Harm Reduction in Health Centers

The federal Ending the HIV Epidemic in the U.S. plan identifies Health Resources and Services Administration's (HRSA)  Health Center Programs as playing a critical role in diagnosing, treating, preventing and responding to the HIV epidemic. The plan identifies four key strategies; Diagnosis, Treat, Prevent and Respond. Syringe services programs (SSPs) are key to the prevention strategy.

"Having an SSP at the clinic has required minimal staff time, minimal expense and has allowed us to connect with lots of folks experiencing substance use disorders who otherwise never would have connected with services. I think every FQHC system should be required to provide this service!"—Chief Medical Officer of an FQHC in California

Legal Framework

The federal Consolidated Appropriations Act of 2016 modified the ban on the use of federal funds to support SSPs for Department of Health and Human Services (HHS) programs, including HRSA programs.

Federal law now allows federal funds to be used to support all aspects of syringe services programs, except for the purchase of needles and syringes.

The Appropriations Act states that in order to use federal funds to support SSPs, the State or local health department must first receive a determination from CDC indicating the jurisdiction is experiencing, or is at risk for, a significant increase in hepatitis infections or an HIV outbreak due to injection drug use. California received approval of its request for a "Determination of Need" in August 2016. In its letter approving the request (PDF), CDC agreed that all counties in California are at risk for an increase in viral hepatitis or HIV infections due to injection drug use.

The following documents provide additional information about providing harm reduction services in a health center:

• ​​Health Resources & Services Administration (HRSA) – Health Center Program - Health Center Program Compliance Frequently Asked Questions – Provides step-by-step guidance on how to request prior approval from HRSA to use  Health Center Program funding to operate an SSP within a health center. There are four requirements set by HRSA. Please email sspinfo@cdph.ca.gov if you need assistance.
• Department of Health and Human Services - Implementation Guidance to Support Certain Components of Syringe Services Programs, 2016 (PDF, 1.4MB) – This document provides guidance for programs directly funded by HHS (including HRSA) and interested in implementing or expanding SSPs for people who inject drugs.
• HIV.gov – HIV.gov - See section entitled, "HHS Funds Can Support Certain Components of SSPs"
• ​National Association of Community Health Centers
• ​Infectious Disease Programs Page
• ​Sample Policy and Procedure for Syringe Services Programs (PDF)
• California Department of Public Health 
• ​Harm Reduction in Health Centers (PDF): Provides detailed information on how California health centers are integrating harm reduction into their services.
• ​California Law and Syringe Services Programs (PDF) - Describes California laws specific to syringe possession, syringe distribution, other safer drug use materials distributed for public health purposes, and naloxone.
• ​​​California Fatal Opioid Overdose and HIV or Hepatitis C Virus (HCV) Vulnerability Assessment - Action Planning Checklist (PDF) - Provides evidence-based strategies that local health jurisdictions, health care providers, community-based organizations, local opioid safety coalitions, and other partners can use to reduce their county-level vulnerability.

Authorization

California law authorizes SSPs to operate in several ways:

• Physicians - Business and Professions Code (BCP) 4145.5 allows physicians to provide sterile syringes with or without a prescription under their license to practice medicine. Some health centers offer syringe services under BCP 4145.5, which requires no additional authorization by state or local government.
• Pharmacists - BCP 4145.5 permits the nonprescription sale or provision of syringes by California pharmacists. For more information see the CDPH/OA Non-Prescription Syringe Sales webpage.
• Authorization by California Department of Public Health - Health and Safety Code Section 121349(c) allows CDPH to authorize SSPs in locations where the conditions exist for the rapid spread of HIV, hepatitis C virus and other blood-borne infections among people who inject drugs. The CDPH/OA Harm Reduction Unit assists providers in preparing the application for state authorization. Email: SSPinfo@cdph.ca.gov.
• Authorization by County or City Government - Health and Safety Code Section 121349(b) allows local government to authorize SSPs.  The CDPH/OA Harm Reduction Unit can provide technical assistance on how to achieve authorization through local government. Email: SSPinfo@cdph.ca.gov.
• Authorization under Tribal Authority – Tribal governments have the authority to enact and enforce laws, authorize and provide programs and services, including syringe services programs.

Resources

Articles and Guidance

•  Harm Reduction Principles for Healthcare Settings   Hawk, M., Coulter, R. W. S., Egan, J. E., Fisk, S., Reuel Friedman, M., Tula, M., & Kinsky, S. (2017). Harm Reduction Journal, 14(1)
• Implementing Harm Reduction in Non-Urban Communities Affected by Opioids and Polysubstance Use: A Qualitative Study Exploring Challenges and Mitigating Strategies Childs, E., Biello, K., Valente, P., Salhaney, P., Biancarelli, D., Olson, J., Earlywine, J., Marshall, B., & Bazzi, A. (2021). International Journal of Drug Policy, 90, 103080
• Connecting: A Guide to using Harm Reduction Supplies as Engagement Tools (PDF) Miskovic, M., Zurba, N., Beaumont, D., Conway, J. Ontario Harm Reduction Distribution Program, Kingston Community Health Centres, Kingston Ontario
• Quality Healthcare is Your Right! A guide for people who use drugs to encourage them and support them in getting better health care.  National Harm Reduction Coalition (2020) 

Videos

• Harm Reduction in Healthcare Video Series – The Introduction to Harm Reduction in Healthcare Video Series demonstrates practical strategies to support the health of people who use drugs. Grounded in the belief that healthcare is a human right, this series supports the vision of a healthcare system that works for everyone.
• Providing Services in Non-Clinical Settings  – This twenty-minute video explains the benefits of providing services outside of the clinic setting. 

Tools and Technical Assistance

• California Bridge Program - Harm reduction resources for hospitals and other health care settings.
• Harm Reduction Kit
• Harm Reduction Supplies Order Set
• National Harm Reduction Technical Assistance Center – Provides free help to anyone in the country providing (or planning to provide) harm reduction services to their community. 
• National Harm Reduction Coalition - Manuals, brochures, and capacity-building assistance for health departments and organizations that work to improve the health and wellbeing of people who use drugs.
• CDC's Syringe Services Programs Webpage - Information from CDC that includes fact sheets summarizing the evidence supporting syringe services programs, as well as links to additional resources and data.
• National Alliance of State and Territorial AIDS Departments (NASTAD) – Provides resources, trainings and articles on working with people who use drugs to reduce harm and improve wellness.
• CDPH's Office of Viral Hepatitis Prevention - Information on hepatitis A, B and C, data for providers and local health departments.
• CDPH's Office of AIDS / Harm Reduction Unit - Information on syringe services and harm reduction for California programs.