Statement of Need

San Bernardino county experienced 349 opioid-related overdose deaths in 2021, the most recent full year of data available. In a report published by the California Department of Public Health the annual crude mortality rate from 2021 increased by 159% from 2019. The need for harm reduction-based services, more specifically syringe exchange services is clear. San Bernardino County has seen a 21 percent rise in new HIV diagnoses in recent years, from 224 newly diagnosed residents in 2016 to 278 in 2018. When compared to the State of California, San Bernardino County has a very different epidemiologic profile, with a higher proportion of HIV cases among people of color, cisgender women (especially cisgender women of color), heterosexuals, and people who inject drugs.

 

Our next mission is working with the National Harm Reduction Coalition & other local agencies, organizations, & stakeholders with the intent to establish a mobile/street-based outreach syringe services program in San Bernardino County using specific Objectives as to what we aim to provide throughout the county, our plan will have Measurable objectives, & we have set Achievable evidence-based goals that are not overly ambitious yet within reach given the available human, financial & other resources. When compared to the State of California, San Bernardino County has a very different epidemiologic profile, with a higher proportion of HIV cases among people who use drugs, people who inject drugs, LGBTQIA+, of color, & cisgender women (especially cisgender women of color). Other areas of focus are individuals & families experiencing homelessness, reproductive health, LGBTQIA+ issues, disease prevention, healthcare access, decriminalization, domestic violence, & community engagement.

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Reasons San Bernadino County May Lack Syringes Service Programs

• Have already safely disposed of syringes

• Homelessness

• Fear of traveling with used injection equipment

• Fear of arrest, police sweeps in the area, etc.

• Police confiscated syringes

• Insufficient supplies/unable to exchange up to their current needs

• Recently initiated injection

• Have begun injecting more frequently

• Traveled from an area that has minimal syringe availability

• Do not prepare drugs themselves/someone else/partner holds injection equipment

• We're not planning on injecting

• Housing program/shelter restrictions

• Hiding syringes out of shame/secretive use

• Fearful/drug-induced paranoia

• May not be an injector (getting syringes for friends/family)

• Safety reason (i.e. they have lost the cap on a syringe)

• Previously disposed of syringes to keep away from children

 

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Projected Program Outlook

Strategy Approach, Planning, & Design

• Involve people with lived experience of injection drug use, substance use disorder, homelessness, or other pervasive issues affecting the population served

• Create meaningful engagement opportunities, ranging from short-term roles to consulting, committee/board membership, paid peer distribution programs (secondary), & long-term employment.

• Commit to learning from people who inject drugs (PWID) in order to train staff on key concerns affecting participants & help shape programming to be useful, effective, & respectful of participant autonomy.

• Involve people who inject drugs (PWID) in all phases of program design, implementation, & evaluation

  • Acknowledge PWID experience as an invaluable resource — ideally, we will provide PWID compensation for their time.

 

 

Delivery Model Pros & Cons List

Mobile Unit/Street-Based Outreach Model

• Pros

  • Transportation for people who use drugs (PWUDs) to a brick-&-mortar site can be a barrier

  • Fixed sites may deter participants due to previous experiences of stigma or poor treatment the past

  • Easily targeted groups of people who might face transportation issues or may fear stigma

  • Often more acceptable to community residents & businesses

  • Participants will be seen out in the open, which may create privacy concerns

  • Able to service large areas

  • Provides an opportunity for intimate contact & information-sharing about injection practices, health & other issues

  • Brings services directly to people

• Cons

  • The upfront cost of the unit (e.g., car, van, gasoline, insurance, etc.)

  • The varying schedule can make it harder for participants to remember where & when services are available, & is subject to weather or other unforeseen circumstances

  • May be more challenging to support HCV, HIV testing

 

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Peer Delivery Model (Secondary)

Peer delivery occurs when participating drug users receive equipment from the SSP & redistribute syringes within their drug-using networks.

• Pros

  • Gain peer knowledge of drugs, drug use, & the local drug scene

  • Increase access to groups otherwise unlikely to access SSP services

  • Empowers peers to get involved within their own community

  • Extends reach to IDUs unable to come to the program site

• Cons

  • Potential complications with peer training & supervision

  • Collection & transportation of other participants’ used injection equipment by peers

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Summary of Services

Syringe Services

• Syringe distribution & safe disposal education are core services

  • Syringe distribution & disposal options are core SSP services.

  • Needs-Based Distribution

    • Needs-based distribution emphasizes actual & current injection needs by asking participants, “How many syringes do you need?” as a means to identify the number of syringes that will be distributed during a transaction.

    • Some regulations may place limits or caps on syringe distribution per transaction.

    • Needs-based distribution is the syringe access policy most likely to meet the true needs of injection drug users but is likely to receive community opposition, which can have a serious impact on long-term sustainability.

  • Syringe Collection Services

    • Nearby Orange County shut down a local SSP in 2018 with concerns about syringe collection. To combat similar problems from occurring in San Bernardino County, safe disposal will be offered onsite; portable sharps containers will be provided whenever possible. If neither of these disposal options is possible, then education about safe home disposal will be provided.

