Guidance SSP

3/29/2016

Department of Health and Human Services Implementation

Guidance to Support Certain Components of

Syringe Services Programs, 2016

Introduction
The purpose of this document is to provide implementation guidance for programs directly funded by the
Department of Health and Human Services (HHS) interested in implementing or expanding syringe services
programs (SSPs) for persons who inject drugs (PWID). As described in summary guidance from the Centers
for Disease Control and Prevention (CDC) and HHS1, the term SSPs includes provision of sterile needles,
syringes and other drug preparation equipment and disposal services, as well as some or all of the following
services: comprehensive sexual and injection risk reduction counselling; HIV, viral hepatitis, other sexually
transmitted diseases (STDs) and tuberculosis (TB) screening; provision of naloxone to reverse opioid
overdoses; referral and linkage to HIV, viral hepatitis, other STDs and TB prevention care and treatment
services, referral and linkage to hepatitis A virus (HAV) and hepatitis B virus (HBV) vaccination, as well as
referral to integrated and coordinated f substance use disorder, mental health services, physical health care,
social services, and recovery support services.
On December 18, 2015, President Barack Obama signed the Consolidated Appropriations Act, 2016 (Pub. L.
114-113),2 which modifies the restriction on use of federal funds for programs distributing sterile needles or
syringes (referred to as SSPs, or as syringe exchange programs) for HHS programs. The Consolidated
Appropriations Act, 2016, Division H states:
SEC. 520. Notwithstanding any other provision of this Act, no funds appropriated in this Act shall be
used to purchase sterile needles or syringes for the hypodermic injection of any illegal drug: Provided,
That such limitation does not apply to the use of funds for elements of a program other than making
such purchases if the relevant State or local health department, in consultation with the Centers for
Disease Control and Prevention, determines that the State or local jurisdiction, as applicable, is
experiencing, or is at risk for, a significant increase in hepatitis infections or an HIV outbreak due to
injection drug use, and such program is operating in accordance with State and local law.
While the provision still prohibits the use of federal funds to purchase sterile needles or syringes for the
purposes of hypodermic injection of any illegal drug, it allows for federal funds to be used for other aspects of
SSPs based on evidence of a demonstrated need (i.e., experiencing, or at risk for, a significant increase in
hepatitis infections or an HIV outbreak due to injection drug use) by the state or local health department and
in consultation with the CDC. This guidance details what can be supported with federal funds and what
criteria will be used to determine demonstrated need.

1

CDC. (2012) Integrated Prevention Services for HIV Infection, Viral Hepatitis, Sexually Transmitted Diseases, and Tuberculosis for
Persons Who Use Drugs Illicitly: Summary Guidance from CDC and the U.S. Department of Health and Human Services.
MMWR;61(RR05):1-40.
2
https://www.congress.gov/114/bills/hr2029/BILLS-114hr2029enr.pdf. Accessed on December 22, 2015.
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Principles guiding the use of HHS funding for SSPs
• Programs that use federal funding for SSPs must adhere to federal, state and local laws, regulations,
and other requirements related to such programs or services. State and local laws may vary and will
impact the ability of federally funded recipients to implement these programs.
• Recipients should coordinate with and work toward obtaining cooperation from local law

enforcement officials when implementing SSPs.

• SSPs, as they are implemented, should be a part of a comprehensive service program3 that
includes, as appropriate:
o Provision of sterile needles, syringes and other drug preparation equipment (purchased
with non-federal funds) and disposal services;
o Education and counseling to reduce sexual, injection and overdose risks;
o Provision of condoms to reduce risk of sexual transmission of viral hepatitis, HIV or other
STDs;
o HIV, viral hepatitis, STD and TB screening;
o Provision of naloxone to reverse opioid overdoses;
o Referral and linkage to HIV, viral hepatitis, STD and TB prevention, treatment and care
services, including antiretroviral therapy for hepatitis C virus (HCV)and HIV, pre-exposure
prophylaxis (PrEP), post-exposure prophylaxis (PEP), prevention of mother-to-child
transmission and partner services;
o Referral and linkage to hepatitis A virus (HAV) and hepatitis B virus (HBV) vaccination;
o Referral and linkage to and provision of substance use disorder treatment (including
medication-assisted treatment for opioid use disorder which combines drug therapy (e.g.,
methadone, buprenorphine, or naltrexone) with counseling and behavioral therapy);
o Referral to medical care, mental health services, and other support services.
• Recipients should ensure that SSPs supported with federal funds provide referral and linkage to HIV,
viral hepatitis, and substance use disorder prevention, care and treatment services, as appropriate.
• HHS recipients should coordinate and collaborate with other local agencies, organizations, and
providers involved in comprehensive prevention programs for PWID to minimize duplication of
effort.
• SSPs are subject to the terms and conditions incorporated or referenced in the recipient’s

federal funding.

• Federal funds can only be used to establish a new SSP or expand an existing SSP with prior

approval from the respective federal agency.

3

CDC. (2012) Integrated Prevention Services for HIV Infection, Viral Hepatitis, Sexually Transmitted Diseases, and Tuberculosis for
Persons Who Use Drugs Illicitly: Summary Guidance from CDC and the U.S. Department of Health and Human Services. MMWR;
61(RR05):1-40.
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Use of Federal Funds
Funds may be used to support various components of SSPs4 including, but not necessarily limited to, the
following:
o Personnel (e.g., program staff, as well as staff for planning, monitoring, evaluation, and
quality assurance);
o Supplies, exclusive of needles/syringes and devices solely used in the preparation of
substances for illicit drug injection, e.g., cookers;
o Testing kits for HCV and HIV;
o Syringe disposal services (e.g., contract or other arrangement for disposal of biohazardous
material);
o Navigation services to ensure linkage to HIV and viral hepatitis prevention, treatment and
care services, including antiretroviral therapy for HCV and HIV, PrEP, PEP, prevention of
mother to child transmission and partner services; HAV and HBV vaccination, substance use
disorder treatment, recovery support services and medical and mental health services;
o Provision of naloxone to reverse opioid overdoses;
o Educational materials, including information about safer injection practices, overdose
prevention and reversing a opioid overdose with naloxone, HIV and viral hepatitis
prevention, treatment and care services, and mental health and substance use disorder
treatment including medication-assisted treatment and recovery support services;
o Condoms to reduce sexual risk of sexual transmission of HIV, viral hepatitis, and other
STDs;
o Communication and outreach activities; and
o Planning and evaluation activities.
Note: Not all of the components listed above will be supported by all HHS agencies; use of funding will
depend on each HHS agency’s authorities, policies and procedures as well as state and local laws and
regulations. Approval to use federal funds to support SSPs will be contingent on first demonstrating need,
in consultation with CDC.
Process for demonstrating need in consultation with CDC
State, local, territorial, and tribal health departments should consult with CDC by providing evidence that
their jurisdiction is (1) experiencing or, (2) at risk for a significant increase in viral hepatitis infections or an
HIV outbreak due to injection drug use.5 The scope of the presented evidence should address the
geographic area that will be served by the SSPs and include county, city and state level data, as
appropriate.

