Understanding Syringe Access in Rural Middle and West Tennessee

West Tennessee, a 21-county area home to roughly 1.56 million people over 10,650 squre miles, is home to two three Syringe Services Programs (SSP) — also, as of June 2021, Tennessee Harm Reduction became rural West Tennessee’s first (underground) syringe exchange! In comparison, Middle Tennessee is home to 38 counties, 2.68 million people, 17,009 square miles, and just one syringe exchange. East Tennessee, home to the three five SSPs — the most of any of Tennessee’s Grand Divisions — hosts 2.4 million people across its 36 counties’ 13,558 square miles.

When it comes to syringe exchanges in West Tennessee, all three official SSPs are in Memphis, which is in the far southwestern extreme of the state. Tucked away in the corner, only three counties (and part of a fourth) in West Tennessee are within a reasonable drive of Memphis. The other 18— what we can call rural West Tennessee — don’t have access to any SSPs. Now, however, rural West Tennesseans can visit Tennessee Harm Reductionthat’s us! — in Jackson for 100% free syringes, naloxone, fentanyl test strips, and other harm reduction supplies.

Outside of these three SSPs, which happen to be in the far southwestern extreme of West Tennessee, there’s essentially nothing good for drug users in terms of treatment programs, syringe access, or softer drug policies. I live in Martin, which is about 125 miles from Memphis and 145 miles from Nashville* — both are roughly two-and-a-half hour drives. No matter where you are in Northwest Tennessee, you’re at least, give or take a few minutes, an hour-and-a-half’s drive from your starting location to Memphis or Nashville.

It’s like this — if you aren’t already in Nashville or Memphis, you’re probably not participating in any of Tennessee’s recognized Syringe Services Programs. Even people inside those cities sometimes find it difficult to visit the physical locations where services are provided to participants; in other words, both Nashville and Memphis are all but havens for syringe access.

*An Update

As of March 2021, I moved to Jackson, which is about 70 miles northeast of Memphis (since I-40 connects Jackson to Memphis, the trip is less than an hour long — if you drive fast, at least!).

Located in the dead center of West Tennessee, Jackson is the second-most populated city in the region behind Memphis. Although its 70,000-odd residents pale in comparison to Memphis’s 633,000, Jackson acts as a center of trade for rural West Tennessee. Naturally, people from across rural West Tennessee visit Jackson to buy drugs.

Jackson is unique in that it’s the only locality in West Tennessee other than Memphis that has homelessness, sex work, and drug use “out in the open.” Moving to Jackson allowed me to ramp up my harm reduction efforts considerably because of its “openness.” I’m proud to say Tennessee Harm Reduction became rural West Tennessee’s first (underground) syringe exchange in mid-2021 and is still the region’s only syringe exchange — and distributor of intramuscular naloxone kits and fentanyl test strips, as far as I’m aware.

Here’s One Resource We Do Have — But It Sure Ain’t Syringe Access

The Tennessee Department of Health established the role of Regional Overdose Prevention Specialist in Oct. 2017. Currently, there are 21 22 Regional Overdose Prevention Specialists (ROPS) across 13 districts. ROPS are hold town hall-style naloxone trainings and distribute the lifesaving drug for free. According to the Volunteer State, ROPS primarily target three audiences:

  • First responders.
  • Entities that provide community-based resources, addiction recovery services, or treatment.
  • People who’re most likely to experience overdose, including their friends and family members.
Multi-color map of Tennessee broken down into counties. Each color represents one of 13 areas that the Tennessee Department of Health's Regional Overdose Prevention Specialists (ROPS) are assigned to.
Districts assigned to the state’s 22 ROPS. I’m in Region 6N. As of March 2021, however, I belong to Region 6S — that’s the one in green on the bottom half of West Tennessee.

From what I understand, a significant portion of attendees tend to attend ROPS training events to satisfy continuing education requirements. None of the 35 to 75 people I’ve given syringes, naloxone, and other harm reduction supplies to in my time as a practicing harm reductionist — virtually all of whom were long-term, often-problematic drug users; in other words, the most generally-disadvantaged drug users — have been familiar with Regional Overdose Prevention Specialists.

I’ve talked to some ROPS, all of whom admitted that they largely failed to reach regular often-illicit opioid users who are at high risk of overdose, as well as people who they’re close with. Yes, they inevitably reach some people at risk of experiencing opioid overdose, but not nearly enough.

Do Pharmacies Play a Role in Syringe Access?

In rural Middle and West Tennessee, if not elsewhere in the Volunteer State, injection drug users like me primarily get their syringes in black-market fashion. Pharmacies are given legal discretion to sell syringes without prescriptions, even if they feel that the sharps they sell will be used for injecting illicit drugs.

However, in actuality, very few pharmacists sell syringes without prescriptions. The relatively few active injection drug users who’ve tried buying syringes from pharmacies aren’t likely to keep asking pharmacists to sell them syringes; rather, it often feels like pharmacists are sworn enemies of people who use drugs.

