the Indianapolis Opioid Advisory Council and the Behavioral Health and Diversion Advisory Group through 2020, and currently collaborates with IMPD on Overdose Fatality Review and Drug Seizure Round Tables to coordinate overdose prevention efforts following a large seizure in the Indianapolis area.

The greatest delay to program start-up was the completion of the mobile unit's customization. The mobile unit was completed and transported to Indianapolis on April 5, 2019, nearly nine months after purchase was requisitioned. On April 12, 2019, MCPHD, the Indianapolis Mayor, and funder Fairbanks Foundation hosted a presentation and van tour for the press and members of the public prior to the program's launch.  This offered the media an up-close look at harm reduction, as well as an alternative to seeking video footage of the program during operation, which would challenge the anonymity of program participants. The event gained significant media coverage from all local stations, including interviews with people in recovery from SUD, neighborhood members, and other respected individuals offering support for the program's value.

Safe Syringe launched on April 19, 2019, with two mobile service locations. One hundred unique clients were reached by September 2019, and at that time, Safe Syringe expanded hours to include storefront operations at MCPHD's Eagledale District Health Office (DHO), located on Indianapolis' West Side, an area vulnerable to overdose fatalities and drug-related arrests.

The strategic plans of public health programs were impacted universally by the COVID-19 pandemic. Following the governor's announcement to suspend non-essential services in Indiana due to COVID-19, Safe Syringe limited operations to no-contact delivery from March 30 through June 5, 2020. Clients were able to call or text a peer recovery coach to arrange for pick-up of used sharps and drop-off of new supplies as needed. In the month leading up to the city/state shutdown, supply and naloxone distribution were increased in anticipation of limited access to supplies because of the pandemic.

On June 5, 2020, mobile unit operations resumed in a food truck” delivery model in which clients are served from a window of the mobile unit with cones placed to promote social distancing among visitors In consideration of health department policies to allow public visitation of district health offices by appointment only, as well as the limited utilization of the storefront, Safe Syringe's Eagledale hours of operation were not continued.  Immunizations and point-of-care testing services did not resume until 2021 due to both a limited workforce and ability to enact appropriate infection control measures.

While Safe Syringe was not able to recover public health nurses from MCPHD's workforce for immunizations, partnership with Eskenazi Emergency Department resumed in late 2020 to provide point-of-care HIV and HCV testing. This collaboration continued until fall 2022. Beginning in February 2023, MCPHD's Bell Flower Clinic began providing comprehensive STI testing with Safe Syringe at Brookside Community Church. Bell Flower Clinic is able to provide gift card incentives to clients who receive testing on a quarterly basis.

Immunizations resumed during the summer of 2021 during good weather” days as staffing was available. A public health nurse administered COVID-19 vaccine in addition to the previous supply of immunizations from an outdoor set-up to promote social distancing and infection prevention. Clients responded favorably to this model of delivery; positive peer pressure encouraged COVID-19 vaccinations, as well as an increase in hepatitis A and B vaccination.

Beginning in fall 2020, Safe Syringe contracted with Indiana Addiction Issues Coalition for additional peer recovery coach support. The IAIC Coach provides referral support to supplement Safe Syringe's peer support specialists (Peers), enhancing Safe Syringe's connections to SUD treatment in the following ways: (1) reducing the workload of Peers during outreach to focus entirely on harm reduction; (2) providing more time for clients to discuss treatment options and needs; (3) increasing the diversity of staff to represent all populations utilizing Safe Syringe; and (4) providing management support and back up for a position with historically high turnover. In the first day of implementation, the IAIC Coach was able to connect his first two clients to immediate SUD treatment enrollment.

Shalom Health Center, a local FQHC, explored harm reduction services in 2020. While their team ultimately decided not to pursue harm reduction in the immediate future, Shalom was able to purchase and outfit a recreational vehicle to expand their community outreach. Beginning in 2022, Shalom's mobile unit joined Safe Syringe and Bell Flower Clinic at Brookside Community Church to provide primary care services to Safe Syringe clients. A nurse practitioner offers physical and gynecological exams, wound care, and more. The mobile unit is stocked with a supply of common antibiotics for easy client access to needed treatment.

Given the complexity of Indiana's syringe exchange law, only eight programs currently operate legally in the state. As a result, Safe Syringe serves a significant portion of clients from outside Marion County. In January 2021, Safe Syringe began operating one afternoon per week on Indianapolis's south side, a location more manageable for clients coming from rural counties, at MCPHD's South DHO. A permanent office was added to Safe Syringe's operating locations in November 2022 at a former branch of Eskenazi Health's FQHC. This space allows Safe Syringe to operate at 36 hours per week (4 hours for staff development) and includes a remodeled pharmacy for walk-up exchange, as well as a clinic space for testing, immunizations, and recovery consultations.