4

CDC. (2012) Integrated Prevention Services for HIV Infection, Viral Hepatitis, Sexually Transmitted Diseases, and Tuberculosis for

Persons Who Use Drugs Illicitly: Summary Guidance from CDC and the U.S. Department of Health and Human Services.

MMWR;61(RR05):1-40.of the

5
The state executive branch agency responsible for the administration of discretionary and/or formula grant funds authorized by

Title V, Part B, Subpart 1 of the Public Health Service (PHS) Act and Title XIX, Part B, Subpart II of the PHS Act (42 U.S.C. 300x-21)

awarded by Substance Abuse and Mental Health Services Administration, as applicable, must contact the state health department,

if the agency believes a determination is warranted.

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First, jurisdictions should assess if they are experiencing significant increases in viral hepatitis or HIV
infections. For jurisdictions experiencing significant increases in viral hepatitis or HIV infections, state or local
health departments may use multi-year data from surveillance systems to demonstrate an increase in acute
hepatitis C virus [HCV], acute hepatitis B virus [HBV], or HIV infections (Table 1a). Health departments must
also provide evidence that the significant increase in infections resulted from injection drug use. Such
evidence may include transmission category (i.e., risk factor most likely to have been responsible for
transmission of HIV infection, HCV or HBV) collected as part of routine case reporting, epidemiologic surveys,
scientific data, or social or ethnographic community data. Health departments should assess any significant
increases within the context of local surveillance practices, disease patterns and long-term trends.
Second, for jurisdictions at risk for – but not yet experiencing – significant increases in viral hepatitis or HIV
infections due to injection drug use, data should come from multiple sources that when triangulated
(combined) provide compelling evidence that there is likely an increase in injection drug use in the
jurisdiction. Multiple data sources are recommended because a single data source may be insufficient. For
example, increases in arrests for syringe and drug possession may be due to increased enforcement by the
police force, or additional human resources for drug enforcement units. Similarly, increases in emergency
department visits for drug-related overdoses may be due to new hospital initiatives to improve reporting
or greater awareness of the condition among staff responsible for reporting. Evidence from multiple data
sources, that when considered together, indicate likely increases in injection drug use provides
reassurance that the problem assessment is accurate.
CDC recently conducted analyses to identify a set of outcomes associated with acute HCV infection, a proxy
for unsafe injection drug use. Tables 1b illustrates some of these outcomes and data sources that may be
useful as evidence. In addition, health departments may use local data sources not listed in these tables and
that provide valuable insights unavailable from national or state sources. Examples of data triangulation are
available in the National Institute on Drug Abuse Community Epidemiology Work Group reports (see
http://www.drugabuse.gov/about-nida/organization/workgroups-interest-groups-consortia/communityepidemiology-work-group-cewg/meeting-reports/area-reports-june-2014). Health departments are
encouraged to conduct similar analyses to provide evidence of increases in injection drug use in their
jurisdictions.
Table 1a. Requested outcomes for jurisdictions experiencing significant increases in viral hepatitis or HIV
infections*
Outcomes
Acute HCV or HBV attributed to injection
drug use

Example Data Sources
•
•
•

HIV infections attributed to injection drug
use

•
•
•

National Notifiable Disease Surveillance System
(NNDSS)
State or local surveillance systems
Multi-year cohort studies of persons who inject drugs
(PWID)
National HIV Surveillance System (NHSS)
State or local surveillance systems
Multi-year cohort studies of PWID

* Must provide evidence that increases resulted from injection drug use; such evidence may include transmission
category from case reporting, existing published data and reports, surveys, or social or ethnographic community
data.
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Table 1b. Examples of outcomes for jurisdictions at risk for significant increases in viral hepatitis or HIV
infections
Example Outcomes

Example Data Sources

Brief Rationale

Drug use, injection drug
use and uptake of SSP
services

• Substance Abuse and Mental Health Services
Administration (SAMHSA), National Survey on
Drug Use and Health (NSDUH)
• Scientific surveys, syringe services program
data, or social or ethnographic community
data
• Community poison control data
• CDC, Youth Risk Behavior Surveillance System
(YRBSS)

Provides evidence of
injection drug use

Substance use disorder
treatment admissions
related to injection drug
use

• SAMHSA, Treatment Episode Data Set (TEDS)
• State treatment admissions data
• Health care Cost and Utilization Project
(HCUP)-State Inpatient Databases (SID)
• State hospital discharge files

Drug-related crime

•
•

Substance use disorder
treatment such as
medication-assisted
treatment for opioid
use disorder can
provide evidence of
injection drug use
Arrests for possession
of drug injection
paraphernalia,
possession or
trafficking of heroin
and other drug-related
arrests provide
evidence of local
injection drug use

•
•

Drug-related overdose
mortality

•

•
•
•

Emergency department
or other medical care
related to substance use

•

State or county arrest records
Federal Bureau of Investigations (FBI),
Uniform Crime Reports
Uniform Crime Reports via Inter-university
Consortium for Political and Social Research
(ICPRS)
National Forensic Laboratory Information
System (NFLIS)
CDC, National Center for Health Statistics
(NCHS)/National Vital Statistics System
(accessible through Wide-ranging Online Data
for Epidemiologic Research [WONDER])
CDC, Web-based Injury Statistics Query and
Reporting System (WISQARS™)
State Vital Statistics System
State or county Medical Examiner/Coroner
files

Healthcare Cost and Utilization Project
(HCUP): State Inpatient Databases (SID)
• HCUP- State Emergency Department
Databases (SEDD)
• State emergency department surveillance
systems and EMS systems

Provides evidence of
ongoing substance use
disorder that may be
related to higher or
more frequent doses
or injection drug use

Measures overdoses
and other medical
conditions or
treatments related to
drug use such as
diagnoses of substance
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• State hospital discharge data

use disorder,
dependence, and
endocarditis or
administration of
naloxone

As part of the consultation with CDC, state, local, territorial, and tribal health departments should submit to
CDC a request for determination of need that indicates whether the jurisdiction is (1) experiencing or (2) at
risk of, but not yet experiencing significant increases in viral hepatitis or HIV infections due to injection drug
use. The request should specify: outcomes analyzed, data sources, geographic area covered, assessment
period (beginning year/date to end year/date), type of measure (e.g., number, rate), and relative percent
increase during the assessment period. For jurisdictions at risk for increases, the request should also include a
brief summary of how the data when taken together (i.e., “triangulated”) support this determination. An
example of how the outcomes may be presented and summarized is provided in Appendix 2. Determination
of need requests are strengthened by 1) the use of real-time data sources and 2) evidence of collaborative
data sharing among relevant stakeholders within the jurisdiction.
State, local, territorial, and tribal health departments should submit the request for need determination to
SSPCOORDINATOR@CDC.GOV. Within 30 days after receipt, CDC will notify the requestor whether the
evidence is sufficient to demonstrate need for SSPs. If the evidence is sufficient, the state, local, territorial, or
tribal health department will receive notice of approval regarding determination of need for the jurisdiction.
This notice may be used by the state, local, territorial, or tribal health department or other eligible HHS
recipients as identified by each federal agency to apply to the respective federal agency for redirection of
funds. If the evidence is insufficient, no programmatic or budgetary changes will be authorized. However,
jurisdictions may choose to revise and resubmit their request with additional evidence based on feedback
from CDC.

