Syringe Exchange FAQs Syringe Exchange in North Carolina What is the North Carolina Safer Syringe Initiative? The Safer Syringe Initiative is a project through the North Carolina Division of Public Health to increase access to clean needles, hypodermic syringes and other injection supplies, facilitate the safe disposal of used needles and syringes, provide information about harm reduction and preventative health and connect people who inject drugs (PWID) or otherwise use drugs with treatment and medical and social services, as requested. Syringe exchange programs (SEPs) can also provide support and information for people taking opioid medications for monitored pain management, as prescribed by a health care provider. The Safer Syringe Initiative began after syringe exchange programs were legalized in North Carolina in July 2016. The Division of Public Health and the Department of Health and Human Services do not operate syringe exchanges in North Carolina. What are syringe exchange programs? Syringe exchange programs distribute unused sterile syringes and provide safe disposal methods for used syringes. All syringe exchanges in North Carolina also provide connections to treatment programs, medication-assisted treatment (MAT), and other medical and social services; opioid overdose prevention resources, including naloxone (also known under the brand names of Narcan™ or Evzio™); and educational materials, including HIV (Human Immunodeficiency Virus) prevention and treatment, hepatitis prevention and treatment and mental health care. These services are provided free of charge. Syringe exchanges operate under the health perspective or philosophy of harm reduction. Are syringe exchanges legal? Syringe exchange programs became legal in North Carolina on July 11, 2016, when the Legislature passed NC General Statute 90-113.27. Find the full text of the law here. What are the benefits of syringe exchange? People who inject or otherwise use drugs are often cut off or excluded from traditional medical care and social services because of stigma, inaccessibility, cost, distrust and fear of judgment or legal ramifications. Syringe exchanges acknowledge and respond to the medical and social needs and contexts of people who use drugs by working with and listening to their participants. Beyond providing unused syringes and supplies that reduce the health harms and risks associated with injection drug use, exchanges connect people to the services they want and need, including medical care, counseling and substance use disorder treatment. These services are often available to people affected by or involved with drug use in different ways, including friends, family members and partners of people who use drugs. Syringe exchange programs are financially practical ways to reduce costs associated with treating HIV and hepatitis C infections. According to the Harm Reduction Coalition Approximately 20 percent of AIDS cases and upwards of 55 percent of hepatitis C cases can be attributed to injection drug use, which underscores the viability of syringe exchange programs (SEPs) as a tool in the fight against HIV/AIDS. Cost-effectiveness addresses the relationship between the cost of intervention and the number of new infections prevented. SEPs are not only successful at reducing HIV and Hepatitis viral infections, but have repeatedly been shown to be cost-effective, yielding a significant cost savings. Many studies have confirmed the cost efficiency of syringe exchange programs as a prevention effort to reduce the spread of HIV, hepatitis C and other bloodborne illnesses. Syringe exchanges are important for public safety. Fear or hesitation to disclose syringe possession puts law enforcement officers and other emergency responders are at risk of needle stick injuries from used syringes. In addition to providing limited immunity for possession of drug paraphernalia (including used syringes), syringe exchange laws authorize places to safely and securely dispose of used syringes, limiting risk of harm to others. Furthermore, by investing in relationships with their communities, exchanges can alert public health agencies about observed changes in drug use, new health risks, and spread of infectious diseases. Why does North Carolina need syringe exchanges? Syringe exchange programs arose in the United States during the early days of the HIV/AIDS epidemic when people realized that injection drug users were at a high risk of contracting the virus. Since then, exchanges have been a pragmatic and effective tool for addressing the health needs of people who inject or otherwise use drugs. Accidental overdose deaths from the use of prescription opioids (including pain medications like Vicodin, OxyContin, and Percocet), heroin, and cocaine have risen steadily in North Carolina since 2013. Heroin-linked fatal overdoses rose from 37 deaths in 2010 to 364 deaths in 2015. Prescription opioid pain medications are responsible for more deaths than heroin and cocaine combined (738 overdose deaths from prescription opioid medication in 2015). North Carolina also has a high burden of fentanyl-linked deaths (fentanyl is a particularly strong synthetic opioid that can be combined, sometimes unknowingly to the user, with heroin). If current trends continue, unintentional drug and medication poisoning deaths (accidental overdoses) will surpass motor vehicle deaths as the leading cause of injury death in North Carolina by 2017. Additionally, reported cases of hepatitis C, which is easily spread by sharing syringes and injection equipment, tripled between 2010 and 2014. Each hepatitis C diagnosis represents about $100,000 in medical costs. Unintentional needle sticks, often caused by fear of disclosing possession of syringes or limited access to safe syringe disposal, put our communities and law enforcement officers at risk