Science
California communities are banning syringe programs. Now the state is fighting back in court
As Indiana officials struggled to contain an outbreak of HIV among people who injected drugs, then-Gov. Mike Pence reluctantly followed the urgings of public health officials and cleared the way for an overwhelmed county to hand out clean syringes.
Pence was far from enthusiastic about launching the program in Scott County, but after it rolled out in 2015, the percentage of injection drug users there who said they shared needles dropped from 74% to 22%. Within a few years, the number of new HIV infections plummeted by 96% and new cases of hepatitis C fell by 76%.
The Sierra Harm Reduction Coalition wanted to keep those same diseases in check in California. The tiny nonprofit got approval from the state to deliver syringes in El Dorado County to prevent the spread of life-threatening illnesses.
Yet when the program was discussed at a December meeting of the county’s Board of Supervisors, the success story in Indiana held little sway. Faced with complaints about discarded needles and overdose deaths, the supervisors voted to prohibit syringe programs in the county’s unincorporated areas.
“These programs may work in other parts of California and throughout the United States, although I have my doubts,” Sheriff Jeff Leikauf said at the meeting. “El Dorado County does not want or need these types of programs.”
El Dorado is among a growing number of California communities that have banned syringe programs, testing the state’s power and political will to defend them as a public health strategy. It is part of a broader pushback against “harm reduction” — the practical philosophy of trying to reduce the negative effects of drug use — as overdose deaths have soared.
Now California is fighting back. In a recently filed lawsuit, the Department of Public Health argued that local ordinances prohibiting syringe programs in El Dorado County were preempted by state law, making them unenforceable.
The state is seeking a court order telling El Dorado County and the city of Placerville, its county seat, to stop enforcing their bans and allow syringe programs to resume.
An El Dorado County spokesperson said Monday that the county does not comment on pending legal issues. Its district attorney, however, said he was outraged to learn of the lawsuit, saying that state leaders were “seeking to impose the normalization of hardcore drug use.”
“Don’t come into our county and double down on your failed policy,” El Dorado County Dist. Atty. Vern Pierson said in a statement. “Allowing addicts to use fentanyl and other hardcore drugs is exactly what has caused other California counties to experience a death rate that is out of control and getting worse.”
Mona Ebrahimi, the city attorney for Placerville, said the city had put a 45-day temporary moratorium in place “to study the ongoing effects of syringe service programs in the city.”
“The city wants to protect the health, safety and welfare of its residents,” Ebrahimi said.
The California Department of Public Health has long endorsed handing out sterile syringes as a proven way to prevent dangerous infections from running rampant when people share contaminated syringes. Researchers have linked syringe programs with a roughly 50% reduction in HIV and hepatitis C.
“It sounds crazy: ‘Wait, you want to give out the tools to people to do this thing that we all agree is a bad idea?’” said Peter Davidson, a medical sociologist at UC San Diego. But it works, said Davidson, who called the programs “probably the best studied public health intervention of the last 70 years.”
Public health officials also see them as a crucial way to reach people who use drugs and link them to addiction and overdose-prevention services. In Seattle, for instance, researchers found that injection drug users who started going to a needle exchange were five times more likely to enter drug treatment than those who never went.
Signs direct visitors to the syringe-exchange program at the Austin Community Outreach Center in Austin, Ind., in 2015. The program was set up to curb an outbreak of HIV among people who injected drugs.
(Darron Cummings / Associated Press)
And in California, harm reduction groups have been particularly effective in getting Narcan — a nasal spray that can reverse opioid overdoses — into the hands of people who need it.
It’s “hugely important to reduce overdose in the community, and these are the programs that do that,” said Barrot Lambdin, a health policy fellow at RTI International who studies the implementation of health interventions.
Yet leaders in some cities and counties have strenuously rejected the health benefits of syringe programs.
In El Dorado County, local leaders asserted that the efforts of the Sierra Harm Reduction Coalition had not “meaningfully reduced” HIV or hepatitis C cases since its syringe program began four years ago and said the free needles were ramping up the risk of deadly overdoses, which they argued were a bigger threat.
The El Dorado County Courthouse in Placerville, Calif.
(Max Whittaker / For The Times)
Alessandra Ross, a harm reduction expert at the California Department of Public Health, disputed such arguments in a letter to county officials. Ross pointed out that in just one year, the coalition handed out more than 2,200 doses of medication to reverse opioid overdoses, saving at least 421 lives. Without the group’s efforts, she wrote, “El Dorado County could have potentially lost more than ten times as many people to overdose.”