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APPENDIX 1

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Implementation Guidance to Support Certain Components of Syringe Services Programs
TOOLS AND RESOURCES

The purpose of this document is to provide tools and resources for planning, designing and implementing effective syringe services programs (SSPs) as
part of a comprehensive HIV and viral hepatitis prevention approach for persons who inject drugs (PWID), and for monitoring and evaluating SSP progress
and outcomes. This document is divided into sections based on the stage of program development and activity, and each section includes a summary of
key principles and a list of resources and tools.
The resources presented in this document do not all constitute official Centers for Disease Control and Prevention (CDC) advice and may not represent the
views of CDC or the U.S. Department of Health and Human Services (HHS), nor does this document provide a comprehensive review of all relevant
resources available.

Section I. Assessing Local Injection Drug Use

Effective programs are based on an understanding of the extent of injection drug use in the community, who is injecting drugs, which drugs are being
used, and the key risk behaviors among PWID related to transmission of HIV, viral hepatitis, and other blood-borne infections (e.g., type of injection
equipment shared). Information is also needed on potential barriers and motivators to engaging PWID in SSPs. Because non-medical injection drug use is
illegal, and PWID are a highly stigmatized and marginalized population, local data on injection drug use is often limited. However, triangulating data from
multiple data sources may be useful in providing a more complete picture of injection drug use in a community that may not be possible to obtain with a
single data source. Data may come from national and local surveillance systems, health and prevention service providers, law enforcement, published
research findings and local reports, surveys, or social or ethnographic community data.
Below are examples of national and local data sources, publications and other resources that may be used in assessing local injection drug use and in
demonstrating that a jurisdiction is experiencing or at risk for a significant increase in viral hepatitis or HIV infections due to injection drug use (see also
Tables 1A and 1B of the main Implementation Guidance document). Resources are organized into four tables: (1) Examples of National and Local Data
Sources; (2) Examples of National and Local Data Sources Available Locally; (3) Example Surveillance Reports and Publications; and (4) Guides, Reports,
Surveys, or Social or Ethnographic Community Data. The types of data and resources used in assessing local injection drug use may differ by availability,
quality and relevance of the data in the local setting. In most circumstances, data available locally (see second table in Section I, Examples of National and
Local Data Sources Available Locally at Request) will be most relevant and timely. For example, characteristics of admissions for substance use disorder
treatment are available at the national and state levels through public access on the Substance Abuse and Mental Health Services Administration
(SAMHSA) web site; however, program managers, in either a state health department or other singular agency for substance abuse within a state, who
report these data to SAMHSA will likely be able to provide data for more recent time periods, smaller geographic areas, and that may include additional
variables not required for SAMHSA reporting. Furthermore, in assessing local injection drug use, indicators that are more directly associated with drug
injection (e.g., treatment admissions, arrests for drug injection paraphernalia, syringe services programs, overdose deaths) should be prioritized and
indicators of more upstream events potentially leading to drug injection (e.g., prescribing and dispensing practices of controlled prescription drugs) may
be examined as additional supporting evidence.
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Examples of National, State and
Local Data Sources

Description

Web Link

Substance Abuse and Mental Health
Services Administration (SAMHSA),
Treatment Episode Data Set (TEDS)

Information collected by States from local alcohol and substance use disorder
treatment facilities and reported to SAMHSA to characterize admissions to
alcohol and drug treatment. Data include demographic and drug history
information about individuals admitted to treatment. State level estimates
are available through the online “Quick Statistic Tables” page on the
SAMHSA.gov web link; estimates at lower geographic units can be obtained
through the “Online Analysis & Public Use Files/SAMHDA” page.
Annual survey of prevalence, patterns, and consequences of drug and alcohol
use and abuse in the general U.S. civilian non-institutionalized population age
12 and over. Available data include demographic and drug use characteristics
among participants. National and state level estimates are available.
National school-based survey conducted by CDC and state, territorial, and
tribal governments, and local education and health agencies. Monitors
health-risk behaviors and includes a question on ever injected any illegal drug
(used a needle to inject any illegal drug into their body one or more times
during their life). National, and select state, district, territorial, and tribal
government results are available.
Provides data on vital events (births, deaths, marriages, divorces, and fetal
deaths). For help abstracting drug overdose (poisoning) data from CDC
WONDER’s Multiple Cause of Death file, two guidance documents found on
CDC’s website can be consulted: 1) Guide to CDC WONDER multiple cause of
death query system
(http://www.cdc.gov/drugoverdose/pdf/pdo_wonder_guide_mcod_dataseta.pdf), and 2) Guide to ICD9-CM and ICD10 Codes Related to Poisonings and
Pain, version 1.3 (http://www.cdc.gov/drugoverdose/pdf/pdo_guide_to_icd9-cm_and_icd-10_codes-a.pdf). See Table 3 for Underlying Cause Codes and
Multiple Cause Codes (T-codes) for specific drugs and/or drug categories. For
drug overdose deaths, all intents, you will use Underlying Cause Codes X4044, X60-64, X85, and Y10-Y14. You may also optionally include T-codes for
specific drugs, e.g., T40.1 for heroin. National, state, and county data are
available subject to suppression rules. State and county-level drug-specific
overdose death rates should not be compared due to variability in the
specificity of drugs implicated in a death across jurisdictions.
Family of databases developed through a Federal-State-Industry partnership
that contain encounter-level, clinical, and nonclinical information, including
all-listed diagnoses and procedures, discharge status, patient demographics,
and charges for all patients. The SID capture hospital inpatient stays in a given
State. A number of States make their SID files available (1990-2013) for

http://www.samhsa.gov/data/client-leveldata-teds

SAMHSA, National Survey on Drug Use
and Health (NSDUH)
CDC, Youth Risk Behavior Surveillance
System (YRBSS)

CDC, National Center for Health
Statistics (NCHS)/National Vital
Statistics System (accessible through
Wide-ranging Online Data for
Epidemiologic Research [WONDER])

Healthcare Cost and Utilization Project
(HCUP): State Inpatient Databases
(SID)

http://www.samhsa.gov/data/populationdata-nsduh
http://www.cdc.gov/healthyyouth/data/y
rbs/

http://wonder.cdc.gov/

http://www.ahrq.gov/research/data/hcup
Some state-level HCUP data are also
available through an online query system,
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Healthcare Cost and Utilization Project
(HCUP), State Emergency Department
Databases (SEDD)