of injury and disease transmission. Syringe exchange programs are a sensible, compassionate, cost-effective way to respond to the personal and community health issues posed by high-risk opioid and injection drug use. Syringe exchange programs are also particularly needed in suburban and rural areas, which may have limited medical services and which have been particularly affected by the current opioid epidemic. What are syringe exchanges in North Carolina required to provide? Syringe exchange programs operating in North Carolina are required to provide the following: Safe disposal of used needles and hypodermic syringes New needles, hypodermic syringes and other injection supplies free of charge and in sufficient quantities to ensure that needles, syringes and other injection supplies are not shared or reused Reasonable and adequate security for program sites, equipment and personnel. Upon registration with the Division of Public Health, SEPs are required to submit a security plan to the police and/or sheriff’s offices that have jurisdiction over the exchange’s location. For mobile and outreach exchanges, security plans should be shared with law enforcement entities (police and/or sheriff’s departments) in each exchange location. Security plans should be updated annually and redistributed to police and sheriff’s departments with jurisdiction. Educational materials on all of the following: overdose prevention; the prevention of HIV and viral hepatitis transmission; drug abuse prevention; treatment options for mental health issues, including treatment referrals; and treatment for substance use disorders, including referrals for MAT Access to naloxone kits that contain naloxone hydrochloride or referrals to programs that provide access to naloxone For each individual requesting services, personal consultation from a program employee or volunteer concerning mental health or substance use disorder treatment, as appropriate Visiting and Participating in Syringe Exchange Programs Who can visit a syringe exchange? In short, anyone can. Policies may vary by exchange based on the services offered. If the exchange has a drop-in center, for example, they may ask that only people who currently or formerly used drugs use that space to ensure privacy. It is important that exchange services are provided anonymously, so harm reduction programs are protective of their participants’ safety, security, and privacy. People often begin visiting exchanges through referrals from friends or family; connections may also come from medical and social service providers, Internet searches, or program outreach. Contact the exchange(s) operating in your area to see if they have any policies for visitation (like being a current or former drug user). At the same time, harm reduction work is based on offering support and resources to anyone who may need them, without judgment. This list will vary based on the services an exchange offers, but many types of people may want to visit a syringe exchange: People who inject or otherwise use drugs People on prescribed opioid pain management regimens who may have questions or want naloxone People who keep prescription or non-prescription opioids in their home and who want naloxone in case someone else (including children), intentionally or unintentionally overdoses Friends and family of someone who injects or uses drugs, who may want to have new syringes, supplies or naloxone on-hand People engaged in other high-risk, stigmatized health behaviors (including sex work) People who use syringes to administer prescribed or non-prescription medications, including hormones or steroids (these medications require syringes that differ from those typically used in drug injection) People looking for safer sex supplies and information, including STI and HIV testing, treatment and pre-exposure prophylaxis (PrEP) People interested in case management or referrals to medication-assisted treatment, detox or treatment programs or mental health services People interested in volunteering with or otherwise supporting the syringe exchange Exchanges may develop their own policies around working with young adults. State law does not prohibit programs from serving or working with participants under age 18. Programs may choose to develop peer support and youth-focused outreach efforts to connect young adults with additional social and medical services and support. To assess the need for resources and referrals tailored to youth and young adults, exchanges may use specialized intake procedures to discuss education status, familial and other relationships, food security and housing status. Please refer to the North Carolina Harm Reduction Coalition Syringe Exchange Policy & Procedures guide or contact NCHRC for more information. What do syringe exchanges do besides provide new syringes and dispose of used ones? Providing new syringes and disposing of used ones is foundational for syringe exchange programs, but it is not usually the only service they provide. Many also offer supplies for safer injection (cotton filters, tourniquets, cookers or steel spoons, sometimes collectively referred to as “works”), alcohol swabs and other wound care supplies (antibiotic wipes and ointment, bandages), bleach kits, acidifiers, and safer sex supplies (internal [female] and external [male] condoms, lubricants, finger cots, dental dams). Programs should also provide information about safer injection practices, preventative health, safer sex practices, mental health services and other issues affecting people who inject or otherwise use drugs. Exchanges may offer HIV and hepatitis C testing, wound care, hygiene kits, case management services, and nutrition or community meal programs. They provide information about HIV care, medication-assisted treatment (MAT, including methadone, buprenorphine, suboxone, and