Paraphernalia Laws, Criminalizing Possession and Distribution of Items Used to Consume Illicit Drugs, and Injection-related Harm

Corey S. Davis, JD, MSPH; Derek H. Carr, JD; Elizabeth A. Samuels, MD, MPH, MHS

Disclosures

Am J Public Health. 2019;109(11):1564-1567. 

In This Article

Abstract and Introduction

Abstract

The United States remains in the grip of an unprecedented epidemic of drug-related harm. Infections of HIV, hepatitis C, and endocarditis related to lack of access to new syringes and subsequent syringe sharing among people who inject drugs have increased alongside a surge in opioid overdose deaths.

Overwhelming evidence shows that using a new syringe with every injection prevents injection-related blood-borne disease transmission. Additionally, there is promising research suggesting that the distribution of fentanyl test strips to people who inject drugs changes individuals' injection decisions, which enables safer drug use and reduces the risk of fatal overdose. However, laws prohibiting the possession of syringes and fentanyl test strips persist in nearly every state.

The full and immediate repeal of state paraphernalia laws is both warranted and needed to reduce opioid overdose death and related harms. Such repeal would improve the health of people who inject drugs and those with whom they interact, reducing the spread of blood-borne disease and fatal overdose associated with infiltration of illicitly manufactured fentanyl into the illicit drug supply. It would also free up scarce public resources that could be redirected toward evidence-based approaches to reducing drug-related harm.

Introduction

The United States remains in the grip of an unprecedented epidemic of drug-related harm. In 2017 more than 70 000 Americans were killed by drug overdose, surpassing the number lost in any year during the height of the HIV/AIDS crisis.[1] Alongside the surge in overdose deaths, infections related to lack of access to new syringes and subsequent syringe sharing among people who inject drugs (PWID) have increased, with Indiana, Kentucky, Massachusetts, and Ohio all experiencing recent injection-related HIV outbreaks.[2–4] Hepatitis C infections, which overwhelmingly result from use of shared syringes, have increased every year for nearly a decade.[5] Simultaneously, cases of injection-related endocarditis have been rising nationwide.[6]

Law can serve as both a barrier to and facilitator of evidence-based interventions. The United States has made substantial progress in recent years reducing barriers to the opioid overdose reversal medication naloxone and taken incremental steps to expand access to opioid agonist therapy with methadone and buprenorphine, actions that are helping to reduce the toll of preventable opioid-related death and disability.[7,8] However, despite continued rhetoric that the country cannot "arrest its way out of the problem" of drug-related harm, governmental attention continues to focus on criminal justice-oriented approaches to the ongoing epidemic.

State paraphernalia laws, which criminalize the possession and distribution of items used to consume illicit drugs, are perhaps the most indefensible of these unnecessary and harmful legal barriers. Nearly all state paraphernalia laws are based on model legislation developed by the federal Drug Enforcement Administration in 1979, which defines drug paraphernalia as including any item used, intended for use, or designed for use in producing, testing, storing, or consuming controlled substances. These laws criminalize the distribution of syringes and other drug paraphernalia to PWID and subject PWID to arrest and prosecution for possessing these items.

Paraphernalia laws persist in nearly every state despite overwhelming evidence that using a new syringe with every injection prevents injection-related blood-borne disease transmission and qualitative research suggesting that the distribution of fentanyl test strips (FTSs) to PWID changes those individuals' injection decisions, enabling safer drug use and potentially reducing the risk of fatal overdose.[9–11] Repealing paraphernalia laws would improve the health of PWID and those with whom they interact, reducing the spread of blood-borne disease and decreasing overdose risk. Such action would also free up scarce public resources that could be redirected toward evidence-based approaches to reducing drug-related harm.

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