Federal Bureau of Investigation (FBI),
Uniform Crime Reports

National Forensic Laboratory
Information System (NFLIS)

CDC, Web-based Injury Statistics Query

purchase through the HCUP Central Distributor. If purchasing state-level
HCUP data from the HCUP Central Distributor is not an option, a jurisdiction
may alternatively contact their respective state agency for hospital discharge
data files, which may be more accessible and timely. Examples of variables
that may be useful include: CM_DRUG (AHRQ comorbidity measure, drug
abuse). Select state-level data are available.
Captures emergency visits at hospital-affiliated emergency departments (EDs)
that do not result in hospitalization. Information about patients initially seen
in the ED and then admitted to the hospital is included in the State Inpatient
Databases (SID). The SEDD files include all patients, regardless of payer. States
make their SEDD files available (1999-2012) for purchase through the HCUP
Central Distributor. If purchasing state-level HCUP data from the HCUP
Central Distributor is not an option, a jurisdiction may alternatively contact
their respective state agency for emergency department data files, which may
be more accessible and timely. Select state-level data are available; thirty-two
States currently participate in the SEDD
The Uniform Crime Reporting (UCR) Program has been the starting place for
law enforcement executives, students of criminal justice, researchers,
members of the media, and the public at large seeking information on crime
in the nation. The program was conceived in 1929 by the International
Association of Chiefs of Police to meet the need for reliable uniform crime
statistics for the nation. In 1930, the FBI was tasked with collecting,
publishing, and archiving those statistics. Each year, participating law
enforcement agencies contribute reports to the FBI either directly or through
their state reporting programs. National and state data are available.
Uniform Crime Reports may also be accessed via the Inter-university
Consortium for Political and Social Research (ICPRS). The county-level data
provide counts of arrests and offenses aggregated to the county level. County
populations are also reported.
The Drug Enforcement Agency (DEA) systematically collects results from drug
chemistry analyses conducted by state and local forensic laboratories. As a
national drug forensic laboratory reporting system, NFLIS provides timely and
detailed analytical results of drugs seized by law enforcement. It is a unique
source of information for monitoring and understanding drug abuse and
trafficking in the United States, including the diversion of legally
manufactured drugs into illegal markets. Crime laboratory data can provide
information on the proportion of items seized and analyzed that test positive
for drugs typically injected, e.g., heroin. National, state, and county data are
available and may be requested through the DEA or a participating local
forensic laboratory.
An interactive, online database that provides fatal and nonfatal injury data,

3/29/2016
HCUPnet, at http://hcupnet.ahrq.gov/.
The user can query specific diagnostic
codes, e.g., endocarditis (ICD-9-CM 421.0),
to obtain number of discharges for
diagnoses associated with injection drug
use.
http://www.ahrq.gov/research/data/hcup
Some state-level HCUP data are also
available through an online query system,
HCUPnet, at http://hcupnet.ahrq.gov/.
The user can query specific diagnostic
codes, e.g., heroin poisonings (ICD-9-CM
965.01), to obtain number of ED visits for
diagnoses associated with injection drug
use.
https://www.fbi.gov/about-us/cjis/ucr/ucr
Table 69 presents drug abuse violations by
State:
https://www.fbi.gov/aboutus/cjis/ucr/crime-in-the-u.s/2013/crimein-the-u.s.-2013/tables/table69/table_69_arrest_by_state_2013.xls
http://www.icpsr.umich.edu/icpsrweb/ICP
SR/series/57

http://www.deadiversion.usdoj.gov/nflis/

http://www.cdc.gov/injury/wisqars/
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and Reporting System (WISQARS™)

including drug poisonings and adverse drug effects. National and state data
are available.

Examples of National and Local
Data Sources Available Locally at
Request

Description

Comments

Provides HIV and AIDS diagnosis data collected by State health departments.
Diagnosis reports include information on mode of transmission, including
injection drug use.
Provides National Electronic Disease Surveillance System (NEDSS) standards,
tools, and resources to support reporting jurisdictions – state, local,
territorial, and tribal health departments – to help them implement
integrated and interoperable public health surveillance systems. For viral
hepatitis, NNDSS has contained case reports for acute hepatitis C virus (HCV)
infections on rotating annual cycles since 1994 and for past and present HCV
infection since 2003. The amount of demographic and risk behavior collected
by NNDSS for acute cases, including injection drug use, varies by state.
Provide program data on the local population of PWID enrolled in SSPs,
including their drug injection practices and service needs. Program
monitoring data are often collected on ongoing basis, thus may provide
information on changes over time in key characteristics of local PWID. SSP
data, however, may vary in scope, completeness, and quality across
programs.
Reflects information collected by States from local alcohol and substance use
disorder treatment facilities characterizing the admissions to such facilities.
Data include demographic and drug history information about individuals
admitted to treatment, as well as changes in treatment admissions. Unlike
the SAMHSA TEDS database, data may be available for more recent years at
the State level.
Provides arrest data for drug and drug paraphernalia possession that may be
available from local law enforcement agencies.
Provides data collected by jurisdictions on vital events, including death
certificate.
Provides data collected by local medical examiner/coroner on drug overdose
deaths.
Provides data from local emergency systems that may include drug-related
health outcomes, including drug overdose.
Contains hospital discharge data collected by States that may be used to
identify drug injection related hospital care, including drug overdose,
endocarditis, soft and bone tissue infections.

For all data sources listed in this table,
refer to appropriate state/local program
coordinators and/or data managers for
information on obtaining data and
availability by geographic level. In most
circumstances, data available locally will
be most relevant to the local settings, may
include additional variables not required
for reporting at the national level, and
may be available for more recent time
periods.

HIV Surveillance System

National Notifiable Disease
Surveillance System (NNDSS)

Syringe services programs

State treatment admissions data

State or county arrest records
State Vital Statistics System
State or county medical
examiner/coroner files
State emergency department
surveillance and EMS systems
State hospital discharge data

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Community poison control data
Prescription drug monitoring
programs (PDMPs)

Reflects information on potential poison exposures reported to local poison
centers, free, confidential hotlines, including data on prescription drug and
heroin overdoses.
State-run electronic databases used to track the prescribing and dispensing of
controlled prescription drugs to patients. PDMPs are designed to monitor this
information for suspected abuse or diversion (i.e., channeling drugs into
illegal use). PDMPs are housed in different statewide regulatory,
administrative or law enforcement agencies and the housing agency may vary
by state. PDMP data are distributed to authorized individuals under state law.
There is considerable variability across states in PDMP procedures and
practices, including the data PDMPs collect, data quality assurances, analyses
and reports that may be produced, and to which users and under what
conditions data may be available. Contact your state PDMP to assess whether
it is feasible to use these data for documenting local drug abuse patterns and
trends.
Additional information may also be found at:
http://www.deadiversion.usdoj.gov/faq/rx_monitor.htm
http://www.pdmpexcellence.org/sites/all/pdfs/Brandeis_PDMP_Report.pdf