naltrexone), detox and treatment programs, and other medical and social services, and should connect participants to these services as requested. Contact exchanges in your area to find out what services or referrals they offer. If they don’t have what you need, they should help you find somewhere that does. Do people have to bring used syringes back to the exchange in order to receive new ones? No, that model of syringe exchange is called a “one-for-one” exchange and is prohibited under the North Carolina law. Giving a participant the amount of new needles, hypodermic syringes, or injection supplies they require cannot be dependent on returning used supplies. Participants should be encouraged to return used syringes and supplies so exchanges can dispose of them safely. Exchange participants, staff, and volunteers have limited immunity for possessing new and used syringes and paraphernalia—this consideration was included to encourage safe disposal of used injection equipment at exchanges. I don’t inject the drugs I use, why should I visit a syringe exchange? People who use prescription opioids (pills) or who snort or smoke drugs are also encouraged to visit syringe exchanges. Anyone using high doses of opioids (therapeutic or recreational) and/or people around someone using these drugs should have naloxone on-hand and know how to use it. People can combine different types of drug use, so someone who typically sniffs their drugs may also want information about safer injection practices. Exchanges may have safer sex supplies and other social and medical services (including testing and treatment referrals) that are recommended for people who use but do not inject drugs. Exchanges also rely on referrals between participants to connect more people with harm reduction services—so even if you do not inject drugs, knowing about an exchange and being familiar with their services may help you connect someone else to an exchange for safer injection supplies and information. I was stopped while carrying syringes and arrested, but I am a syringe exchange participant. What should I do? The law legalizing syringe exchanges includes limited immunity for possession of syringes and injection supplies. Find more information about limited immunity here. Exchange staff, volunteers and participants must have documentation of participation (in the form of a participant card or other written documentation) in order to claim limited immunity. The exchange may have an existing relationship with the arresting agency and be able to contact them to verify participation in the exchange and learn more about the circumstances of arrest. According to the North Carolina Harm Reduction Coalition, in many cases, the charges are dismissed. Exchanges should discuss the issue of identification with law enforcement agencies when setting up their programs and on a continuing basis, as needed. If you are a syringe exchange participant who is arrested by law enforcement for the possession of syringes or residue in syringes (both protected under the law), you should contact the syringe exchange as soon as possible to notify them of your arrest. Health Services, Harm Reduction and Treatment Resources What are the differences between drug use, dependence and addiction? With evolving understanding of addiction as a medical condition, we need specific and non-judgmental terms to describe associated behaviors and symptoms. Clinicians and public health workers distinguish between drug use, dependence and substance use disorders (a more accurate term than “addiction”) in order to best understand the health circumstances and health of people who use drugs. According to the National Institute on Drug Abuse, Addiction—or compulsive drug use despite harmful consequences—is characterized by an inability to stop using a drug; failure to meet work, social, or family obligations; and, sometimes (depending on the drug), tolerance and withdrawal. The latter [tolerance and withdrawal] reflect physical dependence in which the body adapts to the drug, requiring more of it to achieve a certain effect (tolerance) and eliciting drug-specific physical or mental symptoms if drug use is abruptly ceased (withdrawal). Physical dependence can happen with the chronic use of many drugs—including many prescription drugs, even if taken as instructed. Thus, physical dependence in and of itself does not constitute addiction, but it often accompanies addiction. People who are dependent on drugs may find ways to manage their use and associated effects to lessen or avoid the harmful consequences that characterize substance use disorders. People who use drugs are not necessarily dependent on or addicted to drugs. For people who inject or otherwise use drugs, resources and tools are available through syringe exchange programs to manage or reduce harms. Exchanges also provide information about and connections to treatment and recovery supports for people along the spectrum of drug use and substance use disorders. Please contact the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services or visit the National Institute on Drug Abuse for more information about drug use, dependence, and substance use disorders. What are the requirements for mental health or substance use disorder treatment referrals through exchanges? Referral and connection to care services vary by exchange. Services could include, at minimum, providing written information on mental health and substance use disorder treatment programs in the area, but could also mean offering one-on-one case management with a substance use counselor, social worker, nurse, or other medical professional at the exchange. Exchange staff and volunteers should be able to offer information about referrals to participants or be able to connect participants with someone at the exchange able to provide such