Under state law, the California Department of Public Health has the authority to approve syringe programs anywhere that deadly or disabling infections might spread through used needles, “notwithstanding any other law” that might say otherwise.
The agency argued that the “significant state and public interest in curtailing the spread of HIV, hepatitis, and other bloodborne infections extends to every jurisdiction in the state, especially since Californians travel freely throughout the state.”
After El Dorado County prohibited syringe services in unincorporated areas, the state public health department adjusted its authorization for the Sierra Harm Reduction Coalition program, limiting its operations to Placerville. In the court filing, the agency said it made the change out of concern for the coalition’s staff and volunteers, who could be at risk of arrest if they provided syringes in the unincorporated areas.
The nonprofit said when it stopped providing syringes outside of Placerville city limits, roughly 40% of its clients were cut off. In February, Placerville city officials passed their own urgency ordinance banning syringe programs for 45 days, exempting needle provision at health facilities.
Ebrahimi, its city attorney, said officials took that step “after CDPH concentrated their use by authorizing them only in Placerville and nowhere else in the county.”
The Sierra Harm Reduction Coalition stopped providing syringes in Placerville as well, according to the state lawsuit. The coalition did not respond Monday to requests for comment on the suit.
El Dorado County and Placerville are not alone: A wave of local bans went into effect last year in Placer County after a harm reduction group from Sacramento sought state approval to hand out clean syringes. The county’s sheriff and its probation chief said in a letter to the state that the syringe program proposed by Safer Alternatives thru Networking and Education, or SANE, would “promote the use of addicting drugs” and lead to more “dirty needles discarded recklessly in our parks.”
The Placer County Board of Supervisors voted unanimously to ban syringe programs in its unincorporated areas. Cities including Auburn, Loomis and Rocklin banned them too.
“We are the ones who should make these kinds of decisions,” then-Mayor Alice Dowdin Calvillo said at a September meeting of the Auburn City Council, “and not allow the state to just bully us.”
Public health researchers stress that studies have found that free needle programs do not increase crime or drug use, or worsen syringe litter. Yet as much of Placer County became a no-go zone, SANE withdrew its application for a syringe program there.
“Our political processes are not well set up for us to make reasoned, scientifically sound judgments about public health,” said Ricky Bluthenthal, a USC sociologist whose research has documented the effectiveness of syringe programs. It doesn’t help that “the populations at risk are often marginalized or not politically active.”
Our political processes are not well set up for us to make reasoned, scientifically sound judgments about public health.
— Ricky Bluthenthal, a USC sociologist who studies syringe programs
The California Department of Public Health declined to address whether it planned to challenge local bans on syringe programs elsewhere in the state, saying it “cannot comment on active litigation strategy.”
Syringe programs have long faced public skepticism: In a 2017 survey, only 39% of U.S. adults said they supported legalizing them in their communities.
Experts say the programs have faced increasing jeopardy as public concern wanes about the threat of HIV and frustration swells over other problems like soaring numbers of overdose deaths and the spread of homeless encampments. Even in Indiana’s Scott County, local leaders voted three years ago to shutter its needle exchange.
Clashes are also arising because programs are making moves into new parts of California, bolstered in some cases by state funding. California officials also have taken steps to help syringe programs overcome local opposition, including exempting them from review under the California Environmental Quality Act.
“It’s not surprising that cities and counties are motivated to protect the public health and safety of their residents through whatever tools they have at their disposal,” said attorney David J. Terrazas, who represented a group that successfully sued to overturn state approval of a syringe program in Santa Cruz County.
In that case, a state appeals court ruled last year that the California Department of Public Health conducted an insufficient review of a program run by the Harm Reduction Coalition of Santa Cruz County. The department didn’t do enough to consult with law enforcement agencies in the area, among other shortcomings, the court said.
Although the state health department had considered some comments from law enforcement, “it never engaged with them directly about their concerns,” the appeals court concluded. Internal records showed department staff had decided not to respond to some of their comments and called one police chief an “imbecile.”
Terrazas said local officials are best poised to know what works for their communities. But Denise Elerick, founder of the Harm Reduction Coalition of Santa Cruz County, argued it made no sense for law enforcement to hold sway in public health decisions.
“We wouldn’t consult with them on what to do about COVID,” Elerick said.