I’ve heard that pharmacists in bigger cities are more willing to dispense syringes without prescriptions, though I don’t know this from experience.

Either way, it’s safe to say that pharmacies don’t play a role in expanding syringe access. Thanks to most local pharmacists’ unwillingness to provide injection drug users access to clean syringes, they actually do a good job of keeping disease transmission, likelihood to continue injecting drugs, and likelihood to not seek out drug treatment high.

But Seriously — What Resources for Drug Users Are Here?

We’ve got outdated, non-evidence-based drug rehabs, often-exclusionary 12-step programs, probation and parole, and drug courts, as well as medication-assisted treatment programs — though there’s just 19 physicians prescribing buprenorphine for opioid use disorder and two methadone clinics in Northwest Tennessee, a nine-county area that’s home to 254,000 people.

Outside of that, we’ve got absolutely nothing for drug users like me. This was written in April 2020. Allow January 2022 Daniel to update this section.

In rural West Tennessee at large, there are a total of four methadone clinics — Memphis has four by itself, in addition to rural West Tennessee’s four — and roughly four dozen physicians who prescribe buprenorphine (Suboxone).

Moving to Jackson —and the passage of time — made more resources available to me. Although I never found any other harm reduction services, I did end up getting medication-assisted treatment for free starting in September 2020.

Tennessee’s State Opioid Response (SOR) program started in September 2018. It opened up a hub-and-spoke network of MAT providers in the state. As of now, West Tennessee has seven — two in Jackson (one buprenorphine, one buprenorphine/methadone), five in Memphis — providers in the hub-and-spoke system. Patients must live in Madison County to receive services from Jackson’s providers or live in Shelby County to receive services from Memphis’s providers. You can get buprenorphine (Suboxone) treatment for free through the SOR grant, as it’s called, or methadone for $20/week.

Still, however, rural West Tennessee has been completely devoid of syringe access since I initially wrote this article. I’m the only person or entity in the entirety of rural West Tennessee to have expanded regional syringe access since I wrote this in April 2020 — which I did through my organization, Tennessee Harm Reduction, in June 2021.

More About Sharps on the Black Market

As I’ve already mentioned, most sharps that local injection drug users source are from the black market. What does the “black market” for syringes consist of, exactly? The more popular sources of sharps are:

  • Fellow drug users, typically taking the form of injection drug users.
  • Illicit drug dealers.
  • Most importantly, family members who have prescriptions for syringes.

Drug Users Benefit From Performing Services for Fellow Drug Users

Due to drug laws, participants in illicit drug markets often face scarcity. Since a local market’s illicit drug vendors can’t openly offer their services, few end-users in any given area are familiar with all the dealers worth their salt there — buyers have a seller-finding problem.

Sometimes, end-users rely on fellow end-users to act as middlemen. End-users aren’t likely to give up their connections for two reasons: (1) dealers may not be comfortable with taking on new clients and (2) leveraging a relatively valuable connection by prospective middlemen. The nature of the black market makes opportunities scarce — that’s what ultimately makes these connections with dealers not always easy to come by and, therefore, valuable.

Family members seem more trustworthy than other sources of syringes. However, due to the nature of the black market, you can’t ever be sure family-sourced sharps have never been used. Still, I’d feel safer trusting a family source than a fellow user or dealer.

One time, I drove a well-connected fellow drug user to source drugs. She wouldn’t have been able to get there otherwise. Even though I regularly give her harm reduction supplies (e.g., syringes, naloxone, tourniquets) and she knew she would have still secured my transportation, whether she’s got a clean syringe to spare or not.

I understand she was incentivized and may have felt pressured to procure a syringe for me. What if I were less likely to turn to her as a middleman in the future as a result of her not giving me a clean syringe?

I’d asked her for a syringe upon getting the drugs, to which she obliged. Just before injecting, I found the barrel to contain a little bit of what looked like water.

Syringes never have liquid in them unless they’ve been used. Thank goodness I noticed that before using it. I gave it back to her, told her it must’ve been used before, and that I wasn’t mad at her.

Fortunately, because I’ve secured syringes and company from a free, mail-based harm reduction supply distributor for a year-and-a-half or two years now, I’ve never needed to hit the black market for sharps. I can only imagine how much more risk I could’ve faced without my long-time, super-safe supply source.

Understanding Syringe Laws in Tennessee

Tennessee Code Annotated § 40-7-124 grants immunity to people who inform police they’re in possession of syringes or sharp objects that could be considered drug paraphernalia (a violation of T.C.A. § 39-17-425) from getting charged with or prosecuted for Possession of Drug Paraphernalia for those syringes or sharp objects.

Despite the fact this law came into being in 2015, it’s alarming that many law enforcement officers aren’t aware of the law. I’m sure many agencies across the Volunteer State do a great job of educating their members.