Examples of Surveillance Reports
and Publications

Description

Web Link

CDC, ATLAS

An interactive platform for accessing data collected by CDC’s National Center
for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP). Currently, the
Atlas provides interactive maps, graphs, tables, and figures showing geographic
patterns and time trends of HIV, AIDS, viral hepatitis, tuberculosis, chlamydia,
gonorrhea, and primary and secondary syphilis surveillance data. This tool
provides trends in overall (all modes of transmission categories combined) by
county. Trends in cases for the injection drug transmission category are
provided by State.
Provides data on HIV-related risk behaviors, including injection drugs use, HIV
testing, and use of HIV prevention services. NHBS has been conducted in
rotating annual cycles since 2003 in three different populations at high risk for
HIV infection recruited in 20 cities in the U.S., including persons who inject
drugs. Health Departments participating in NHBS have access to their local
data.
This article demonstrates national increases in acute hepatitis C infection in
young persons throughout the U.S., with a particular concentration east of the
Mississippi river. These data indicate an emerging epidemic of HCV Infection
among young, white persons residing in non-urban areas.

http://www.cdc.gov/NCHHSTP/Atlas/

CDC, National HIV Behavioral
Surveillance (NHBS)

Suryaprasad AG, White JZ, Xu F, et al.
(2014) Emerging epidemic of hepatitis
C virus infections among young
nonurban persons who inject drugs in

http://www.cdc.gov/hiv/statistics/systems/
nhbs

http://www.ncbi.nlm.nih.gov/pubmed/251
14031

Page 11 of 22

the United States, 2006–2012. Clin
Infect Dis;59:1411–9.
CDC. (2015) Increases in Hepatitis C
Virus Infection Related to Injection
Drug Use Among Persons Aged ≤30
Years — Kentucky, Tennessee, Virginia,
and West Virginia, 2006–2012.
MMWR; 64(17);453-458.
CDC. (2008) Use of Enhanced
Surveillance for Hepatitis C Virus
Infection to Detect a Cluster Among
Young Injection-Drug Users --- New
York, November 2004--April 2007.
MMWR; 57(19);517-521.

3/29/2016
This report highlights significant increases in cases of acute HCV infections
identified among persons aged ≤30 years in Kentucky, Tennessee, Virginia, and
West Virginia at the same time as treatment admissions for opioid dependency
increased across the four states. These increases indicate a strong correlation
among opioid abuse, drug injecting, and HCV infection in these four
Appalachian states.
This article describes one of the earliest reports to identify a high number of
new HCV Infections among persons ≤30 years to injection drug use. This
outbreak occurred in Long Island, NY between 2004 and 2007. The authors call
for more enhanced surveillance to identify additional clusters and outbreaks of
HCV infection where IDU is widespread.

http://www.cdc.gov/mmwr/preview/mmwr
html/mm6417a2.htm

Examples of Guides, Reports,
Surveys, or Social or Ethnographic
Community Data

Description

Web Link

National Institute on Drug Abuse
(NIDA), Community Epidemiology
Work Group (CEWG) (1976-2014)
and National Drug Early Warning
System (NDEWS) (2015-present)

Synthesizes available data describing the epidemiology of drug use for both the
country and participating metropolitan areas. Data include drug abuse
indicator data, findings from surveys, and other quantitative information
compiled from local, State, and Federal sources. Data are enhanced with
qualitative information obtained from ethnographic research, focus groups,
and other community-based sources.
Provides guidance for conducting a rapid assessment of injection drug use,
including the extent, nature and diffusion of injection drug use, extent of HIV
and other adverse health consequences, and risk behaviors. The rapid
assessment also aims to identify and initiate effective interventions to reduce
adverse health consequences associated with injection drug use.
Presents an assessment of the HIV prevention needs of PWID in Maine. The
purpose of the assessment was to describe the scope of injection drug use in
Maine and to identify the HIV prevention needs of PWID in Maine. Data from
multiple existing sources were triangulated with information from interviews
with key community stakeholders, including service providers for PWID and
current and former PWID.
Summarizes a meeting that brought together federal partners, health department officials, researchers, staff of community-based organizations, and
other stakeholders to explore the complex factors influencing the HCV
epidemic and to prioritize surveillance initiatives and epidemiology, prevention
interventions, and research questions aimed at more effectively target efforts

http://www.drugabuse.gov/about/organiza
tion/CEWG/CEWGHome.html

World Health Organization (WHO).
(1998) Rapid Assessment and
Response Guide on Injection Drug Use
(IDU-RAR).
HIV/STD Program, Maine Bureau of
Health. (2003) HIV Prevention and
Injection Drug Use in Maine – A
Statewide Needs Assessment.
U.S. Department of Health and Human
Services (HHS). (2013). Hepatitis C
Virus Infection in Young Persons Who
Inject Drugs. Consultation Report,
February 26-27, 2013.

http://www.cdc.gov/mmwr/preview/mmwr
html/mm5719a3.htm

http://www.ndews.org/
https://www.unodc.org/documents/hivaids/IDU%20rapid%20ass.%20and%20resp.
%20guide.pdf
http://www.maine.gov/dhhs/mecdc/phdat
a/non-dhp-pdf-doc/hiv-prevention-andinjection-drug-use-in-maine-a-stateneed.pdf
https://www.aids.gov/pdf/hcv-and-youngpwid-consultation-report.pdf

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3/29/2016
to reduce new HCV infections among young persons who inject drugs in the
United States.

Section II. Planning, Designing, Implementing, and Monitoring SSPs
This section provides resources for health departments and local partners that may be helpful in planning, designing, and implementing SSPs in their
jurisdictions. The resources include national and international guidelines, sources for technical assistance and program supplies, and strategies for working
with law enforcement and for building strong community relationships. Monitoring SSPs is a critical component in the planning, designing and
implementing stages to ensure that the program is operating in conformity to its design, reaching the population it aims to serve, and achieving the
anticipated implementation goals. Some of the example resources provided in this section also include guidance on successfully monitoring and evaluating
SSPs (e.g., NASTAD & UCHAPS 2012).
Examples of Resources and Tools

Description

Web Link

National Alliance of State and
Territorial AIDS Directors (NASTAD)
and the Urban Coalition for
HIV/AIDS Prevention Services
(UCHAPS). (2012) Syringe Services
Program Development and
Implementation Guidelines for
State and Local Health
Departments.
WHO/UNAIDS. (2007) Guide to Starting
and Managing Needle and Syringe
Programmes.