information. What treatment options are available? Please find information about local treatment resources through the Substance Abuse and Mental Health Services Administration and the North Carolina LME/MCO Directory What is medication-assisted treatment? Medication-assisted Treatment (MAT) is the use of medications, in combination with counseling and therapies, to provide a “whole-patient” approach to the treatment of substance use disorders. Research shows that a combination of medication and therapy can successfully treat these disorders, and for some people struggling with addiction, MAT can help sustain recovery. MAT is primarily used for the treatment of addiction to opioids such as heroin and prescription pain relievers that contain opiates. The prescribed medication operates to normalize brain chemistry, block the euphoric effects of alcohol and opioids, relieve physiological cravings, and normalize body functions without the negative effects of the abused drug. Examples of medications include methadone, oral and injectable naltrexone, buprenorphine, and buprenorphine/naloxone. Why is mental healthcare included in treatment referrals? People with mental health disorders are more likely than people without mental health disorders to experience an alcohol or substance use disorder. People experiencing both substance use disorder(s) and mental health condition(s) are often said to have “co-occurring conditions,” referring to the coexistence and relationship between these health issues. Other terms, such as “dual diagnosis” or “co-morbidity” are sometimes used to describe co-occurring disorders or conditions. According to the 2014 National Survey on Drug Use and Health (NSDUH) led by the Substance Abuse and Mental Health Services Administration (SAMHSA), approximately 7.9 million adults in the United States had co-occurring disorders in 2014. Co-occurring disorders can be difficult to diagnose due to the complexity of symptoms, as both may vary in severity. People with co-occurring disorders are best served through integrated treatment. With integrated treatment, practitioners can address mental and substance use disorders at the same time, often lowering costs and creating better outcomes. Early detection and treatment can improve treatment outcomes and the quality of life for those who need these services. What is harm reduction? Harm reduction is an evolving set of practical strategies that reduce the negative consequences of drug use and other high-risk behaviors, operating on a spectrum of safer use to managed use to abstinence. Harm reduction strategies for safer drug use meet people “where they’re at” to address conditions of use along with drug use itself while recognizing that people use drugs for a variety of complex reasons. Because harm reduction demands that interventions and policies designed to serve people who use drugs (and other people involved in high-risk activities) respond to specific individual and community needs, there is no universal definition or formula for harm reduction. The Harm Reduction Coalition grounds harm reduction practice in the following principles: Accepts, for better or worse, that licit (legal) and illicit (illegal) drug use is part of our world and chooses to work to minimize its harmful effects rather than simply ignore or condemn it Understands drug use as a complex, multi-faceted phenomenon that encompasses a continuum of behaviors from total abstinence to severe or debilitating abuse, and acknowledges that some ways of using drugs are clearly safer than others Establishes quality of individual and community life and well-being—not necessarily cessation of all drug use—as the criteria for successful interventions and policies Calls for the non-judgmental, non-coercive provision of services and resources to people who use drugs and the communities in which they live in order to assist them in reducing harm to themselves and others Ensures that people who use drugs and those with a history of drug use routinely have a real voice in the creation and continuation of programs and policies designed to serve them Affirms drug users themselves as the primary agents of reducing the harms and consequences of their use practices, and seeks to empower people who use drugs to share information and support each other in strategies that reflect their actual conditions of use (“where they’re at”) Recognizes that the realities of poverty, class, racism, social isolation, disenfranchisement and stigma, inequitable medical care, past and current traumas, sex-based discrimination, and other social inequalities and injustices affect both people’s vulnerability to drug use and their capacity for effectively dealing with drug-related harm Does not attempt to minimize or ignore the real and tragic harm and danger associated with licit and illicit drug use For more information about reducing the harms associated with injection drug use, inquire about the North Carolina Safer Syringe Initiative Toolkit. What does injecting drugs have to do with safer sex? Sharing syringes and injection supplies is an efficient way to spread bloodborne infections like HIV and viral hepatitis. Residual blood in syringes, cottons, cookers, ties and waters can transmit infections between people who inject drugs. HIV and other sexually transmitted infections (STIs) can be transmitted through unprotected sexual contact between people who inject drugs and people who do not. According to Des Jarlais et al., cohort studies “indicate that the majority of new HIV infections among IDUs in these cities are due to unsafe sexual behavior rather than unsafe injecting behavior.” (2009, p. 1444) Drug use compromises decision-making (like forgoing protection during sexual contact) and can coincide with other high-risk behaviors, like exchanging sex for drugs or money or having