Syringe services programs
Syringe services programs (SSPs), also called needle exchange programs, syringe exchange programs, and needle syringe programs, are community-based programs that provide access to sterile needles, syringes, and other injection equipment free of cost to people who inject drugs (PWID) and promote safe disposal of used injection equipment. SSPs often provide PWID with other supporting services, including overdose risk education, provision of condoms and naloxone, vaccinations, infectious disease testing, and referrals and links to substance use treatment and social support services. SSPs vary by size, scope, geographic location, and setting (e.g., community, hospital, or mobile sites using vans or buses). SSPs can be part of a comprehensive prevention program at the state or local level1.
What could this strategy improve?
Expected Benefits
Our evidence rating is based on the likelihood of achieving these outcomes:
Reduced HIV infection
Reduced injection risk behavior
Potential Benefits
Our evidence rating is not based on these outcomes, but these benefits may also be possible:
Reduced hepatitis C infection
Increased substance use disorder treatment
Reduced drug use
Improved neighborhood safety
Reduced overdose deaths
What does the research say about effectiveness?
There is strong evidence that syringe services programs (SSPs) reduce HIV infection2, 3, 4 and injection risk behavior such as needle or syringe re-use, borrowing, sharing, renting, and lending among people who inject drugs (PWID)2, 3, 4, 5.
SSPs reduce the risk of HIV transmission among PWID that use the services6, with greater effects when services are provided without restrictions or combined with substance use medications7. SSPs reduce injection risk behavior in hospital, pharmacy, community, and mobile settings; effects of SSPs on syringe re-use may vary depending on syringe dispensing policies8. Studies report mixed effects of SSPs alone on hepatitis C virus (HCV) infection, with no effects or an increased risk of HCV infection in PWID9, 10. SSPs combined with opioid substitution therapy, opioid agonist therapy, or implemented with supportive syringe policies and laws can reduce HCV infection among PWID in some cases2, 3, 10, 11. Pharmacy-based SSPs can reduce syringe sharing behavior among PWID2, 12, though additional research is needed to confirm effects of pharmacy-based SSPs on HIV and HCV infection and safe syringe disposal5.
SSPs are more beneficial when implemented in multi-component harm reduction interventions and include 100% coverage (i.e., all injections are done with a new clean needle or syringe), and when the policy and legal environment promotes access to and use of SSPs among PWID4, 11, 13. PWID who receive SSP-based HCV treatment show better outcomes compared to those who do not get treatment through SSPs14. Providing buprenorphine treatment in SSP sites may lead to a decrease in fatal overdose and an increase in treatment engagement among PWID15.
SSPs may increase use of drug treatment and health services, HIV testing, and reduce drug injection among PWID7, 16, 17. Such interventions also appear to increase public safety, protect first responders, and reduce opioid overdose deaths16.
Available evidence suggests that fear of law enforcement encounters and arrest is a common barrier to using SSPs among PWID18, 19. Program location and transportation difficulties also appear to be barriers to regular attendance of SSPs among PWID in rural areas20. Lack of health insurance, limited appointment availability, distance from home to treatment programs, and work or childcare responsibilities appear to be obstacles that prevent SSP participants from starting treatment17. Gaining support from law enforcement and communities, securing funding, engaging participants in planning, program monitoring and evaluation, removing program restrictions, and building strong partnerships with local communities are recommended strategies for successful SSP expansion and sustainable implementation21, 22, 23, 24, 25. Researchers recommend tailoring SSP services by participants’ risk and substance use characteristics26 and taking outreach-based and needs-based approaches in syringe distribution to increase participant enrollment, engagement, and program outcomes27, 28.
Expanding SSPs appears to be cost-effective in preventing HIV among PWID29. The cost to establish and operate a comprehensive SSP varies by number of clients served and geographic location; cost estimates range from about half of a million for a rural SSP (serving 250 clients per year) to $1.9 million for an urban SSP (serving 2,500 clients per year)30.
How could this strategy advance health equity? This strategy is rated potential to decrease disparities: suggested by expert opinion.