However, if law enforcement agencies here were on top of things, I wouldn’t have been arrested for Possession of Drug Paraphernalia for syringes despite the protection afforded to me by T.C.A. § 40-7-124, which I’ve seen nicknamed as the “Needle Possession Officer Awareness” law. What’s worse is that the syringes, albeit used, didn’t test positive for drug residue. I also didn’t admit to using them for illicit drugs. From what I understand, the syringes shouldn’t have been construed as drug paraphernalia based on T.C.A. § 39-17-425.

I’m not an attorney, but I’m intimately familiar with these two laws pretty well — I’d hope anybody else who’s been charged with and prosecuted for Possession of Drug Paraphernalia three times would be, too.

Lastly, I know many officers aren’t familiar with differentiating low-gauge, intramuscular-use syringes from their high-gauge counterparts that are common among injection drug users.

The former, usually ranging from 21 to 25 gauge, is included in naloxone kits.

Again, even though syringes themselves not used for illegal drugs aren’t illegal, people found in possession of naloxone kits containing IM-use syringes are liable to face unfair treatment from law enforcement, including ultimately getting charged with Possession of Drug Paraphernalia even though such a charge would be unfounded.

A local resident who I’ve given naloxone kits told me he’d been pulled over with at least one naloxone kit in his vehicle’s glovebox.

He told me the police asked to search his vehicle. In doing so, they found the naloxone kit and scrutinized him for the (albeit clean, unused) syringe it contained.

While it’s certainly possible to fight unfounded criminal charges in court, many residents of the Volunteer State, especially people living in rural areas and who are particularly-disadvantaged drug users, are unable to post bail or afford private legal representation.

They often prematurely, unnecessarily plead guilty to charges they’ve been accused of, even if defendants are confident they don’t deserve some or all of them.

I’ve been in that same situation. At the time of arrest, I was already on probation and arraigned 6 days out from my next scheduled report date. In court, I was told it’d take at least two weeks to be appointed a public defender and get back in court. Unable to post bail or hire a private attorney, I was forced to plead guilty — if I waited in jail, I could still end up getting charged, resulting in two potential violations since I wouldn’t have showed up on time; if I pled guilty, I could get violated because I caught a criminal charge, the cardinal sin of any probationary agreements.

What Can We Do for Syringe Access in Tennessee?

  1. If you live in Tennessee, get some clean syringes, naloxone, fentanyl test strips, cookers, tourniquets, cotton, and other harm reduction supplies and distribute them to people who use drugs, drug dealers, family members and friends of drug users, and other drug-adjacent people. Don’t know where to look? Check out this guide for finding syringes and naloxone in Tennessee.
  2. Donate to our organization by printing our educational materials. We’re always in need of more brochures. Whether you can print 25 copies or 1,000, your prints will help us spread our message — or save more lives, in other words. Here are our two original brochures. Contact us to get started.
  3. Write letters to your representatives. City mayor, county mayor, judges (especially mental health/recovery court judges), sheriffs, Tennessee General Assembly members (one representative and one senator), state representative (U.S. House of Representatives), state senator (U.S. Senate) — these are a good place to start. Click on the green links to look up which politicians represent you. Too busy to write a letter from scratch? Don’t know what to say? Use our 100% original letter in support of harm reduction programs and drug policy reform! We recommend using our letter as a starting point and summarizing the ideas you find important, then sending that letter to your reps.
  4. Regularly look for new articles about drugs from any of the many local news outlets in Tennessee — especially fentanyl, the “opioid epidemic,” syringe exchanges, or harm reduction. Look for factual inaccuracies. Reach out to the news outlet and kindly, calmly inform them of what they got wrong. Do the same for articles’ authors/reporters. Find where the news outlets shared these reports on their social media accounts and join the discussion — although it’ll be laden with bullshit, alert your fellow readers about what the article got wrong in a kind, calm manner. Interact with other commenters and kindly, calmly challenge their views. Never try to change others’ opinions with hate, vitriol, or even a slightly bad attitude! Doing so will NEVER influence opponents to actually adopt harm reduction-friendly ideas.
  5. Tell your friends, family members, and peers about the lack of syringe access around here. Let them know this leads to higher rates of HIV, viral hepatitis, and other blood-borne diseases. It also leads to abscesses, blown veins, and scarring.
  6. If you have lived experience with addiction, injection drug use, illicit opioid use during today’s fentanyl crisis, or drug use in general, share your testimony with others. You don’t need to have a picture-perfect Cinderella story to make a difference. If you currently use drugs, don’t be scared — advocate for our shared beliefs as an active, open drug user! I’ve been out of the closet (as an injection illicit opioid user) for over three years now and I wouldn’t have it any other way.
  7. Share Tennessee Harm Reduction online or with people you know! Here’s everywhere you can find us:
    • Instagram: @TennesseeHarmReduction
    • Facebook: Facebook.com/TennesseeHarmReduction
    • Facebook (for people in West Tennessee): Facebook.com/TNHRWest
    • Website: tennesseeharmreduction.com

I’m sure there are other ways you can advocate for improved syringe access in the Volunteer State, but I’m drawing blank for now. Whether you get engaged in syringe access advocacy or not, at least you’re now better informed about syringe access in rural Tennessee.

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