‘No public health justification’: Harm reductionists concerned as pipe ban set to go into effect

Experts who work in harm reduction have been left to ask why lawmakers in West Virginia overwhelmingly passed legislation to prohibit syringe service programs from distributing safe smoking materials. (Lori Kersey | West Virginia Watch)

As lawmakers in West Virginia overwhelmingly passed legislation this session to prohibit syringe service programs from distributing safe smoking materials — a medically sound option to decrease more risky intravenous drug use — experts who work in harm reduction have been left to ponder one question: Why?

House Bill 4667 — which will go into effect unless vetoed by the governor in coming days — passed both the Senate and the House , along with several committees , with no statement from any lawmakers explaining why they supported and voted for the proposed law.

“It’s confusing to me because there is no public health justification for banning these,” said Robin Pollini, an infectious disease epidemiologist at West Virginia University who specializes in drug use. “What we know is that when you provide smoking supplies, people will inject less and smoke more. That nearly eliminates all of the risks associated with injection, which are many, so that is reducing harm — quite literally the point of any harm reduction program.”

The bill adds one new line into state code: Syringe service programs licensed by the state “shall not distribute any smoking devices, including, but not limited to, hand pipes, bubblers, bongs, dab rigs, hookahs, crack pipes, or disposable smoking devices.”

The single line was inserted into language adopted by the Legislature in 2021 to ban the existence of low-barrier, needs-based syringe service programs, which — according to a mountain of peer-reviewed evidence and research going back decades — are the most effective at reducing transmission of diseases tied to IV drug use, limiting needle litter in communities and increasing rates of people enter treatment for substance use disorder.

In the wake of that law, the number of syringe service programs operating in West Virginia — where HIV and hepatitis clusters persist — shrunk from 16 in 2020 to eight in 2022.

The new law regulating smoking supplies, while not as far reaching as the 2021 syringe law, is the most recent example of an ongoing trend adopted by lawmakers, especially when it comes to drug use: disregarding settled science in favor of policies that promote stigma and misinformation.

“This isn’t solving a problem, because there is no problem that exists that this kind of law solves,” said Laura Jones, executive director of Milan Puskar Health Right, in Morgantown, which is home to the largest remaining syringe service program in the state. “What they’ve done is they’ve taken a helpful harm reduction technique that public health people pretty much agree is a good idea and made that no longer accessible to people who use drugs. Who is that helping?”

Jones said her team at Milan Puskar Health Right began distributing smoking supplies — paid for through private grants and foundations — at the beginning of the COVID-19 pandemic. Given the unknowns about the virus at the time and the lack of a vaccine, she said it seemed like an obvious choice to try and prevent people from sharing syringes as the illness circulated.

“Then we started doing more research and it was like a big, hit yourself in the head, ‘duh!’ — [we learned] it’s a lot safer to smoke drugs than inject them,” Jones said. “Our clients, if they smoke, the likelihood of getting hep C or HIV, it’s incredibly unlikely. The risks of contracting MRSA, injection site wounds or infections, endocarditis, those drop drastically. So it made sense for us to keep giving them out because we realize all of those things, for years, have been increasing in West Virginia. It was a strategy we could use to keep the risk low for the people we see.”

While not due to the availability of smoking supplies alone, Milan Puskar’s strategies — largely its efforts to continue supplying sterile syringes in the community even under tight restrictions — have proven effective.

Unlike Kanawha and Cabell counties and despite the similarities between the areas, Monongalia County has not experienced an HIV cluster tied to IV drug use among residents. Both the others have, with the Centers for Disease Control and Prevention in 2021 calling Kanawha’s outbreak the “most concerning” in the nation tied to IV drug use.

Rates of other diseases, including hepatitis and endocarditis , are consistently lower in Monongalia County than in other high-risk areas of the state. According to the state Office of Drug Control Policy , the per capita number of fatal overdoses as well as emergency room visits for suspected overdoses are annually lower in Monongalia County.

But for a Legislature that tends to ignore the basis of science in certain cases and often leaves experts out of the decision-making process — see the recent moves to water down the state’s effective vaccination laws and further prohibit gender affirming care for at-risk minors, despite outcries from the medical community on both issues — that evidence doesn’t seem to matter, Pollini said.

“There is clear science about all of this. The work has been done, and we know what works and what doesn’t work. Now, our largest struggle is getting politicians to allow us to do what works,” Pollini said. “But instead of coming together and working on solutions, we’re seeing another tool taken out of our toolbox. Another strategy to help people taken away.”

Dr. Sara Glick, an epidemiologist at the University of Washington School of Medicine, said sentiments like those held by West Virginia lawmakers aren’t unique. In state Legislatures and other local governments across the country, harm reductionists are finding themselves under attack as they struggle to promote sustainable programming to help their clients in a climate that is growing increasingly hostile toward the work they do and the strategies they know could prove successful.

“We are in a good place with the science. We know that [syringe service programs] reduce HIV, hepatitis, they reduce risk of overdose. And yet, people in the U.S. tend to be moving to places where the science isn’t as considered,” Glick said. “It does seem that what we hear in the media, the most extreme responses like what you’re seeing in West Virginia, tend to be in more conservative areas. That’s not a rule, but it is a trend.”

In Idaho — where, just like West Virginia, Republicans hold a supermajority in the state Legislature as well as all statewide constitutional offices — police last month executed raids on harm reduction programs because of concerns about distributing drug paraphernalia, including pipes. A lawmaker there has since introduced legislation to repeal the state’s Syringe and Needle Exchange Act .

In 2021, officials in Scott County, Indiana ​​ shut down a syringe service program that experts credited for helping control a historic HIV outbreak tied to drug use.

When these attacks are launched, real people suffer, Glick said. And when a harm reduction or syringe service program is hindered by politics, in turn limiting the kinds of resources it can provide to people who use drugs, efforts to help those people are also hindered.

Pollini said one of the largest concerns that will come when HB 4667 is likely enacted is the number of people who could lose connections with their syringe service programs. That will mean a missed opportunity to get Narcan into someone’s hand, test and treat them for diseases like HIV, transition them away from injecting drugs or provide them resources and education that could promote recovery.

“There are people who do come in [to syringe service programs] just for smoking supplies. We’re no longer going to engage with those people,” Pollini said. “Those connections that we’re able to build — people coming in, engaging with staff, being treated friendly — that’s what motivates [people who use drugs] to change behavior. And now, those engagements won’t happen.

“These laws, they aren’t about pipes or syringes or anything like that,” Pollini continued. “They’re about not wanting a certain group of people around, in our communities. These laws discourage doing the things we know keep people alive and as healthy as possible.”

Correction: This article was updated to correct that Dr. Sara Glick works at the University of Washington School of Medicine.

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