Syringe services programs (SSPs) have the potential to decrease disparities in HIV and HCV infection and transmission as well as the potential to increase access to harm reduction services38, 39, 40. Opening new SSPs can benefit people who inject drugs (PWID) who face higher financial and transportation barriers40. SSPs have the potential to improve equity and access to opioid treatment by expanding telehealth services that connect people with opioid use disorders (OUD) to buprenorphine treatment38. Expanding SSPs in rural areas is recommended to meet the needs of PWID living there39. Scaling up SSPs in rural areas, including mobile SSP units, is recommended to serve PWID in rural communities and help them overcome barriers to revisiting SSPs; these barriers include long distance to SSPs, underdeveloped infrastructure, lack of resources, and stigma against PWID41, 42. In rural communities, homelessness may not decrease the use of SSPs among PWID; however, housing instability may decrease the frequency of SSP use43. Low funding levels are a major barrier to scaling up SSPs in rural and suburban areas44.
Studies report disparities in SSP participation across racial and ethnic groups. Black, Hispanic, and Indigenous individuals are less likely to use SSPs for syringe exchange and services than non-Hispanic white individuals45, 46, 47. Black SSP participants are more likely to experience biased response from law enforcement at SSPs than other participants48. To increase SSP participation among Indigenous groups, tailoring SSPs to their cultural needs is recommended47. Among those from ethnically minoritized groups, men are more likely to use pharmacy-based SSP services than women; more research is needed to confirm the impact of gender on SSP use12. Low SSP use in the U.S. is likely due to legal and regulatory issues, insufficient funding, and misunderstanding of the safety of SSPs that prohibit effective SSP establishment in communities31.
The estimated incidence rate of HIV among PWID in 2022 is highest in white populations, followed by Black and Hispanic populations for both males and females49. The acute HCV incidence rate in 2022 is higher among American Indian/Alaska Native people and rural states compared to other races/ethnicities and urban areas50.
Implementing SSPs for people involved in the justice system may increase their access to health care51.
What is the relevant historical background?
Opioid overdose deaths have been increasing since 199952. The rise in opioid overdose deaths began in the 1990s with a substantial increase in the prescription of both natural and semi-synthetic opioids because they were effective at managing chronic pain and falsely marketed to health care providers as non-addictive53, 54, 55. Prescription opioid sales increased fourfold between 1999 and 200856. Many patients who became addicted to prescribed opioids turned to non-prescribed forms of opioids, such as heroin, which lead to a second wave of opioid overdoses in 2010. In 2013, a third wave began when synthetic opioids such as fentanyl, which are much more potent than other forms of opioids, were combined with other drugs or counterfeit prescription pills, often unknown to the purchaser53. Synthetic opioids like fentanyl have contributed to nearly 74,000 overdose deaths in 2022, a 4% increase from the previous year57. In 2013, the U.S. Department of Health and Human Services declared the misuse of prescription opioids an epidemic. Four years later, in 2017 the opioid epidemic was declared a national public health emergency58. Between 2020 and 2021, the opioid overdose death rate increased by over 15% and the synthetic opioid overdose death rate increased by over 22%53. However, between 2022 and 2023 there has been a decrease in opioid related deaths for some groups, but increases are seen for non-Hispanic Black individuals and Native Hawaiian or Other Pacific Islander Non-Hispanic people59.
The dramatic increase in opioid sales was the result of pharmaceutical companies that overproduced and oversupplied opioid drugs for huge profits, pharmacies that filled the prescriptions, and health care providers who overprescribed the medications56. In rural areas many physicians overprescribed opioids to patients who travel long distances for treatment, do not have the ability to attend frequent appointments, and do not have alternative pain management interventions in their area56. In addition, Black individuals have historically experienced lack of access to preventive and management resources, due to structural deficits, provider bias, socioeconomic obstacles, geographic barriers, and collective stigma and distrust45.
Increasing overdose deaths highlight the need to connect communities to appropriate resources and to expand prevention methods. Syringe services programs (SSPs) began in the late 1980s in response to the HIV epidemic7. The early SSPs in the 1990s were funded privately or by state and local health departments44. U.S. federal funding for SSPs is still limited and has many restrictions in the 2020s44.
Equity Considerations
- Does your community provide syringe services programs (SSPs)? How are the SSPs implemented in your community? What are the disparities in SSP use in your community? What groups are most affected?
- Who can you partner with to create or expand SSPs in your community? How can you engage people who inject drugs in the planning, implementation, and evaluation of SSPs?
- What are legal and regulatory restrictions in providing services and treatment in SSPs in your community? What changes can the state and local governments make to expand access to SSPs services?
