A comprehensive review of state laws that govern the distribution and possession of drug use equipment in the United States.

The United States continues to experience a large amount of drug-related harm, including high rates of both overdose mortality and harms associated with lack of access to new drug use equipment such as syringes and pipes. These harms include the spread of bloodborne disease as well as endocarditis, osteomyelitis, and other skin and soft tissue infections. Laws that prohibit or restrict access to drug use equipment may increase these harms. This manuscript provides a comprehensive legal review of laws that criminalize or otherwise restrict the distribution and possession of equipment for both injecting and inhaling drugs from both syringe services programs and other venues. We also report novel data on the severity of penalties associated with violations of prohibitions on the above activities. We find great heterogeneity in these laws. The free distribution of injection equipment for illicit drug use is permitted in 19 states, and the free distribution of smoking equipment is permitted in 14 states. The possession of injection equipment is permitted in 21 states, and the possession of smoking equipment in 15. Where possession or distribution of drug use equipment is prohibited or restricted, we found large differences in the penalties imposed for violations. There is also wide variation in laws governing the operation of syringe services programs, which are permitted in some form in 40 states but often highly regulated. We suggest that states evaluate and, where indicated, remove legal barriers to these supplies.