WA State Syringe Exchange Health Survey, 2019 Results

Respondents were majority male, with a substantial minority female and 1% identifying as transgender or other (Table below). Across a broad range of ages, the mean age was 36 years with a median age of 38 (Figure below). Most respondents self-identified as White with the proportion of other race/ethnicity categories varying by county. A disproportionately high percentage self-identified as American Indian/Alaska Native, 11% compared to 2% of the population in Washington State (Office of Financial Management, 2019). This is notable given that in Washington State, American Indians/Alaska Natives have a significantly elevated rate of fatal drug overdoses compared to other race/ethnicity groups.

Two thirds of respondents (69%) reported having unstable or no housing at all and over half of non-King County respondents (57%) had no legal monthly income. Over a third of respondents had been incarcerated in the past 12 months; interruptions in opioid tolerance caused by incarceration are a known risk for overdose.

Respondents were asked to list any use of a substance in the past three months and to identify which drug or drug combination was their “main” drug as they defined it. Any use of methamphetamine and/or heroin was reported by a majority of respondents (Table below). Almost a third (31%) reported using methadone or buprenorphine, followed by alcohol (29%), which was included for the first time in the 2019 survey. A smaller proportion reported using fentanyl (by itself or mixed in something), benzodiazepines, other opiate medications (the common term opiate used as an equivalent to opioid) and cocaine in its different forms or in combination with heroin.

While a slightly higher proportion reported any methamphetamine use in the past three months (84%) than any heroin use (78%), a much higher percentage identified heroin as their main drug (57%) compared to methamphetamine (26%). Use of methamphetamine and heroin combined (i.e., “goofball”) was also common.

Although surveying at SSPs specifically targets PWID (97% had injected a drug in the past three months), a sizable percentage reported also smoking drugs. A slightly higher percentage reported smoking methamphetamine than injecting it, 79% versus 73% respectively. While virtually all those who had used heroin did so by injection, half had also smoked it, a notable change from a decade ago when smoking heroin was uncommon in Washington State.

In this survey, 18% reported any use of fentanyl, by itself or believed to be mixed in with another drug, in the prior 3 months, with only one person reporting it as their main drug. However, the situation with fentanyl is unclear in Washington State in terms of the prevalence, appearance, sources, and which specific fentanyl compounds are involved. The most common appearance of fentanyl reported was “mixed with heroin or meth(amphetamine),” which contrasts with the relatively high prevalence of fentanyl in bogus pharmaceutical pills in some regions and police evidence testing results from the Washington State Patrol. Conflicting information likely reflects a wide range of community perceptions and differing perspectives provided by numerous data sources.

The figure below compares drug use across time periods. Methamphetamine use in the prior week was reported by 78% of respondents, with nearly half (49%) of all respondents using 5-7 days in past week. Conversely, a slightly smaller proportion (72%) reported any heroin use in the past week yet a higher proportion (59%) used heroin 5-7 days in the past week. Daily or near-daily use is more common for heroin than methamphetamine given heroin’s shorter-acting effects and its rapid onset of physical dependence.

Polysubstance use was reported by the vast majority of participants. The table below shows the variety of substances used in the past week by either heroin or methamphetamine as main drug. Past week use of a drug other than the “main” drug was nearly twice as likely among those whose main drug was heroin (91%) than those whose main drug was methamphetamine (48%). This pattern corresponds to long term trends for heroin and methamphetamine seen in multiple data sources for Washington State including fatal drug overdose data that indicate most heroin overdose deaths involve other substances compared to only about half of methamphetamine-related overdose deaths (data available at ADAI Interactive Drug Data).

Looking specifically at use of both opioids and stimulants in the past week, the figure below shows that most main heroin users had also used stimulants (methamphetamine and/or cocaine), yet, conversely, most main methamphetamine users had not used opioids. In 2018 ADAI conducted qualitative interviews with SSP participants to explore motivations and patterns of concurrent methamphetamine and opioid use and produced this summary report: 2018 Qualitative Interviews with Syringe Exchange Participants.

On the day they were surveyed, two-thirds reported they were exchanging syringes for other people (i.e., “secondary exchange”) as well as themselves and for an average of two additional people (Table below). The majority also reported using an SSP more than once in the past month, with an average of three times per month. Frequency of SSP utilization is closely tied to the number of hours and days each SSP can operate and, along with rates of secondary exchange, indicate the potential reach of SSPs into the drug use and social networks of those individuals who access services in person.

The median age of first injecting any drug was 23, with over half (59%) injecting for the first time before the age of 26 (Figure below).

The majority (78%) of people
injected 5-7 days in the last week with most injecting every day (Table below).
The average number of injections per day was 3.5, and 65% of respondents
reported that they typically use a syringe only once before disposing of it. While
one-time use of syringes is promoted at SSPs to minimize vein damage and skin
infections, one-time use may be difficult in areas where inadequate funding for
SSPs limits syringe supply or the number of days an SSP can provide services
each week.  