The final component to expanding syringe services in Indianapolis lies in recognizing that every organization has its strengths and its weaknesses. Marginalized communities, such as those with justice involvement and communities of color, have an institutional distrust of local health departments, including misconceptions of ties to law enforcement and negative downstream effects. Established nonprofits often have ties to local communities, developing rapports and exercising the flexibility to meet unique needs. Safe Syringe began subcontracting with Damien Center to offer syringe exchange through their own offices in March 2022. Damien Center now operates syringe services four afternoons per week from two locations. A partnership with Step Up, another Indianapolis ASO, began in January 2023 to similarly expand services. Harm reduction efforts are rooted in the advocacy and bravery of grassroots organizations; Safe Syringe seeks to continue the legacy of harm reduction by ensuring the value of organizations other than local health departments is utilized and shared. 

The overarching objective of Safe Syringe is to reduce the incidence of infectious diseases, primarily viral hepatitis and HIV, related to IDU in Marion County, thus preventing an outbreak of HIV related to IDU. This objective thus far has been successful, though infectious disease data is effected by the COVID-19 pandemic in that (1) decreased community testing was practiced in 2020 and (2) public health investigative efforts were diverted to COVID-19 and diseases with high morbidity and/or public interference (i.e., viral hepatitis was not a priority for investigation in 2020-2021; roughly 40% of cases were investigated by medical record review during this time). From 2017 to 2021, the incidence of acute hepatitis B decreased from 4.7 to 1.6 cases per 100,000 population; acute hepatitis C decreased from 7.6 to 3.3 cases per 100,000; and HIV/AIDS new diagnoses decreased from 25.1 to 23.8 cases per 100,000. While medical record review noted 50% of acute hepatitis C cases were associated with IDU, 93% were associated with substance use of any type.[1]

Additional objectives include: enhancing access to substance use disorder treatment services, providing on-site testing for HIV and HCV, and reducing the number of opioid-related overdose deaths in Marion County through the provision of naloxone and overdose education, reducing emergency department visits related to bacterial infections secondary to IDU, and removing hazardous needle waste from the community.

Syringe services programs are often inappropriately identified as recovery-based initiatives in the public arena in order to gain political and justice system favor. To emphasize the singular goal of preventing infectious diseases, no specific outcome measures were provided for the above-listed additional objectives, such as entry into treatment programs. Any utilization of wraparound services is celebrated by Safe Syringe.

Two hundred and forty-eight clients have been connected to SUD treatment through Safe Syringe. In addition to peer recovery coaches operating the program, Safe Syringe partners with Indiana Addiction Issues Coalition to provide additional recovery support by (1) reducing the workload of Peers during outreach to focus entirely on harm reduction; (2) providing more time for clients to discuss treatment options and needs; (3) increasing the diversity of staff to represent all populations utilizing Safe Syringe; and (4) providing management support and back up for a position with historically high turnover.

Until the COVID-19 pandemic, Safe Syringe utilized MCPHD's Community-Based Care public health nursing staff to support immunizations and testing through the program. However, diversion of public health activities beginning in March 2020 crippled Safe Syringe's ability to provide these interventions with internal support. Eskenazi Health Emergency Department's Public Health team provided a tester/counselor to Safe Syringe from 2019 through 2021 to support point-of-care testing. In February 2022, this service was replaced by Bell Flower Clinic, MCPHD's sexually transmitted infection program, and now includes comprehensive STI testing in addition to HIV and HCV. Since the program's start, testers have performed: 365 HIV (1% reactivity), 143 HCV (43% reactivity), 182 syphilis, 167 chlamydia, and 181 gonorrhea tests. Approximately 150 clients have received 240 immunizations through Safe Syringe, including influenza, hepatitis A, hepatitis B, human papillomavirus, tetanus-diphtheria-pertussis, and COVID-19 (data for COVID-19 immunizations is not readily available through MCPHD's database).  