multiple partners. Stigma and judgment around drug use can complicate disclosure of behaviors and STI risk factors to sexual partners. This also makes it difficult to receive consistent medical care and information about STI treatment and prevention, including pre-exposure prophylaxis (PrEP) regimens to prevent HIV infection. Untreated infections can make people more susceptible to other infections. What is pre-exposure prophylaxis (PrEP)? Pre-exposure prophylaxis, commonly referred to as “PrEP,” is a medication regimen to prevent HIV infection. It is recommended for people who are at a substantial risk of HIV infection—people in serodiscordant relationships (where one partner has HIV/AIDS and the other does not), people with multiple sex partners (including through sex work), and people who inject drugs (particularly people with limited access to new syringes and injection supplies and who may share supplies). PrEP is also known by its brand name, Truvada. It is a combination of two medications (tenofovir and emtricitabine) that are used to treat HIV infection, but which also effectively prevent infection when taken consistently, reducing the risk of HIV infection by up to 92%. The regimen is much less effective if not taken consistently. Your local exchange(s) should be able to provide information about PrEP or be able to connect people with further information or services. Starting and Operating Syringe Exchanges in North Carolina Who can start a syringe exchange program in North Carolina? According to the law authorizing syringe exchange in North Carolina, “any governmental or nongovernmental organization, including a local or district health department or an organization that promotes scientifically proven ways of mitigating health risks associated with drug use and other high-risk behaviors, may establish and operate a needle and hypodermic syringe exchange program.” This list includes, but is not limited to: harm reduction organizations, health departments, AIDS service organizations (ASOs), and community-based organizations (CBOs). What are the requirements for starting a syringe exchange program? Each syringe exchange must report the following information to the North Carolina Division of Public Health before starting operations: 1. The legal name of the organization or agency operating the program; 2. The areas and populations to be served by the program; 3. The methods by which the program will meet operational requirements (including how the program will provide/dispose of syringes and provide adequate security, treatment referrals, overdose prevention and health materials, naloxone, and consultations, as appropriate). The exchange must also provide police and/or sheriff’s departments that have jurisdiction over any sites of operation a copy of the program’s security plan annually. The registration form for starting an exchange can be found here. How will syringe exchange programs be funded? As of July 1, 2017, local funds can be used to purchase syringes, needles, and injection supplies (this provision was included in the STOP Act). Programs can use local and/or state funds for all other expenses, including staff, health care costs, HIV and hepatitis C testing, naloxone training and distribution, wound care, treatment and medical and social service referrals, hygiene kits, clothing or food distribution programs, and more. Organizations can secure funding for syringes and injection supplies through sources such as private grants, individual donors, corporate giving, fundraisers, and donations from medical organizations. This information will be updated as appropriate. Please see the Funding Syringe Exchange Programs page for more information about funding strategies. What are the restrictions on using public funds for syringes and injection supplies? Local health departments or other organizations receiving public funding may use local funds to buy needles, syringes, and injection supplies for syringe exchange programs. Local and/or state funds may be used for all other program costs. Other health department programs or services that use injection equipment (like immunization services) are not affected by the restriction on use of state funds for syringes or injection supplies. The language in the law specifies that the public funds restriction applies to “programs established pursuant to” the section of the law (G.S. 90-113.27) that authorizes syringe exchange programs. Is there a restriction on how many syringes can be given per exchange? No, there is not. According to the law, exchange programs must provide “needles, hypodermic syringes, and other injection supplies at no cost and in quantities sufficient to ensure that needles, hypodermic syringes, and other injection supplies are not shared or reused.” That means “one-for-one” policies, where participants are only given a new syringe for every used one they return to the exchange, are prohibited. What does “limited immunity” mean? Included in the syringe exchange authorization is a provision that protects program employees, volunteers, and participants from being charged with possession of syringes or other injection supplies, including those with residual amounts of controlled substances, if the syringes or supplies were obtained or returned to a SEP. Limited immunity does not provide protection for people stopped while holding illegal drugs or holding paraphernalia not obtained from a syringe exchange. Program employees, volunteers, and participants must provide written verification (such as a participant card or other documentation) to be granted limited immunity. Programs should provide information about limited immunity and interacting with law enforcement when participants begin visiting an exchange. Exchanges should provide (anonymous) exchange IDs or proof of participation in a syringe exchange