Results from the 2023 WA State Syringe Services Program Health Survey

The majority of respondents identified as male (63%) and white (72%); these and other proportions of gender and race/ethnicity identities (Table 2) were consistent with past surveys. Respondents ranged in age from 18 to 75, with a mean age of 41 and a median age of 39. Only a minority (20%) had permanent housing; most were living unhoused (55%) or in temporary/unstable situations such as a tiny home village or “couch surfing” (25%). 8% were men who have sex with men and 10% were women who have sex with women.

Over half (56%) said they had used the SSP where they were taking the survey at least twice in the past 30 days; 12% were using that SSP for the first time on the day they took the survey.

Table 2: Demographics of SSP survey respondents, n=1667. (Table 2 long description.)

Incarceration

About a third (30%, n=502) of all respondents had been in jail or prison in the past year. Of these, 23% (n=115) reported they had been offered naloxone upon release. Among the 1,116 individuals who had used opioids in the past week or were currently taking medications for opioid use disorder (MOUD), a third (33%, n=371) had been incarcerated in the past year, of whom 28% had been offered naloxone upon release. A minority of these individuals said they had been offered a chance while incarcerated to start or continue MOUD (Table 3). The survey did not ask about incarceration type or length, so we cannot describe the impact of these important characteristics.

Table 3: "The last time you were in jail or prison, were you offered a chance to start or continue...," n=371 (among those incarcerated in the past year AND past week opioid use or currently on MOUD)

Past week drug use and “main” drug

Participants were asked about their use of methamphetamine, fentanyl, cocaine (powder or crack), heroin, and benzodiazepines [5]. More people had used methamphetamine (89%) in the past week than had used fentanyl (61%). Past week use of heroin or cocaine was much lower (Table 4). Equal proportions (39%) identified either fentanyl or methamphetamine as their “main drug” as they defined it.

Table 4: Substances used in past week compared to "main drug," n=1667. (Table 4 long description.)

Figure 1 shows patterns of stimulant and/or opioid use among respondents. Over half (59%) had used both a stimulant and an opioid in the past week. Few people (7%) used only opioids in the past week. In fact, most (88%) of those who considered their main drug to be fentanyl said they had also used in a stimulant in the past week. Conversely, past week use of opioids among those whose main drug was methamphetamine was much lower (27%).

Figure 1: Patterns of stimulant and opioid use in the past week.

Frequency of drug use

Figure 2 shows the number of days respondents had used each drug listed in the past seven days. Most had used methamphetamine (62%) or fentanyl (51%) nearly every day (5-7 days) of the past week. The average number of days used was similar for both drugs, 5.5 days and 6.1 days respectively.

Figure 2: Frequency of drug use in the past 7 days, n=1667.

Participants who were living unhoused or in temporary/unstable housing (n=1,338) were asked “How might your main drug use change if you had stable housing?” (Figure 3). Many felt that stable housing would help them reduce use of their main drug (43%) or help them quit using their main drug altogether (25%).  

Figure 3: How participants felt stable housing might impact their drug use.

[4] The PHSKC survey included “goofball” (i.e., methamphetamine and fentanyl/opioids combined) in the list of drugs used in the past week. Both statewide and PHSKC surveys included it as a “main drug” option.
[5] Use of other substances has been documented in previous surveys done by ADAI CEDEER.

Drug injection

Just under half of participants (47%) said they had injected any of the drugs listed in the past week (Figure 4) and only a minority used drugs exclusively by injection (10%). Of those who said they had injected any drug in the past week:

• 17% reported any syringe sharing in the past 3 months.
• 24% reported having an abscess or skin/soft tissue infection in the past 3 months.

Drug smoking

Drug smoking was far more prevalent than drug injection. The majority of respondents (89%) had smoked any of the drugs listed in the past week and about a third (36%) had both smoked and injected one of those drugs in the past week (Figure 4). Over half (52%) used drugs by smoking only.

Figure 4: Routes of drug administration in the past week, n=1667

Compared to previous years, these data reflect a significant shift from majority injection to majority smoking. This change has been documented widely and largely reflects the displacement of heroin (typically injected in WA State) by fentanyl (typically smoked) in the local drug market and perhaps more people who smoke drugs coming to SSPs to obtain safer smoking supplies.

Figure 5 shows how participants had used either methamphetamine or fentanyl in the past week. Most participants reported using either drug only by smoking. A smaller proportion reported both injecting and smoking, and a minority used either drug by injection only.

Figure 5: Injecting and/or smoking of methamphetamine or fentanyl among those who had used either.

Interest in safer smoking supplies

As drug smoking has become more prevalent, many SSPs are distributing safer smoking supplies (in addition to sterile injection equipment) to provide an alternative to higher-risk drug injection and reduce the spread of infectious disease via smoking. This has also been an important way to attract and connect new individuals to harm reduction education, personal support, and linkage with health care, behavioral health, and substance use treatment services [6].  At the time of the survey, nine SSP organizations were providing safer smoking supplies; these organizations represented 988 respondents who had smoked a drug in the past week. The remaining 15 SSP organizations were not yet providing safer smoking supplies, although many are interested or preparing to do so. These organizations represented 489 respondents who had smoked a drug in the past week.

Figure 6 shows the prevalence of drug smoking among participants is high at all SSPs sites, no matter if that program distributed safer smoking supplies or not.

Figure 6: Percentage of participants who smoked a drug in past week, by SSP type.

Overall, there was very high use of smoking supplies at SSPs that distributed them and great interest in getting safer smoking supplies at SSPs that do not yet distribute them.  

