Hawaii's Syringe Exchange Program Adapts as Drug Users Shift From Injecting to Smoking

Hawaii's syringe exchange program, the oldest state-funded initiative of its kind in the United States, is undergoing a profound transformation. After decades of focusing primarily on needle distribution to prevent infectious disease transmission, the program is pivoting toward safer smoking supplies and expanded naloxone access as drug users across the islands increasingly abandon injection in favor of smoking fentanyl and other substances.

The shift reflects both changing drug use patterns and a legislative overhaul through Act 106, which took effect in May 2025 and removed the strict one-for-one syringe swap model that had governed Hawaii's harm reduction approach since the program's inception in 1990.

The Numbers Tell a Clear Story

Data from the Hawaiʻi Health & Harm Reduction Center (HHHRC), which operates the statewide program, reveals a dramatic decline in syringe exchanges over the past three years. In 2021, the program's peak year, staff distributed and collected over 1.2 million syringes. By 2023, that number had fallen to roughly 600,000. Last year, it dropped further to just over 484,000—a decline of more than 60 percent from the peak.

Yet the drop in needle exchanges does not signal reduced program engagement. HHHRC's 2024 evaluation shows that overall client visits for harm reduction services have remained steady or increased. What has changed is what participants are requesting. Demand for naloxone, wound care kits, safer sex supplies, and—critically—safer smoking equipment has surged as smoking replaces injecting as the preferred route of administration.

The trend mirrors broader patterns observed across the continental United States, where fentanyl's dominance in the illicit drug supply has reshaped consumption habits. Fentanyl's potency makes smoking a viable alternative to injection, offering users a faster onset of effects without the risks associated with needle use—though respiratory overdose remains a lethal threat regardless of administration method.

Act 106: A Legislative Pivot

Recognizing these shifting realities, Hawaii lawmakers passed SB1433, which became Act 106 on May 29, 2025. The legislation fundamentally restructured the state's approach to harm reduction services, moving away from the one-for-one syringe exchange model that had been the program's cornerstone for over three decades.

Under the previous system, participants were generally expected to return used syringes to receive clean ones—a harm reduction strategy designed to prevent needle sharing while ensuring proper disposal of biohazardous materials. Act 106 replaced this with a needs-based distribution model that gives providers flexibility to offer supplies based on individual client requirements rather than rigid exchange ratios.

The law also expanded the range of "authorized objects" that programs can legally distribute and added liability protections for both participants and staff. Importantly, the legislation clarifies that possession or delivery of used syringes returned to a program should not be treated as a drug possession offense under specified conditions, addressing a longstanding concern that discouraged some users from accessing services.

On the Ground: How Programs Are Adapting

HHHRC operates a network of fixed and mobile sites across Oʻahu, Maui, Kauaʻi, and Hawaiʻi Island. The organization's mobile outreach van serves Chinatown in Honolulu, while weekday exchanges operate at Aʻala Place and the Punawai rest stop. All services remain free and confidential.

Frontline staff have adjusted both their supply inventories and their metrics for success. Where program evaluation once focused heavily on syringe exchange volume, staff now track naloxone refills, safer smoking kit distribution, wound care interventions, and connections to testing and treatment services. Peer outreach—engaging people with lived experience to connect with active drug users—has become an increasingly central component of the work.

The 2024 program evaluation recommends expanding fixed site locations, building testing and treatment referrals directly into exchange visits, and continuing to tailor supply distribution to match participant preferences rather than predetermined program models.

Broader Implications for Harm Reduction

Hawaii's experience offers lessons for harm reduction programs nationwide as they grapple with evolving drug markets and shifting federal policy. The state's ability to adapt its legislative framework to match on-the-ground realities demonstrates how policy can enable rather than constrain public health innovation.

The shift from injection to smoking carries both risks and opportunities. Smoking eliminates bloodborne disease transmission pathways—HIV and hepatitis C among them—that have long plagued injection drug use. However, smoking fentanyl carries its own overdose dangers, particularly as the drug supply grows increasingly unpredictable with adulterants like xylazine and medetomidine appearing with alarming frequency.

Naloxone remains effective for fentanyl overdoses regardless of administration route, making expanded distribution of the overdose reversal medication a critical priority. Hawaii's program has responded by prioritizing naloxone access alongside its evolving supply distribution model.

Looking Forward

As Hawaii's syringe exchange program enters its fourth decade, it faces the same challenge that has defined harm reduction work from the beginning: meeting people where they are with the services they actually need, not the services policymakers assumed they would want.

The decline in needle exchanges is not a failure—it is evidence of success in reducing injection drug use and the infectious disease burden that accompanies it. The program's continued relevance depends on its ability to evolve alongside the populations it serves, adapting to new substances, new consumption patterns, and new public health threats.

For the thousands of Hawaii residents who rely on these services, that adaptability may mean the difference between surviving the next wave of the overdose crisis and becoming another statistic in it.

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HHHRC operates syringe exchange and harm reduction services across Hawaii. For locations, hours, and contact information, visit their website or call (808) 521-2437.