to participants to be used in the event they are stopped with syringes or injection supplies. Why do law enforcement agencies need to be notified of exchange operations? Organizational security plans are needed to ensure the safety of exchange staff, volunteers, and participants, and responding law enforcement officers should be aware of internal security plans should an emergency occur. Also, because the syringe exchange authorization provides limited immunity for SEP staff, volunteers, and participants, police and/or sheriff’s departments should be notified of any syringe exchange activities taking place in their jurisdictions. Exchange programs should provide staff, volunteers, and participants with written identification or proof of participation to present to a law enforcement officer if stopped while carrying injection equipment and are advised to share with law enforcement what form of documentation they are issuing. What does “reasonable and adequate security of program sites, equipment, and personnel” in the new law mean? Reasonable and adequate program security depends on the exchange’s size, location, resources and housed services. At minimum, exchange sites should be securely locked when not operating. Syringes and other supplies should be kept locked and the exchange must take reasonable steps to protect the health and safety of staff, volunteers and participants. Information about the program’s security plan must be sent to all police and/or sheriff’s offices with jurisdiction upon registration with the Division of Public Health and updated annually. What are the requirements for an exchange after the program has been registered with the Division of Public Health? Syringe exchanges must provide an annual report to the Division of Public Health that includes, but is not limited to, the following information: 1. The number of unique individuals served by the program and the total number of exchanges/interactions; 2. The number of needles, hypodermic syringes and injection supplies dispensed by and returned to the exchange; 3. The number of naloxone kits distributed and reversals reported; 4. The number and type of treatment referrals provided, including a separate report of the number of individuals referred to programs that provide access to naloxone (if the exchange itself does not provide naloxone to participants). The exchange must also provide an updated security plan annually to police and/or sheriff’s offices with jurisdiction over any sites of operation. The annual reporting form can be found here. Why does this information need to be reported to the Division of Public Health? By working directly with people who inject or otherwise use drugs, community-based organizations and health departments (among other groups or programs) will have a detailed understanding of specific health issues or trends in the areas they serve. Reporting that information to the Division of Public Health allows North Carolina to gain a deeper understanding of drug use and associated health effects across the state. Annual reporting is also an opportunity to provide input as North Carolina establishes syringe exchange programs and provides an assessment of the level of need for clean syringes in the community. If you are a staff member or volunteer and your exchange is responding to unusual or urgent issues among your participants (different kinds of drugs, localized disease outbreaks, harassment or barriers to care, etc.), please contact the Division of Public Health outside of annual reporting times at SyringeExchangeNC@dhhs.nc.gov. To whom should we submit registration forms and/or annual reports at the Division of Public Health? Submit forms and any questions to SyringeExchangeNC@dhhs.nc.gov. Please also notify the Division of Public Health through SyringeExchangeNC@dhhs.nc.gov if your exchange closes or otherwise halts or changes service. How can I start a syringe exchange program in my area? The first step to starting an exchange is gathering your stakeholders and creating a plan for how to organize, staff, fund, and operate the exchange. Potential stakeholders can include local health departments or programs, HIV prevention and AIDS service organizations, drug treatment centers and recovery communities, local user unions, and people otherwise affected by drug use. It is also helpful to reach out to local law enforcement (even before submitting your security plan). Once you have created a plan with stakeholders, decided on an exchange model, and secured reliable funding, you need to submit the registration form mentioned above to the Division of Public Health before you can begin operations. For more information visit the Syringe Exchange Models page or inquire about the North Carolina Safer Syringe Initiative Toolkit. An important note: when starting an exchange, you may want to offer as many services and as much availability as possible. Because effective exchange programs become extremely important, relied-upon, and trusted resources for preventative health and medical and social services, it is wiser to expand services only once you are sure that new programs can be sustained rather than starting with many resources that may then have to be cut. Develop a robust referral or connection to care system for exchange participants until you can reliably provide your own in-house programs. Syringe exchange programs in North Carolina, whether operated by community organizations or state or county entities, may not use state funds for the purchasing of needles, hypodermic syringes, or other injection supplies but may use state funds for other parts of program development and operation. Local funds may be used for the purchasing of these supplies. Please check the Funding Syringe Exchange Programs for information about purchased and donated syringes and injection equipment.