• At SSPs with safer smoking supplies, 84% of participants who had smoked drugs in the past week had gotten smoking supplies at their SSP in the past year.
• At SSPs without safer smoking supplies, 90% of participants who smoked drugs in the past week were interested in getting safer smoking supplies at their SSP.

[6] More information is available in Singh S, Banta-Green C, Kingston S. Distribution of Safer Drug Smoking Supplies as a Public Health Strategy. UW ADAI, January 2022.

84% percent of respondents reported carrying a naloxone kit in the past three months; the percentage was slightly higher (91%, n=1,011) among those who had used an opioid in the past week.

Figure 7: Number of opioid overdoses had in past 3 months, among those who had used opioids or were on MOUD, n=1,116

Among participants who had used an opioid in the past week or who were currently on MOUD (n=1,116), 28% had experienced at least one opioid overdose in the past three months (Figure 7). Overdose was defined in the survey as “where your breathing slowed down or stopped, you couldn’t wake up, or someone had to Narcan you.” The percentage who reported having at least one opioid overdose in the past three months was higher among those who were also homeless (32%) and among those who had also been in jail or prison in the past year (39%).  

Figure 8: Number of ER/urgent care visits in past year.

The majority of respondents (91%) had some type of health insurance, predominantly Medicaid (82%). Just over half (58%) reported they had been in the emergency room (ER) or urgent care at least once in the past year.

Communicable disease testing

Testing for HIV or hepatitis C virus (HCV) was common:

• 89% had ever been tested for HCV, 40% within the past year. A quarter (25%) of those ever tested had been diagnosed with HCV.
• 89% had ever been tested for HIV, 43% within the past year.

Only 30% had been tested for syphilis in the past year. Cases of primary and secondary syphilis have increased significantly in WA State, disproportionately impacting many populations, including people who use drugs.

Interest in health care services at SSPs

Over half (55%) reported there was a time in the past year when they “thought they should see a health care provider but did not go.” While the 2023 survey did not ask the reasons for not seeking needed healthcare, the 2017 WA State SSP Health Survey showed the most common reasons to be distrust of medical providers and fear of being judged for using drugs [7]. The majority of participants, however, said they would see either a health care provider (75%) or a counselor for mental health support (68%) at the SSP where they were taking the survey (Figure 9). A few SSPs currently offer some level of onsite health care, mental health support, and/or access to same-day MOUD.

Figure 9: Willingness to access health care services located at SSPs.

[7] Banta-Green C, Newman A, Kingston S. Washington State Syringe Exchange Health Survey: 2017 Results. Seattle, WA: UW ADAI, 2018.

The majority of respondents were interested in reducing or stopping their use of stimulants and/or opioids. About two-thirds (68%) of those who had used an opioid in the last week were interested in reducing or stopping their opioid use (Figure 10). Slightly fewer (59%) of those who had used a stimulant in the past week were interested in reducing or stopping their stimulant use.

Figure 10: Interest in reducing or stopping drug use, among those who had used opioids or stimulants in the past week.

Over a third (35%) of respondents had utilized at least one type of substance use treatment or support group in the past 12 months (Figure 11). At the time of the survey, a minority of all respondents were currently taking medications for opioid use disorder (methadone, 9%; buprenorphine, 5%; naltrexone, <1%).

Figure 11: Drug treatment/supports used in past 12 months, n=1667.

About one-third (32%) said there was a time in the last 12 months when they “tried to get help to reduce their drug use but didn’t/couldn’t get it.” These participants were then asked, “What got in the way of that happening?” and their open responses were coded into the categories below (Table 5). Other common barriers mentioned included mental health issues, withdrawal side effects too hard to deal with, could not stop using, partners not also able to stop or get into treatment, legal issues, and other health problems.

Table 5: Barriers faced when trying to get help to reduce drug use, n=357 responses given.

Respondents were asked to identify the “top need in your life right now” and their open responses were coded. The largest percentage (44%) said housing was their top need, followed by other needs:

• Housing, 44%
• Income or job,15%.
• To stop or reduce drug use, 9%.
• Positive relationships, social support, friendship, “love,” 6%.
• Basic survival needs (e.g., food, water, personal safety, tent/tarp, clothing), 6%.

Other needs mentioned included mental health supports, drug treatment, stability, transportation, sense of purpose, and help with legal issues or getting an identification card.

Community-based drug checking [8] provides ways for people who use drugs to analyze the chemical contents of drug residue so they can make safer, more informed choices about if or how they may use that drug. SSPs in WA State distribute immunoassay test strips so participants can self-test their drugs for fentanyl and xylazine [9]. At the time of this survey, six SSP organizations were also providing point-of-care drug checking for their participants using Fourier-transform infrared (FTIR) spectroscopy, with samples sent to a laboratory for secondary testing.

Only about one-third of respondents at either type of SSP (FTIR drug checking or no FTIR drug checking) had used a “test strip” themselves to check their drugs (Table 6). At SSPs with onsite FTIR drug checking, 17% of respondents had used the service, a notable measure of uptake given that the service was still somewhat new (<6 months) for most sites. Overall, the majority of respondents said they were interested in having their drugs tested at their SSP.

Table 6: Use of drug checking technologies/services, n=1667. (Table 6 long description)

[8] Learn more about drug checking in WA state in Kingston S, Biamont B, Banta-Green C. The Use and Impact of Community Drug Checking Services. Seattle, WA: UW ADAI, November 2023.

[9] Benzodiazepine and methamphetamine test strips are available but not distributed by local SSPs.