Marion County emergency departments treated 7,204 overdoses in 2021. Moreover, overdose deaths doubled during the pandemic with 806 reported overdose fatalities in 2021. The increase in opioid-induced overdose driven in part by the shift from predominantly heroin use to fentanyl; 23% of overdose fatalities in 2016 were caused by fentanyl, compared to 79% in 2020.[2] Safe Syringe has distributed over 33,000 doses of naloxone to clients since 2019 with at least 1,899 overdoses reversed by laypeople. An ongoing, external cost-effectiveness analysis has so far demonstrated significant reductions in the number of Indianapolis Emergency Medical Services ambulance runs related to overdoses. By counterfactual approach, the study estimates that the number of runs in the last quarter of 2020 through 2021 would have been 20 to 30 percent higher in the absence of Safe Syringe.[3]

Data for Safe Syringe is collected through MCPHD's Safe Syringe database and analyzed using Viya. Additional data and reporting is collected from Indiana Department of Health's Syringe Exchange Database. MCPHD records health-related data, such as testing and immunizations, through Insight and analyzes using Viya. Lastly, MCPHD Epidemiology utilizes ESSENCE syndromic surveillance data for Emergency Department utilization.

A primary source of start-up and personnel funding for this program was the US Department of Justice Comprehensive Opioid-Abuse Programs award from 2018-2021. This award included evaluation by Dr. Bradley Ray, former Director of the Center for Criminal Justice Research under the Indiana University Public Policy Institute. Dr. Ray and his team examined the interactions of Safe Syringe with local law enforcement, including performing a survey of officer attitudes following a presentation on harm reduction by Safe Syringe staff and surveys of clients covering their interactions with law enforcement.

The most significant barrier to program success is the conflict between existing public health initiatives and the criminalization of syringes for illicit drug use. The legalization of syringe services programs did not negate IC 16-42-19-18 Unlawful Possession of a Syringe.” While leadership at IMPD, Marion County Prosecutor's Office, and Marion County Sheriff's Office are supportive of Safe Syringe, the only protection afforded participants exists under Section 9 of the Syringe Exchange Program Law, which specifies that attending an SSP does not constitute probable cause for law enforcement to stop, search, or seize an individual. MCPHD provided education to all IMPD patrolmen during their shift roll call; a post-presentation survey was disseminated by researchers at IU-SPEA with the following results:[4]

Despite generally positive attitudes toward Safe Syringe, over half of officers reported that harm reduction promotes drug use and that they would arrest participants for illegal possession of a syringe. Harm reduction initiatives benefit law enforcement by reducing the prevalence of HIV and HCV in the community and decreasing the risk of needle stick injury for by 66% through the provision of sharps disposals and public interaction with law enforcement.[5] The results of this survey led to collaboration between MCPHD, Indiana State Department of Health, Dr. Ray and his research team, IMPD and other law enforcement throughout Indiana to tailor an officer safety curriculum (SHIELD) developed by Northwestern University to reflect local policies, enhance law enforcement's support of harm reduction programs, and reduce the risk of needlestick injury and COVID-19 infection in our first responders.

Dr. Brad Ray and his team conducted the second part of their evaluation in 2020 and 2021 following completion of the IMPD survey study. This phase focused on 30 client interviews covering their interactions with law enforcement while enrolled in Safe Syringe. Staff included flyers for participation in client harm reduction kits for one month; clients that reported law enforcement interaction to staff were encouraged verbally to participate in the study. Study participants received a $50 gift card to compensate for their time. Findings from these qualitative interviews indicated positive client perception of Safe Syringe and its staff, as well as reduced needle sharing among participants, increased appropriate disposal of used syringes, and increased access to treatment and other resources.

Of those interviewed, seven had been stopped and searched by police since enrolling in the program. Six of the seven were able to provide law enforcement with their participant identification card, yet six of the seven were still arrested for syringe possession. Two clients reported relatively positive police interactions: one in which the officer stated he supported the program and would not arrest if no drugs were found on the person, and one in which the client was released, but the syringes were confiscated.

While syringe charges decreased overall from 2019 to 2020, some spikes were still observed immediately following the launch of Safe Syringe in 2019, and during Safe Syringe's limited operations in spring 2020. Marion County Sheriff's Office and Marion County Coroner's Office data demonstrated that every jail booking per incarcerate increased the likelihood of overdose fatality by 20%; the presence of a syringe charge at the most recent booking more than tripled the rate of overdose fatality.

Dr. Ray collaborated with Corey Davis, Deputy Director of the Network of Public Health Law, and Detected Sergeant Ronald Martin of North Carolina, to present findings from Marion County and provide insight into paraphernalia decriminalization in other jurisdictions, the negative impact of decriminalization on morbidity and mortality, and the positive impact observed in communities in which decriminalization has been implemented.

Source: Ray, B. (2021, May 26). Implementation of a Syringe Services Program and Law Enforcement Barriers. Wayne State University. Data from Marion County Sheriff's Office.