- How can communication campaigns related to SSPs in your community be adjusted to reduce stigma and distrust?
Implementation Examples
As of March 2025, 37 states and Washington, D.C. have laws either explicitly or implicitly authorizing syringe services programs (SSPs) in locations throughout the state; seven states require participants to register or enroll in SSPs31. Washington State, for example, has about 30 SSPs operated through local health departments, community organizations, and tribal entities32. California provides a wide range of services in more than 90 syringe exchange programs statewide33. New Mexico provides SSPs and a variety of health and social services through community organizations and federally qualified health centers (FQHCs); New Mexico’s harm reduction efforts are intended to reach vulnerable populations (e.g., including PWID, those in SUD treatment or having infectious disease) and reduce stigma and obstacles to care and treatment34. As of March 2025, there are over 550 operational SSPs, including 25 mobile sites, in 45 states, Washington, D.C., and Puerto Rico: five states – Kansas, Mississippi, Nebraska, South Dakota, and Wyoming – do not have an operational SSP35. As of September 2022, there are 21 SSPs located in tribal communities in the U.S.; eight of them also provide on-site medications for opioid use disorder36.
The Consolidated Appropriations Act of 2018 permits the use of federal funds from the Department of Health and Human Services (DHHS) to support SSPs. State, local, tribal, and territorial governments that intend to implement new SSPs or expand existing programs can request permission to use federal funds to support certain components of SSPs (e.g., syringe disposal services, screening and treatment for HIV and HCV, and referrals to substance abuse prevention and treatment services), with the exception of purchasing sterile needles or syringes. DHHS and the Centers for Disease Control and Prevention provide guidance for funding and program implementation37.
Implementation Resources
‡ Resources with a focus on equity.
NHRC-SSP Resource - National Harm Reduction Coalition (NHRC). (n.d.). All resources. Retrieved September 9, 2025.
Rural SSP guide - Belle RL. A guide to establishing syringe services programs in rural, at-risk areas. Comer Family Foundation; 2019.
Addictions-Treatment - Addictions.com. Addiction treatment options.
Footnotes
* Journal subscription may be required for access.
1 CDC-SSP - Centers for Disease Control and Prevention (CDC). Syringe services programs (SSPs).
2 Palmateer 2022 - Palmateer, N., Hamill, V., Bergenstrom, A., Bloomfield, H., Gordon, L., Stone, J., Fraser, H., Seyler, T., Duan, Y., Tran, R., Trayner, K., Biggam, C., Smith, S., Vickerman, P., Hickman, M., & Hutchinson, S. (2022). Interventions to prevent HIV and Hepatitis C among people who inject drugs: Latest evidence of effectiveness from a systematic review (2011 to 2020). The International Journal on Drug Policy, 109, 103872.
3 Tonin 2024 - Tonin, F. S., Alves da Costa, F., & Fernandez-Llimos, F. (2024). Impact of harm minimization interventions on reducing blood-borne infection transmission and some injecting behaviors among people who inject drugs: An overview and evidence gap mapping. Addiction Science & Clinical Practice, 19(1), 9.
4 Fernandes 2017 - Fernandes RM, Cary M, Duarte G, et al. Effectiveness of needle and syringe programmes in people who inject drugs - An overview of systematic reviews. BioMed Central (BMC) Public Health. 2017;17:1-15.
5 Sawangjit 2017 - Sawangjit R, Khan TM, Chaiyakunapruk N. Effectiveness of pharmacy-based needle/syringe exchange programme for people who inject drugs: A systematic review and meta-analysis. Addiction. 2017;112(2):236-247.
6 Aspinall 2014 - Aspinall EJ, Nambiar D, Goldberg DJ, et al. Are needle and syringe programmes associated with a reduction in HIV transmission among people who inject drugs: A systematic review and meta-analysis. International Journal of Epidemiology. 2014;43(1):235-248.
7 Broz 2021 - Broz, D., Carnes, N., Chapin-Bardales, J., Des Jarlais, D. C., Handanagic, S., Jones, C. M., McClung, R. P., & Asher, A. D. (2021). Syringe services programs’ role in ending the HIV epidemic in the U.S.: Why we cannot do it without them. American Journal of Preventive Medicine, 61(5), S118 - S129.
8 Jones 2010b - Jones L, Pickering L, Sumnall H, et al. Optimal provision of needle and syringe programmes for injecting drug users: A systematic review. International Journal of Drug Policy. 2010;21(5):335-342.