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Education/Prevention Practices

• Safer-Use Practices

  • Open discussion around the dangers of improper use of techniques

• Syringe Disposal Education

  • Nearby Orange County shut down a local SSP in 2018 with concerns about syringe collection. To combat similar problems from occurring in San Bernardino County, safe disposal will be offered onsite; portable sharps containers will be provided whenever possible. If neither of these disposal options is possible, then education about safe home disposal will be provided.

  • Education on proper disposal with the use of sharps containers &/or other containers (detergent bottles or beverage containers, for example) 

  • Discussing the dangers of improper disposal techniques

• Overdose Prevention

  • Comprehensive community/peer training on overdose prevention, recognition & response.

  • Implementation of an Overdose Prevention Program for all interns, volunteers, & staff

• Naloxone Distribution & Training

  • Naloxone distribution & training is a lifesaving intervention demonstrated to reverse overdose & reduce mortality; naloxone should be provided directly to participants & their immediate networks whenever possible.

• Infectious Disease/Sexual Health Education

  • Provision of condoms to reduce the risk of sexual transmission of viral hepatitis, HIV, or other STDs.

  • HIV, viral hepatitis, STD & TB screening.

  • Referral & linkage to HIV, viral hepatitis, STD & TB prevention, treatment & care services, including antiretroviral therapy for hepatitis C virus (HCV) & HIV, pre-exposure prophylaxis (PrEP), post-exposure prophylaxis (PEP), prevention of mother-to-child transmission & partner services.

  • Referral & linkage to hepatitis A virus (HAV) & hepatitis B virus (HBV) vaccination.

 

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Expanded Services

• Expanded services complement core services & improve PWID health & well-being; while SSPs provide all core services, ideally & when possible. Expanded services complement core services & facilitate in the establishment of a continuum of care which may include:

  • Sexual health initiatives

    • Distribution of safe-sex supplies & educational materials

    • Mobile testing unit to prevent the spread of infectious disease

  • Mobile screenings screening services for other infectious diseases

  • Syringe-vending machines throughout San Bernadino County, are accessible 24 hours a day, seven days a week.

    • Boxes of Narcan (2 doses per unit) available at no-cost "Harm Reduction Packs” which may include several needles & syringes, alcohol swabs, cotton, wool, & sterile water. educational materials, & other safe-use supplies.

  • Linkage to care/healthcare access &/or referrals to providers, or referral to treatment whenever possible & desired (e.g., Methadone, Buprenorphine, or Naltrexone) &/or referrals to counseling & behavioral therapy. Whenever possible, link PWID to care to provide &/or coordinate the provision of other health & social services, especially for PWID who do not receive care elsewhere.

    • Other supportive services are vital primary & secondary prevention approaches that help achieve the overall purpose of reducing harm & improving the health of PWIDs.

 

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Ensuring Program Sustainability

• Create meaningful engagement opportunities to encourage participant ownership of the program & compensate appropriately.

  • Address & accommodate the needs & concerns of the local PWID communities.

• Foster relationships with a variety of stakeholders to increase & diversify community support, both financially & socially.

  • We will partner with jurisdictional health & social service agencies, local & regional foundations, other community-based organizations, opioid coalitions, public safety, & other state entities to ensure program sustainability.

  • Health department support & legal counsel can play an important role in addressing community concerns, especially around syringe disposal.

• Diversify funding sources for increased program sustainability by engaging potential & any committed stakeholders early & throughout the process, to gauge their level of support or resistance & address any concerns they may have in a proactive manner.

  • Potential stakeholders may include:

    • Local community-based organizations (CBOs)

    • AIDS service organizations (ASOs)

    • Law enforcement, including police & district attorneys

    • Faith-based organizations

    • Health departments, other government agencies, & elected officials

    • Local community boards, neighborhood groups, tenant & block associations

    • Relevant city workers & departments, such as Sanitation Departments, Fire Departments &/or Parks Departments

    • Local residents & business owners/managers

    • Methadone & other drug treatment programs

• Collecting Data, Monitoring, & Evaluation

  • Collect data on trends, needs, & overall program effectiveness.

    • Data collection is essential to informing program planning & evaluation. Data will help our San Bernadino-based programs better understand provided services & available resources in the context of local needs for PWIDs.

    • Efforts should be made to collect reliable data on key demographics, services provided, & trends in service utilization.

    • Ongoing monitoring will include regular review of collected data to assess program effectiveness, with particular attention to reaching marginalized &/or highly stigmatized populations (e.g., people of color, women, & transgender persons).

 

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Budget Considerations

• Stipends

  • Volunteers, interns &/or peers

• Travel Reimbursement

  • Volunteers, interns &/or peers

  • Travel reimbursement

  • Implementing participant compensation programs (if necessary)

• Insurance

  • Vehicle insurance

• Office Supplies

  • Staff development costs

  • On-going training & support for staff &/or volunteers

  • Clinical supervision

  • Retreats &/or team-building activities