The Centers for Disease Control and Prevention recently reported a devastating 108,000 overdose deaths in 2021. Despite more than 10 years of successful efforts to reduce opioid prescribing, the overdose death rate, which began its exponential rise in the late 1970s long before opioids were liberally prescribed, continues its incessant climb.

In contrast, Germany, second only to the U.S. in opioid prescribing, has not seen overdoses go up this century. And Canada, ranked third in opioid prescribing, has an overdose rate more than a third lower than the U.S. One reason is that both countries have long embraced harm-reduction strategies toward drug abuse.

Harm-reduction strategies avoid measures that exacerbate the harms the black market inflicts on nonmedical users and focuses strictly on the goal of reducing the spread of disease and death from drug use. From Surgeon General Jerome Adams in the Trump administration to Rahul Gupta, the Biden administration’s “Drug Czar,” policymakers have begun to appreciate and promote harm reduction. But state-level drug paraphernalia laws stand in the way.

Federal laws prohibit transporting drug paraphernalia across state lines, while state laws focus on intrastate trafficking. Federal and state statutes vary in how and what they define as paraphernalia. Both federal and state paraphernalia laws obstruct harm‐​reduction organizations that seek to save lives, but state paraphernalia laws have a more direct and deleterious effect on harm reduction.

Simple possession of drug paraphernalia is not a federal crime. However, some state laws prohibit owning or possessing these items. In some instances, local police may check an item for residue. If they determine the possessor uses it to ingest an illicit substance, they may press charges against that individual. Unfortunately, many types of drug paraphernalia that states restrict or prohibit are also important harm‐​reduction tools.

Fentanyl test strips save lives by enabling drug users to detect the presence of this dangerous opioid in other drugs, such as heroin and cocaine. Users who detect fentanyl typically discard the contaminated drugs, use smaller amounts, and/​or take the drug more slowly, thereby reducing the risk of overdose.

Many states prohibit distributing fentanyl test strips, as paraphernalia, because individuals use them to test or analyze an illicit drug. As a result, people end up overdosing because the ban prevents them from determining what would be a nonlethal dose.

Decades of evidence on Syringe Services Programs (called SSPs or “needle exchange programs”) show that they reduce drug overdoses and the spread of HIV, hepatitis and other blood‐​borne infectious diseases. These programs distribute clean needles and syringes to intravenous (IV) drug users.

Many programs also distribute the overdose antidote naloxone and fentanyl test strips along with bleach and other materials to clean syringes and needles. Some offer HIV and hepatitis blood tests and refer for treatment those who test positive. The CDC endorses and promotes SSPs with guidance and, in some cases, provides financial assistance for these facilities to local jurisdictions.

Despite convincing evidence and support from organizations ranging from the American Medical Association to the National Academy of Sciences, Engineering and Medicine, many state-level drug paraphernalia laws inhibit private organizations from creating SSPs. My colleague Sophia Heimowitz and I recently published a policy analysis comparing the drug paraphernalia laws of all 50 states and the District of Columbia, and the degree to which they undermine harm-reduction strategies.

For example, Alaska has no laws restricting drug paraphernalia, which leaves residents with maximum freedom to design syringe exchange programs and other harm‐​reduction initiatives.

Of the other 49 states and the District of Columbia, 40 define drug paraphernalia to include syringes, and 45 include testing materials. Thirty‐​five states and the District of Columbia limit both syringes and testing equipment. Four states limit syringes but not testing materials, whereas nine states limit purity testing equipment but not syringes. Only South Carolina excludes both syringes and testing materials from its definitions of drug paraphernalia, allowing SSPs to operate without restrictions.

SSPs exist in most states, including states where they are illegal. States that legally authorize SSPs impose various restrictions on their structure and operation, as well as on state‐​level funding opportunities. Restrictions on how SSPs operate limit their scope, hamper their success, and work against the goal of reducing the spread of disease.

With no statewide drug paraphernalia laws on Alaska’s books, charitable and other nongovernmental organizations can implement SSPs and other harm‐​reduction strategies.

If states want to get serious about reducing the risk of harm from using illegal drugs, lawmakers should repeal their drug paraphernalia laws. Eliminating state drug paraphernalia laws will let SSPs and other evidence‐​based harm‐​reduction strategies work to their full potential and, more importantly, will save lives.