9 Davis 2017a - Davis SM, Daily S, Kristjansson AL, et al. Needle exchange programs for the prevention of hepatitis C virus infection in people who inject drugs: A systematic review with meta-analysis. Harm Reduction Journal. 2017;14(1):25.
10 Cochrane-Platt 2017 - Platt L, Minozzi S, Reed J, et al. Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject drugs. Cochrane Database of Systematic Reviews. 2017;(9).
11 Abdul-Quader 2013 - Abdul-Quader AS, Feelemyer J, Modi S, et al. Effectiveness of structural-level needle/syringe programs to reduce HCV and HIV infection among people who inject drugs: A systematic review. AIDS and Behavior. 2013;17(9):2878-2892.
12 Thomson 2019 - Thomson, K., Hillier-Brown, F., Walton, N., Bilaj, M., Bambra, C., & Todd, A. (2019). The effects of community pharmacy-delivered public health interventions on population health and health inequalities: A review of reviews. Preventive Medicine, 124, 98-109.
13 Bartholomew 2021 - Bartholomew, T., Feaster, D. J., Patel, H., Forrest, D. W., Tookes, H. E. (2021). Reduction in injection risk behaviors after implementation of a syringe services program, Miami, Florida. Journal of Substance Abuse Treatment, 127, 108344.
14 Yoder 2025 - Yoder, T., Hirose, K., Tsui, J. I., Feinberg, J., Hagan, H., Pho, M. T., & Rowan, S. E. (2025). Approaches to offering Hepatitis C treatment at syringe services programs in the United States: A scoping review. Open Forum Infectious Diseases, 12(4), ofaf211.
15 Adams 2022b - Adams, J. W., Savinkina, A., Fox, A., Behrends, C. N., Madushani, R. W. M. A., Wang, J., Chatterjee, A., Walley, A. Y., Barocas, J. A., & Linas, B. P. (2022). Modeling the cost-effectiveness and impact on fatal overdose and initiation of buprenorphine–naloxone treatment at syringe service programs. Addiction, 117(10), 2635-2648.
16 CDC-SSP 2024 - Centers for Disease Control and Prevention (CDC). (February 8, 2024). Safety and effectiveness of syringe services programs (SSPs).
17 Jakubowski 2023 - Jakubowski, A., Fowler, S. & Fox, A.D. (2023). Three decades of research in substance use disorder treatment for syringe services program participants: A scoping review of the literature. Addiction Science & Clinical Practice, 18, 40.
18 Beletsky 2014 - Beletsky L, Heller D, Jenness SM, et al. Syringe access, syringe sharing, and police encounters among people who inject drugs in New York City: A community-level perspective. International Journal of Drug Policy. 2014;25(1):105-111.
19 Davis 2019 - Davis SM, Kristjansson AL, Davidov D, et al. Barriers to using new needles encountered by rural Appalachian people who inject drugs: Implications for needle exchange. Harm Reduction Journal. 2019;16.
20 Davis 2018a - Davis SM, Davidov D, Kristjansson AL, Zullig K, Baus A, Fisher M. Qualitative case study of needle exchange programs in the central Appalachian region of the United States. PLoS ONE. 2018;13(10):e0205466.
21 NACO-Carroll - Carroll, J. J. (n.d.). Syringe services programs. National Association of Counties (NACo). Retrieved September 9, 2025.
22 Resiak 2021 - Resiak, D., Mpofu, E., & Rothwell, R. (2021). Sustainable harm reduction needle and syringe programs for people who inject drugs: A scoping review of their implementation qualities. Sustainability, 13(5), 2834.
23 Pridgen 2025 - Pridgen, B. E., Bontemps, A. P., Lloyd, A. R., Wagner, W. P., Kay, E. S., Eaton, E. F., & Cropsey, K. L. (2025). U.S. substance use harm reduction efforts: A review of the current state of policy, policy barriers, and recommendations. Harm Reduction Journal, 22, 101.
24 Sharp 2020 - Sharp, A., Barnett, J. T., & Vroom, E. B. (2020). Community perceptions of harm reduction and its implications for syringe exchange policy. Journal of Drug Issues, 50(4), 507-523.