Eighty-five percent (85%) reported that they had not shared a syringe with another person in the last three months, and 60% reported that they had not shared other drug injection materials (e.g., cottons, cookers, water) in the last three months. Because sharing other injection materials can transmit infectious diseases like HIV and hepatitis C, all SSPs provide these materials in addition to exchanging used syringes for new syringes.

Nearly half (42%) reported having an abscess or skin infection in the last 12 months while other drug injection-related conditions (e.g., blood clots, blood infections, endocarditis) and sexually transmitted infections were less common (Table below). Few women reported being pregnant in the prior year.

The same proportion (93%) of respondents had ever been tested for HIV or hepatitis C virus (HCV), over half within the last year (Figure below).

Only 28% of those diagnosed with HCV had completed, or at least started, HCV treatment (Figure below). Among people who had been diagnosed with but not treated for HCV, the majority (68%) were interested in hepatitis C treatment, which is important given that most respondents have Medicaid coverage that, as of 2019, pays for HCV treatment.

Substantial majorities expressed some level of concern about either depression or anxiety (Figure below). Twenty percent (20%) of respondents said they were “very concerned” about both depression and anxiety while a similar proportion (19%) had no concerns at all about either.

Only 8% reported having no health care coverage, with most reporting some form of public insurance, most commonly Medicaid (Figure below).

Most respondents accessed medical care in the past 12 months through a number of settings such as medical offices/clinics, syringe exchanges, jails and mobile medical clinics (Figure below). Nearly a quarter (23%) of respondents had been admitted to a hospital, and just over half (56%) had used an emergency department, with about one third reporting multiple visits in the last 12 months (Figures below).

Among people who had used opioids, 22% had experienced at least one opioid overdose (defined in the survey as “when breathing slows down or stops and a person can’t be woken up”) in the past 12 months (Figure below).

Over half (59%) of all respondents had witnessed at least one opioid overdose (Figure below). Many survey respondents had experienced or had witnessed multiple opioid overdoses.

About one-third (33%) reported they injected drugs alone most or all of the time, which increases the risk that an overdose could be fatal because bystanders are not available to intervene (Figure below).

The substantial majority of those who used opioids reported owning a naloxone kit in the last three months (Figure below). Distribution of free naloxone kits through SSPs across the state has steadily increased over the past four years, most notably outside King County since 2016 with the implementation of a five-year federal SAMHSA grant¹ to scale-up naloxone distribution in high-need areas of the state. At the time of writing, all SSPs in WA State distribute naloxone to participants at no cost and collectively represent the largest channel of naloxone distribution to laypersons in the state.

Among people who had used methamphetamine by itself or mixed with heroin (i.e., “goofball”) in the last three months, a quarter (25%) reported acute psychiatric conditions related to methamphetamine use in that time period and 15% reported acute physical conditions (Figure below). A small percentage (9%) reported they had been to the emergency room for acute psychiatric or physiological symptoms related to methamphetamine².

1. The Washington State Program to Prevent Prescription Drug/Opioid Overdose project grant awarded to WA State Health Care Authority, Division of Behavioral Health and Recovery and implemented under contract by ADAI.
2. Overdose related to methamphetamine has been challenging to document in these SSP surveys as the clinical presentation of potentially fatal symptoms is more complex and variable than in opioid overdoses. The 2017 survey asked about experience with “overamping” (defined in the survey as an event that “usually looks like a heart attack, stroke, seizure, intense overheating or really extreme sudden psychosis”) but that definition proved confusing and imprecise for some respondents. The 2019 survey continued to refine this question by focusing on specific symptoms.

Over half (60%) of people who reported heroin as their main drug reported receiving some kind of substance use treatment, most often buprenorphine and methadone, in the prior year (Figure below).

However, only one in four people (25%) reporting methamphetamine as their main drug reported any type of substance use treatment in the past 12 months (Figure below). This may reflect the fact that there are not yet treatment medications proven effective for methamphetamine and/or the fact detailed below that people who use methamphetamine reported less interest in stopping or reducing their stimulant use. A minority of people whose main drug was methamphetamine also reported use of medications to treat opioid use disorder.

Of those whose main was drug was heroin and who had used heroin in the past week, 82% said they were “very” or “somewhat” interested in reducing or stopping their opioid use, and these respondents were most interested in treatment medications for opioid use disorder (Figures below). Other services preferred to help reduce opioid use ranged from specialty addiction treatment services (e.g., detox, inpatient and outpatient treatment), to individual counseling, help navigating services, and mental health medications. “Other” types of help included housing, adequate pain treatment, and employment or education opportunities.

Among main methamphetamine users, however, only 48% were very or somewhat interested in reducing their stimulant use, although there was similar interest in a range of services, including interest in any medications that might help reduce stimulant use, counseling, care navigation and other services (Figures below)¹.

1. Currently there are no FDA-approved medications proven effective to treat stimulant use disorder. Find a summary of the evidence on treatment approaches for stimulant use disorder here.