Provides guidelines to assist state and local health departments that wish to
support SSPs for PWID to prevent transmission of HIV and other blood-borne
viruses such as HCV, and to link PWID to vital prevention, medical and social
services. The guidelines provide information on the background of SSPs,
structural elements to be considered before implementing SSPs, operating
principles, SSP delivery models, and suggestions for monitoring SSPs and
capacity building needs. The document also lists additional resources and
tools.

http://www.uchaps.org/assets/NASTADUCHAPS-SSPGuidelines-8-2012.pdf

Provides guidance for developing and implementing effective SSPs. The
guidance includes practical information on planning the program, modes of
delivery, staffing, and supplies, and management guidance on the spectrum of
services, managing staff and external relationships. The guide also provides
additional resources, publications, and tools.
Provides a comprehensive review and summary of available evidence for
effectiveness and cost-effectiveness of SSPs.

http://www.who.int/hiv/pub/idu/needle
program/en/

Based on implementation of SSPs in India, presents standard operating
procedures and offers assistance in the establishment and implementation of
an SSP, as well as monitoring and evaluating of the same.

http://www.unodc.org/documents/south
asia/publications/sops/needle-syringeexchange-program-for-injecting-drugusers.pdf
http://www.unaids.org/sites/default/file
s/sub_landing/files/17_Framework_ME_
Prevention_Prog_MARP_E.pdf

WHO. (2004) Effectiveness of Sterile
Needle and Syringe Programming in
Reducing HIV/AIDS among Injecting
Drug Users.
United Nations Office on Drugs and
Crime (UNODC). (2012) Needle Syringe
Exchange Program for Injecting Drug
Users.
UNAIDS. (2007) A Framework for
Monitoring and Evaluating HIV
Prevention Programmes for Most-At-

Provides guidance in monitoring and evaluating HIV prevention programs for
most-at-risk populations, including PWID. It includes methods and tools that
can be applied at the local and national level.

http://www.who.int/hiv/pub/prev_care/
en/effectivenesssterileneedle.pdf

Page 13 of 22

Risk Populations.
NYC Department of Health and Mental
Hygiene. (2009) Recommended Best
Practices for Effective Syringe
Exchange Programs in the United
States: Results of a Consensus
Meeting.
North American Syringe Exchange
Network (NASEN)

Harm Reduction Coalition

Public Health Law Research’s Law
Atlas: Syringe Distribution Laws Map
Kentucky Harm Reduction and Syringe
Exchange Program. (2015) Guidelines
for Local Health Departments
Implementing Needle Exchange
Programs.

3/29/2016
Summarizes the consensus among SSP experts of the underlying principles and
programmatic elements that enable or constrain SSP effectiveness.

https://www.cdph.ca.gov/programs/Doc
uments/US_SEP_recs_final_report.pdf

A national network of syringe exchange programs, those who support them,
and the people they serve. NASEN support SEPs through technical and financial
assistance programs, expand and support the network of individuals and
organizations interested in syringe exchange as an effective public health
intervention, and disseminate information related to syringe exchange and
disease prevention.
A national advocacy and capacity-building organization that promotes the
health and dignity of individuals and communities impacted by drug use. Harm
Reduction Coalition develops tools and resources that on methods for reducing
drug-related harm (e.g., brochures, factsheets, training curricula), and provide
training and capacity building to community-based organizations and other
stakeholders.
Provides a longitudinal dataset, displaying laws regarding access to sterile
syringes from July 1, 2012 through April 30, 2015. Historically, state laws have
created barriers that make it difficult for PWID to access sterile syringes by
criminalizing distribution and possession of those syringes.
Provides an example of state-level guidance for local health department
jurisdictions wishing to operate SSPs.

https://nasen.org/

http://harmreduction.org/

http://lawatlas.org/query?dataset=syring
e-policies-laws-regulating-non-retaildistribution-of-drug-paraphernalia
https://louisvilleky.gov/sites/default/files
/health_and_wellness/clinics/2015_kydp
h_hrsep_guidelines_long_version.pdf

Section III. Comprehensive Prevention Programs for PWID
A comprehensive, multi-component, prevention program is the most effective approach for preventing the transmission and acquisition of HIV and other
blood-borne infections among drug-using populations. SSPs are an important component of this approach and are particularly key in establishing contact
with otherwise hard-to-reach populations to deliver health services, including HIV, sexually transmitted diseases (STDs) and viral hepatitis counseling
(including for risk reduction) and testing, overdose prevention, and substance use disorder treatment referrals. This section provides resources and tools
to consider in implementing SSPs as part of a comprehensive prevention approach that addresses the myriad of health and social circumstances of PWID.
Resources to guide monitoring and evaluation of comprehensive prevention programs for PWID, which are key operational activities to ensuring that the
programs are meeting their implementation goals, are also provided.
Page 14 of 22

3/29/2016

Examples of Resources and Tools

Description

Web Link

CDC. (2012) Integrated Prevention
Services for HIV Infection, Viral
Hepatitis, Sexually Transmitted
Diseases, and Tuberculosis for
Persons Who Use Drugs Illicitly:
Summary Guidance from CDC and
the U.S. Department of Health and
Human Services. MMWR; 61
(RR05):1-40.
CDC and Academy for Educational
Development (AED). (2000) A
Comprehensive Approach:
Preventing Blood-Borne Infections
among Injection Drug Users.

Summarizes current (as of 2011) public health recommendations and guidelines
from multiple agencies of the HHS for science-based public health strategies for
the prevention HIV infection, viral hepatitis, STDs, and tuberculosis (TB) among
persons who use drugs illicitly and their contacts (sex and drug-using partners)
in the United States.

http://www.cdc.gov/mmwr/pdf/rr/rr610
5.pdf

Technical assistance document that describes key strategies for prevention of
HIV and other blood-borne infections among PWID. The assistance document
also provides guidance on coordination of different services and coordination
with providers, strategies to ensure access, coverage and high quality, and how
to recognize and overcome stigma.

http://www.cdc.gov/idu/pubs/ca/compr
ehensive-approach.pdf

NASTAD. (2015) Maximizing
Health, Minimizing Harm: The
Role of Public Health Program in
Drug User health
CDC. (2010) Toolkit for
Implementing Comprehensive HIV
Prevention Programs for People
Who Use Drugs.
CDC. (2015) HIV and Injection
Drug Use, Factsheet.