25 Healy 2024 - Healy, E., Means, A.R., Knudtson, K., Frank, N., Juarez, A., Prohaska, S., McKnight, C., Des Jarlais, D., Asher, A., & Glick, S. N. (2024). Facilitators and barriers to monitoring and evaluation at syringe service programs. Harm Reduction Journal, 21, 157.
26 Moon 2023 - Moon, K.J., Bryant, I., Trinh, A., Hasenstab, K. A., Carter, B., Barclay, R., & Nawaz, S. (2023). Differential risks of syringe service program participants in Central Ohio: A latent class analysis. Harm Reduction Journal, 20, 97.
27 Austin 2025 - Austin, E. J., Briggs, E. S., Corcorran, M. A., Chen, J., Cotta, N., Behrends, C. N., Prohaska, S. M., LaKosky, P. A., Kapadia, S. N., Perlman, D. C., Schackman, B. R., Des Jarlais, D. C., Williams, E. C., & Glick, S. N. (2025). “New normal:” Opportunities and challenges faced by syringe service programs following the effects of the COVID-19 pandemic. Substance Use & Misuse, 60(5), 669-676.
28 Turner-Bicknell 2021 - Turner-Bicknell, T. (2021). Implementing best-practice with a local syringe service program: Needs-based syringe distribution. Public Health Nursing, 38(1), 85-92.
29 Bernard 2017 - Bernard CL, Owens DK, Goldhaber-Fiebert JD, et al. Estimation of the cost-effectiveness of HIV prevention portfolios for people who inject drugs in the United States: A model-based analysis. Public Library of Science (PLOS) Medicine. 2017;14(5):1-19.
30 Teshale 2019 - Teshale EH, Asher A, Aslam MV, et al. Estimated cost of comprehensive syringe service program in the United States. Public Library of Science (PLOS) ONE. 2019;14(4):1-10.
31 LAPPA-SSP 2025 - Legislative Analysis and Public Policy Association (LAPPA). (2025, April). Syringe services programs: Summary of state laws. Retrieved August 23, 2025.
32 WA-SSPs - Washington State Department of Health. Syringe service programs (SSPs).
33 CDPH-SSP - California Department of Public Health (CDPH). (April 11, 2025). Syringe services programs in California (SSP).
34 ASTHO-NM SSP - Association of State and Territorial Health Officials (ASTHO). The role of syringe services programs in New Mexico’s opioid crisis response. ASTHO Brief. May 2021.
35 NASEN - North American Syringe Exchange Network (NASEN). (n.d.). NASEN a Dave Purchase Project. Retrieved September 9, 2025.
36 Allen 2025 - Allen, S.T., Keane, E., Alexander, C., Day, S., Kebec, P., Medley, A., Johnson, F., Hughes, P., Barney, B., & Walls, M. (2025). Tribally-affiliated syringe services programs in the United States: A brief report. Harm Reduction Journal, 22, 143.
37 CDC-SSP Funding - Centers for Disease Control and Prevention (CDC). (February 8, 2024). Funding for syringe services programs.
38 Lambdin 2022 - Lambdin, B. H., Kan, D. & Kral, A. H. (2022). Improving equity and access to buprenorphine treatment through telemedicine at syringe services programs. Substance Abuse Treatment, Prevention, and Policy, 17, 51.
39 Rural SSP guide - Belle RL. A guide to establishing syringe services programs in rural, at-risk areas. Comer Family Foundation; 2019.
40 Packham 2022 - Packham, A. (2022). Syringe exchange programs and harm reduction: New evidence in the wake of the opioid epidemic. Journal of Public Economics, 215, 104733.
41 Batty 2023 - Batty, E. J., Ibragimov, U., Fadanelli, M., Gross, S., Cooper, K., Klein, E., Ballard, H, A. M., Young, A. M., Lockard, A. S., Oser, C. B., & Cooper, H. L. F. (2023). A qualitative analysis of rural syringe service program fidelity in Appalachian Kentucky: Staff and participant perspectives. The Journal of Rural Health, 39(2), 328-337.
42 Thakarar 2021 - Thakarar, K., Sankar, N., Murray, K., Lucas, F. L., Burris, D., & Smith, R. P. (2021). Injections and infections: Understanding syringe service program utilization in a rural state. Harm Reduction Journal, 18, 74.