A bag is filled with boxes of Narcan nasal spray, one of several harm-reduction supplies distributed to people living on the street in Los Angeles.
(Francine Orr / Los Angeles Times)
Weeks after the court ruling, the state health department rolled back its approval for a syringe program in Orange County that would have been run by the Santa Ana-based Harm Reduction Institute, saying it wanted to consult more with local officials.
The decision was celebrated by city leaders in Santa Ana, who had banned syringe programs in 2020 and sharply opposed efforts to restart one. At a recent meeting, interim city manager Tom Hatch said a previous program was “an epic failure” that left its downtown littered with used syringes.
Orange County is currently the most populous county in the state without any syringe services programs — to the alarm of health researchers who found that syringe reuse increased after a local program was shut down.
The Santa Cruz court ruling was also invoked by the Santa Monica City Council, which directed city officials to investigate how Los Angeles County came to approve a program run by the Venice Family Clinic. That program sends outreach workers into Santa Monica parks once a week to offer clean syringes, Narcan and other supplies and connect people with healthcare, including for addiction.
Devon O’Malley, left, a harm reduction case manager with the Venice Family Clinic, hands out Narcan to Ken Newark at Tongva Park in Santa Monica.
(Mel Melcon / Los Angeles Times)
Critics want the program to relocate indoors, which they say would better protect parkgoers from discarded syringes. In addition, “if someone has to walk inside, there’s a chance for counselors to suggest strongly that it’s time for them to get off the drugs,” said Santa Monica Mayor Phil Brock, who wants the city to formally express its opposition to the program. “We can’t just facilitate their demise.”
Last month, a group called the Santa Monica Coalition filed suit to get L.A. County to halt the program it approved, saying it should instead be in a government building.
But Venice Family Clinic staffers said unhoused people can be reluctant to leave behind their belongings to go elsewhere. Even offering services out of a van reduced participation, said Arron Barba, director of the clinic’s Common Ground program.
“Bringing the service directly to the people is what we know works,” Barba said.
For the last few years, the Marine Mammal Center has been testing any patients with bird-flu-like symptoms, which include respiratory and neurological problems, for the virus.
California lawmakers are taking aim at proposed rules to implement a state law aimed at curbing plastic waste, saying the draft regulations proposed by CalRecycle undermine the letter and intent of the legislation.
In a letter to Gov. Gavin Newsom and two of his top administrators, the lawmakers said CalRecycle exceeded its authority by drafting regulations that don’t abide by the terms set out by the law, Senate Bill 54.
“While we support many changes in the current draft regulations, we have identified several provisions that are inconsistent with the governing statute … and where CalRecycle has exceeded its authority under the law,” the lawmakers wrote in the letter to Newsom, California Environmental Protection agency chief Yana Garcia, and Zoe Heller, director of the state’s Department of Resources Recycling and Recovery, or CalRecycle.
The letter, which was written by Sen. Catherine Blakespear (D-Encinitas) and Sen. Benjamin Allen (D-Santa Monica), was signed by 21 other lawmakers, including Sen. John Laird (D-Santa Cruz) and Assemblymembers Al Muratsuchi (D-Rolling Hills Estates) and Monique Limón (D-Goleta).
CalRecycle submitted informal draft regulations two weeks ago that are designed to implement the law, which was authored by Allen, and signed into law by Newsom in 2022.
The lawmakers’ concerns are directed at the draft regulations’ potential approval of polluting recycling technologies — which the language of the law expressly prohibits — as well as the document’s expansive exemption for products and packaging that fall under the purview of the U.S. Department of Agriculture and the Food and Drug Administration.
The inclusion of such blanket exemptions is “not only contrary to the statute but also risks significantly increasing the program’s costs,” the lawmakers wrote. They said the new regulations allow “producers to unilaterally determine which products are subject to the law, without a requirement or process to back up such a claim.”
Daniel Villaseñor, a spokesman for the governor, said in an email that Newsom “was clear when he asked CalRecycle to restart these regulations that they should work to minimize costs for small businesses and families, and these rules are a step in the right direction …”
At a workshop held at the agency’s headquarters in Sacramento this week, CalRecycle staff responded to similar criticisms, and underscored that these are informal draft regulations, which means they can be changed.
“I know from comments we’ve already been receiving that some of the provisions, as we have written them … don’t quite come across in the way that we intended,” said Karen Kayfetz, chief of CalRecycle’s Product Stewardship branch, adding that she was hopeful “a robust conversation” could help highlight areas where interpretations of the regulations’ language differs from the agency’s intent.