This resource highlights opportunities and provides recommendations for
health department programs to address a range of drug user health issues,
including HIV and HCV infections.

https://www.nastad.org/resource/maxi
mizing-health-minimizing-harm-rolepublic-health-programs-drug-user-health

Provides an overview of tools and resources for key, effective interventions and
planning programs for persons who use drugs, including designing and
implementing programs, monitoring and evaluating program progress and
outcomes, and supporting and developing effective drug and HIV policy.
Provides fast facts on HIV incidence and prevalence among PWID, prevention
challenges, and CDC activities to maximize the effectiveness of current HIV
prevention methods, and improve what we know about the behaviors and risks
faced by PWID.
Provides basic facts about opioid overdose, lists steps for first responders, and
outlines key information for prescribers, patients, and family members.

http://www.cdc.gov/globalaids/resource
s/prevention/docs/toolkit-forimplementing-programs-for-people-whouse-drugs.pdf
http://www.cdc.gov/hiv/pdf/g-l/cdc-hividu-fact-sheet.pdf

SAMHSA. (2014) SAMHSA Opioid
Overdose Prevention Toolkit.
CDC. (2015) Prescription Drug
Overdose: What States Need to know
About the Epidemic.
U.S. Public Health Service and
CDC. (2014) Preexposure
Prophylaxis for the Prevention of
HIV Infection in the United States
– 2014 Clinical Practice Guidelines.
WHO. (2004) Evidence for Action:
Effectiveness of Community-Based

Provides information on overdose prevention strategies, state programs and
policies, and latest opioid overdose data reports.

http://store.samhsa.gov/product/OpioidOverdose-Prevention-Toolkit-Updated2014/SMA14-4742
http://www.cdc.gov/drugoverdose/epide
mic/states.html

Provides comprehensive information for the use of daily oral antiretroviral
preexposure prophylaxis (PrEP) to reduce the risk of acquiring HIV infection in
adults, including PWID.

http://www.cdc.gov/hiv/pdf/prepguideli
nes2014.pdf

Provides the evidence for the effectiveness of community-based outreach
intervention as one component of a comprehensive HIV prevention model for

http://www.who.int/hiv/pub/prev_care/
en/evidenceforactionalcommunityfinal.p
Page 15 of 22

Outreach in Preventing HIV/AIDS
Among Injecting Drug Users.
NIDA. (2000) The NIDA CommunityBased Outreach Model: A Manual to
Reduce the Risk of HIV and Other
Blood-Borne Infections in Drug Users.
NIDA. (2009) Principles of Drug
Addiction Treatment: A ResearchBased Guide.
NIDA. (2006) Methadone Research
Web Guide.

3/29/2016

preventing HIV infection in PWID.

df

Describes a scientifically tested model of community-based outreach to reduce
the risk of HIV and other blood-borne infections in drug users.

http://archives.drugabuse.gov/pdf/CBO
M/Manual.pdf

Summarizes effective drug abuse and addiction treatments and a guide to their
implementation.

https://d14rmgtrwzf5a.cloudfront.net/sit
es/default/files/podat_1.pdf

Provides guidance for developing knowledge and understanding of U.S.
methadone maintenance research, share best practices in methadone
treatment and program design and implementation, and provide access to
approved treatment protocols.
Presents an overview of case management for substance use disorder
treatment providers. Discusses models, program evaluation, managed care
issues, referral and service coordination requirements, linkages with other
service agencies, and clients with special needs.

http://blog.mlive.com/chronicle/2007/12
/MethadoneResearchWebGuide.pdf

SAMHSA. (2005) TIP 43: MedicationAssisted Treatment for Opioid
Addiction in Opioid Treatment
Programs.

Gives a detailed description of medication-assisted treatment for addiction to
opioids, including comprehensive maintenance treatment, detoxification, and
medically supervised withdrawal. Discusses screening, assessment, and
administrative and ethical issues.

http://store.samhsa.gov/product/TIP-43Medication-Assisted-Treatment-forOpioid-Addiction-in-Opioid-TreatmentPrograms/SMA12-4214

WHO. (2014) Policy Brief: HIV
Prevention, Diagnosis, Treatment and
Care for Key Populations.
Consolidated Guidelines.

Provides an overview of key findings, data and figures of the new consolidated
guidelines on HIV prevention, diagnosis, treatment and care for key
populations, including PWID. It also offers an overview of the comprehensive
package on interventions and a table summarizing WHO recommendations
concerning key populations.
Provides guidance in monitoring and evaluating HIV prevention programs for
most-at-risk populations, including PWID. It includes methods and tools that can
be applied to SSPs at the local and national level.

http://www.who.int/hiv/pub/toolkits/ke
ypopulations/en/

Provides technical guidance to countries on monitoring efforts to prevent and
treat HIV infection among PWID and for setting ambitious but achievable
national targets for scaling up towards universal access.

http://apps.who.int/iris/bitstream/10665
/77969/1/9789241504379_eng.pdf

SAMHSA. (2007) TIP 27:
Comprehensive Case Management
for Substance Abuse Treatment.

UNAIDS. (2007) A Framework for
Monitoring and Evaluating HIV
Prevention Programmes for Most-AtRisk Populations.
WHO, UNODC, UNAIDS. (2012)
Technical Guide for Countries to Set
Targets for Universal Access to HIV
Prevention, Treatment and Care for
Injecting Drug Users.

http://store.samhsa.gov/product/TIP-27Comprehensive-Case-Management-forSubstance-Abuse-Treatment/SMA124215

http://www.unaids.org/sites/default/file
s/sub_landing/files/17_Framework_ME_
Prevention_Prog_MARP_E.pdf

Page 16 of 22

3/29/2016

APPENDIX 2

Implementation Guidance to Support Certain Components of Syringe Services Programs,

2016

EXAMPLE OF A REQUEST FOR DETERMINATION OF NEED

This appendix illustrates how existing data can be summarized to provide evidence that a jurisdiction is
experiencing or is at risk for significant increases in viral hepatitis or HIV infections due to injection drug use.
As described in the guidance, a request for determination of need should be submitted by the state health
department to SSPCOORDINATOR@CDC.GOV. Within 30 days after receipt, CDC will notify the recipient
whether the evidence is sufficient to demonstrate need. If the evidence is determined to be sufficient, the
recipient may apply for redirection of funds to the respective federal agency. If the evidence is determined to
be insufficient, no programmatic or budgetary changes will be authorized. Jurisdictions, however, may
choose to revise and resubmit their request with additional evidence based on feedback from CDC.
In order to demonstrate need, the jurisdiction has to fulfill one of the two following criteria; evidence on only
one of the two criteria should be presented to demonstrate need:
A. Jurisdiction is experiencing significant increases in viral hepatitis or HIV infections due to injection drug
use.
B. Jurisdiction is at risk for – but not yet experiencing – significant increases in viral hepatitis or HIV
infections due to injection drug use.
Parts A1 and A2 below provide an example for jurisdictions experiencing significant increases. Part A1
provides an example of relevant data sources. Part A2 has an example of how to present evidence that the
significant increases in HIV and/or viral hepatitis infections resulted from injection drug use. As described in
the guidance, such evidence may include transmission category from case reporting, existing published data
and reports, surveys, or social or ethnographic community data.
Parts B1 and B2 provide an example for jurisdictions at risk. The relevant data sources are described in Part
B1. Part B2 provides an example of how the information can be synthesized (i.e., “triangulated”), and
provides additional details to what is presented in Part B1. Synthesis of data is critical as evidence that is not
sufficient for determination of need by itself may describe a clearer picture when considered together with
other evidence. Therefore it is important that synthesis of information be provided as part of the request for
determination of need. A sample list of data sources and outcomes is provided in the guidance document,
pages 4-5 (Tables 1a and 1b) and in Appendix 1.