Due to confounding variables and delayed program expansion related to the COVID-19 pandemic, the cost-effectiveness analysis for Safe Syringe is still ongoing. Myers and Stauffer published an interim report for City-County Council on June 2, 2022. At the time for the report, the analysts were still awaiting 2021 hospital and infectious disease data from Indiana Department of Health. Key points included:

·         When controlling for initial start-up costs, the average cost per client from October 1, 2020, through December 31, 2021, is $309.05.

·         The initial goal client saturation rate of 20% estimated people who inject drugs in Marion County through 2021 was achieved. If a saturation rate of 33% was achieved through approximately 7,000 more visits, the estimated cost per client would be $99 per visit. The estimated number of people who inject drugs in Marion County was projected at 0.8 percent.

·         Through December 2021, nearly 30% of clients did not have a second visit. If the following variables were positive, there was a 77% probability the client would not return for a second visit: ­­­­­identifies as White, injects daily, heroin as primary drug, hepatitis C positive, condom use, in some form of peer recovery or no interest in treatment. If all the listed variables were negative, the chances the client would not return was reduced to 4%. These trends will continue to be examined as client participation increases, including observed significant delays between first and second visits.

·         Significant reductions in the number of IEMS runs related to overdoses by counterfactual approach, the study estimates that the number of IEMS runs in the last quarter of 2020 throughout 2021 would have been 20 to 30 percent higher in the absence of Safe Syringe.

·         Substantial cost savings for inpatient care related to drug use, particularly as both the number of syringes distributed, and the amount of naloxone provided are increased.

[1] Marion County Public Health Department. Insight Patient Database. Viya Report

[2] Indiana Drug Overdose Dashboard. (2022, Feb 24). Retrieved from https://www.in.gov/health/overdose-prevention/data/indiana/

[3] Myers and Stauffer LC. (2022). Marion County Public Health Department Safe Syringe Access and Support Program Interim Report. Indianapolis, IN.

[4] Sightes, Ray, Paquet, Bailey, Huynh, & Weintraut. (2019). Police officer attitudes toward syringe services programming. Drug and Alcohol Dependence, 205. https://doi.org/10.1016/j.drugalcdep.2019.107617

[5] Groseclose, SL. (1995). Impact of increased legal access to needles and syringes on practices of injecting-drug users and police officers-Connecticut. Journal of Acquired Immune Deficiency Syndroms and Human Retrovirology, 10(1), 82-89.

Safe Syringe faces two sustainability challenges: legal authority and funding.

While Safe Syringe received unanimous City-County Council support in 2018, 2020, and 2022, it will remain up for renewal by bipartisan vote every two years according to current Indiana law. The Indiana code surrounding syringe services is set to expire in 2026; the law was previously extended in 2017 and 2020. Conservatives remain a super majority in Indiana state legislature; however, influential champions exist within the caucus, supported by compelling advocates for harm reduction. MCPHD will continue to work with local and statewide elected officials to promote harm reduction as an effective and necessary public health tool in ending the HIV epidemic and saving lives related to the drug epidemic. Lastly, state law prohibits the use of state taxpayer dollars to purchase syringes for syringe exchange purposes.

Safe Syringe was first approved in 2018 with the commitment not to increase MCPHD's budget from local taxpayer dollars to support the program in its first three years of operation. MCPHD has successfully secured enough grant funding to support the program not only through its first three years of operation, rather the first six years! MCPHD received a generous award from a local philanthropic institute to purchase syringes; this award is anticipated to last through 2025. Staffing costs have been covered through the US Department of Justice Comprehensive Opioid-Abuse Programs (2018-2021/22) and Comprehensive Opioid, Stimulant, and Substance Abuse Programs (2022-2025) and the Indiana State Department of Health HIV Prevention Funds. Additional program costs, such as non-syringe harm reduction materials and infrastructure, are and have been supported by the Substance Abuse and Mental Health Services Administration, Centers for Disease Control and Prevention Overdose Data to Action, AIDS United, and the Health Foundation of Greater Indianapolis.

As previously outlined under the Evaluation section of this report, MCPHD contracted Myers and Stauffer LC, an external accounting firm, to conduct a cost-effectiveness analysis. The analysis utilizes data from Safe Syringe's database, MCPHD's electronic medical records, ESSENCE syndromic surveillance data, IEMS data, and hospital and infectious disease data from the Indiana Department of Health. The findings from this report will provide evidence for the financial value of SSPs, not only in Marion County but across the state, which supports the extension of both Safe Syringe locally and the Indiana syringe exchange law. The secondary audience of the report is local hospital systems and their community foundations in anticipation that additional funding for syringes will be provided.