43 Ballard 2023 - Ballard, A.M., Falk, D., Greenwood, H., Gugerty, P., Feinberg, J., Friedmann, P. D., Go, V. F., Jenkins, W.D., Korthuis, P. T., Miller, W. C., Pho, M. T. , Seal, D. W., Smith, G. S., Stopka, T. J., Westergaard, R.P., Zule, W.A., Young, A.M., & Cooper, H.L.F. (2023). Houselessness and syringe service program utilization among people who inject drugs in eight rural areas across the USA: A cross-sectional analysis. Harm Reduction Journal, 20, 157.
44 Facente 2024 - Facente, S. N., Jamie, L. Humphrey, J. L., Akiba, C., Patel, S. V., Wenger, L. D., Tookes, H., Bluthenthal, R. N., LaKosky, P., Kral, S. P. T. M. A. H., & Lambdin, B. H. (2024). Funding and delivery of syringe services programs in the United States, 2022. American Journal of Public Health, 114(4), 435-443.
45 Ezell 2024 - Ezell, J.M., Simek, E., Shetty, N., Pho, M. T., Bluthenthal, R. N., Goddard-Eckrich, D. A., & Choi, S. (2024). A scoping review of the utilization of opioid use treatment, harm reduction, and culturally tailored interventions among racial/ethnic minorities in the United States. International Journal of Mental Health and Addiction. Advance online publication.
46 Salow 2023 - Salow, K., Jack, H. E., Tinsley, J., Banta-Green, C. J., Kingston, S., Iles-Shih, M., Tsui, J. I., & Glick, S. (2023). Racial disparities in use of syringe service programs in King County, WA: A comparison of two cross-sectional surveys. Harm Reduction Journal, 20, 133.
47 Zolopa 2025 - Zolopa, C., Clifasefi, S. L., Dobischok, S., Gala, N., Fraser-Purdy, H., Phillips, M. K., Blackmore, S., & Wendt, D. C. (2025). A scoping review of harm reduction practices and possibilities among indigenous populations in Australia, Canada, and the United States. Drug and Alcohol Dependence, 269, 112597.
48 Morrissey 2022 - Morrissey, B., Hughes, T., Ostrach, B., Wilson, L., Getty, R., Combs, T. L., Bennett, J., & Carroll, J. J. (2022). “They don’t go by the law around here”: Law enforcement interactions after the legalization of syringe services programs in North Carolina. Harm Reduction Journal, 19, 106.
49 CDC HIV Surveillance 2024 - Centers for Disease Control and Prevention (CDC). (2024). Estimated HIV incidence and prevalence in the United States, 2018–2022. HIV Surveillance Supplemental Report, 29 (No.1). Retrieved August 23, 2025.
50 CDC HCV Surveillance 2024 - Centers for Disease Control and Prevention. (CDC). (2024). Viral Hepatitis Surveillance Report – United States, 2022. Retrieved August 23, 2025.
51 Armstrong-Mensah 2021 - Armstrong-Mensah, E., Dada, D., Rupasinghe, R., & Whately, H. (2021). Injecting substance use in prisons in the United States: A case for needle exchange programs. The American Journal of Drug and Alcohol Abuse, 47(3), 273–279.
52 Freeman 2018 - Freeman PR, Hankosky ER, Lofwall MR, Talbert JC. The changing landscape of naloxone availability in the United States, 2011 – 2017. Drug and Alcohol Dependence. 2018;191:361-364.
53 CDC-Understanding the epidemic - Centers for Disease Control and Prevention (CDC). Understanding the opioid overdose epidemic.
54 Bennett 2021 - Bennett AS, Elliott L. Naloxone’s role in the national opioid crisis — past struggles, current efforts, and future opportunities. Translational Research. 2021;234:43-57.
55 Haffajee 2020 - Haffajee RL, Cherney S, Smart R. Legal requirements and recommendations to prescribe naloxone. Drug and Alcohol Dependence. 2020;209:107896.
56 Judd 2023 - Judd D, King CR, Galke C. The opioid epidemic: A review of the contributing factors, negative consequences, and best practices. Cureus. 2023;15(7):e41621.
57 CDC-Fentanyl - Centers for Disease Control and Prevention (CDC). Overdose prevention. Fentanyl.
58 Salmond 2019 - Salmond S, Allread V. A population health approach to America’s opioid epidemic. Orthopaedic Nursing. 2019;38(2):95-108.
59 CDC-Drug overdose deaths in the US - Centers for Disease Control and Prevention (CDC). Drug overdose deaths in the United States, 2003-2023.
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