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3/29/2016

PART A: Jurisdiction is EXPERIENCING significant increases in viral hepatitis (acute hepatitis C virus [HCV] or acute hepatitis B virus [HBV])
or HIV infections due to injection drug use
REQUEST FOR DETERMINATION OF NEED
Requesting jurisdiction:
State A
Geographic area for which the determination is requested: County X
We are submitting evidence for consultation with CDC to demonstrate our jurisdiction is EXPERIENCING significant increases in viral hepatitis or

HIV infections due to injection drug use.

Part A1: Data Sources
The relevant row in the table below may be completed based on available data.
Outcome(s)

Data source

HIV
attributed to
injection
drug use

N/A

Acute HCV

Example: Viral Hepatitis
Surveillance United States,
2013 (CDC,
http://www.cdc.gov/hepati
tis/statistics/2013surveillan
ce/pdfs/2013hepsurveillanc
erpt.pdf)

Acute HBV

N/A

Geographic area

State A

Assessment period
beginning year and
number or rate

Assessment period
ending year and
number or rate

Month:
Year:

Month:
Year:

Value:
Units:

Value:
Units:

Month: Jan-Dec
Year: 2009

Month: Jan-Dec
Year: 2013

Value: 0.3
Units: cases per
100,00 population

Value: 2.7
Units: cases per
100,00 population

Month:
Year:

Month:
Year:

Value:
Units:

Value:
Units:

Percent increase during the
assessment period

800% increase over 5 years

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3/29/2016

Part A2: Summary of Evidence
Example:

Data submitted to CDC for the state of A indicate an 800% increase in annualized rates of acute hepatitis C infection from 2009 to 2013. During this

period, data from at least three sources1-3 suggest that the majority of these infections (>70%) resulted from injection drug use.

1. Zibbell, J.E., et al., Increases in hepatitis C virus infection related to injection drug use among persons aged < 30 years - Kentucky,
Tennessee, Virginia, and West Virginia, 2006-2012. MMWR Morb Mortal Wkly Rep, 2015. 64(17): p. 453-8.
2. Suryaprasad, A.G., et al., Emerging epidemic of hepatitis C virus infections among young nonurban persons who inject drugs in the United
States, 2006-2012. Clin Infect Dis, 2014. 59(10): p. 1411-9.
3. Centers for Disease Control and Prevention. Viral hepatitis surveillance -- United States, 2013. 2014 (Accessed October 8, 2015).
During 2013, X County had a substantially higher rate of reported HCV cases compared with the state overall: 97 per 100,000 population compared
with 69 per 100,000 population. We therefore believe that rates of acute HCV infection are rising throughout the state with an excess burden of

disease in X County.

Page 19 of 22

PART B: Jurisdiction is AT RISK FOR significant increases in viral hepatitis or HIV infections due to injection drug use

3/29/2016

REQUEST FOR DETERMINATION OF NEED
State XX
Requesting jurisdiction:
Geographic area for which the determination is requested: County B

We are submitting evidence for consultation with CDC to demonstrate our jurisdiction is AT RISK FOR significant increases in viral hepatitis
or HIV infections due to injection drug use.
Part B1: Data Sources
It is recommended that data come from multiple sources that when triangulated (combined) provide compelling evidence that there is likely
an increase in injection drug use in the jurisdiction. Additional sheets may be added if necessary.
Outcomes

Data source

Geographic area

Increase in Injection drug
use among treatment
admissions (any drug) to
publicly funded programs

State Division of
Alcohol and Drug
Abuse

B County

Heroin-related arrests

County arrest
records

B County

Opioid related hospital
discharges

State hospital
discharge files

B County

Drug overdose deaths

State Medical
Examiner/Coroner
files

B County

Assessment period beginning
year and number or rate

Assessment period Ending
year and number or rate

Month: Jan-Dec
Year: 2009

Month: Jan-Dec
Year: 2014

Value: 3,500
Units: number per year
Month: Jan-Dec
Year: 2012

Value: 6,200
Units: number per year
Month: Jan-Dec
Year: 2014

Value: 5,280
Units: number per year
Month: Jan-Dec
Year: 2009

Value: 6,355
Units: number per year
Month: Jan-Dec
Year: 2014

Value: 3,345
Units: number per year
Month: Jan-Dec
Year: 2009

Value: 2,792
Units: number per year
Month: Jan-Dec
Year: 2013

Value: 9.8 per 100,000
Units: rate

Value: 18.3 per 100,000
Units: rate

Percent increase
during the
assessment period
77%

20%

-17%

87%

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Part B2: Summary of Evidence
An example of a summary synthesizing the evidence is presented that indicates the jurisdiction is at risk for increases in viral hepatitis or HIV
due to injection drug use. Note that additional detail and data points are included here to provide a clearer picture
Example:

The state of XX assessed 4 variables related to injection drug use in County B that together suggest an increasing trend in unsafe injection practices

that may lead to increases in viral hepatitis and HIV infections. These variables include substance use disorder treatment admissions for injection drug

use, heroin-related arrests, hospital discharges related to misuse of opioids, and drug overdose deaths involving heroin or other opioid drugs.

The most direct indicator of injection drug use is the treatment admissions dataset. Treatment admissions related to injection drug use increased by

77% from 2009 to 2014. Admissions in the younger age group (15-24 years) increased almost threefold from 502 in 2009 to 1,490 in 2014, suggesting

potential increases in injection initiation. Heroin-related arrests increased 20% from 2012-2014 and were 5,280 in 2012, 5,733 in 2013 and 6,355 in

2014. No new policing initiatives have been documented that may artificially inflate this trend. Heroin-related arrest reports do not distinguish

between the different routes of administration, but based on treatment data, 60% of treatment admissions related injection drug use were for heroin.

Opioid-related hospital discharges did not show increases, but where high: 3,345 in 2012, 3,046 in 2013 and 2,792 in 2014. The overall number of

hospital discharges in County B declined during this time period, therefore, the change in opioid-related hospital discharges may not reflect true

trends in opioid use in the county. On the other hand, drug overdose deaths involving opioids increased substantially (87%) between 2009 and 2013,

with the largest increases among younger people (<30 years). The overall rates per 100,000 persons and numbers of deaths (in parentheses) in drug

overdose mortality were: 9.8 per 100,000 (58) in 2009, 9.1 (80) in 2010, 12.2 (110) in 2011, 15.0 (140) in 2012 and 18.3 (180) in 2013. Although these

data also do not distinguish the route of administration, hospital discharges and opioid-related deaths suggest problematic use of these substances,

which likely includes injection.

Together these data suggest high and increasing levels of unsafe injection drug use in this jurisdiction, and particularly among young people (<30

years) who could greatly benefit from syringe service programs and harm reduction education to prevent future spread of viral hepatitis and HIV.

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