“It was not our intent, of course, to ever go outside of the statute, and so to the extent that it may be interpreted in the language that we’ve provided, that there are provisions that extend beyond … it’s our wish to narrow that back down,” she said.
These new draft regulations are the expedited result of the agency’s attempt to satisfy Newsom’s concerns about the law, which he said could increase costs to California households if not properly implemented.
Newsom rejected the agency’s first attempt at drafting regulations — the result of nearly three years of negotiations by scores of stakeholders, including plastic producers, package developers, agricultural interests, environmental groups, municipalities, recycling companies and waste haulers — and ordered the waste agency to start the process over.
Critics say the new draft regulations cater to industry and could result in even higher costs to both California households, which have seen large increases in their residential waste hauling fees, as well as to the state’s various jurisdictions, which are taxed with cleaning up plastic waste and debris clogging the state’s rivers, highways, beaches and parks.
The law is molded on a series of legislative efforts described as Extended Producer Responsibility laws, which are designed to shift the cost of waste removal and disposal from the state’s jurisdictions and taxpayers to the industries that produce the waste — theoretically incentivizing a circular economy, in which product and packaging producers develop materials that can be reused, recycled or composted.
As promised, federal health officials have dropped longstanding recommendations that healthy children and healthy pregnant women should get the COVID-19 vaccines.
“The COVID-19 vaccine schedule is very clear. The vaccine is not recommended for pregnant women. The vaccine is not recommended for healthy children,” the U.S. Department of Health and Human Services said in a post on X on Friday.
In formal documents, health officials offer “no guidance” on whether pregnant women should get the vaccine, and ask that parents talk with a healthcare provider before getting the vaccine for their children.
The decision was done in a way that is still expected to require insurers to pay for COVID-19 vaccines for children should their parents still want the shots for them.
The new vaccine guidelines were posted to the website of the U.S. Centers for Disease Control and Prevention late Thursday.
The insurance question
It wasn’t immediately clear whether insurers will still be required under federal law to pay for vaccinations for pregnant women.
The Trump administration’s decision came amid criticism from officials at the nation’s leading organizations for pediatricians and obstetricians. Some doctors said there is no new evidence to support removing the recommendation that healthy pregnant women and healthy children should get the COVID vaccine.
“This situation continues to make things unclear and creates confusion for patients, providers and payers,” the American College of Obstetricians and Gynecologists said in a statement Friday.
Earlier in the week, the group’s president, Dr. Steven Fleischman, said the science hasn’t changed, and that the COVID-19 vaccine is safe during pregnancy, and protects both the mom-to-be and their infants after birth.
“It is very clear that COVID-19 infection during pregnancy can be catastrophic,” Fleischman said in a statement.
Dr. Susan Kressly, president of the American Academy of Pediatrics, criticized the recommendation change as being rolled out in a “conflicting, confusing” manner, with “no explanation of the evidence used to reach their conclusions.”
“For many families, the COVID vaccine will remain an important way they protect their child and family from this disease and its complications, including long COVID,” Kressly said in a statement.
Some experts said the Trump administration should have waited to hear recommendations from a committee of doctors and scientists that typically advises the U.S. Centers for Disease Control and Prevention on immunization recommendations, which is set to meet in late June.
California’s view
The California Department of Public Health on Thursday said it supported the longstanding recommendation that “COVID-19 vaccines be available for all persons aged 6 months and older who wish to be vaccinated.”
The changes come as the CDC has faced an exodus of senior leaders and has lacked an acting director. Typically, as was the case during the first Trump administration and in the Biden administration, it is the CDC director who makes final decisions on vaccine recommendations. The CDC director has traditionally accepted the consensus viewpoint of the CDC’s panel of doctors and scientists serving on the Advisory Committee on Immunization Practices.
Even with the longstanding recommendations, vaccination rates were relatively low for children and pregnant women. As of late April, 13% of children, and 14.4% of pregnant women, had received the latest updated COVID-19 vaccine, according to the CDC. About 23% of adults overall received the updated vaccine, as did 27.8% of seniors age 65 and over.
The CDC estimates that since October, there have been 31,000 to 50,000 COVID deaths and between 270,000 and 430,000 COVID hospitalizations.
Here are some key points about the CDC’s decision:
New vaccination guidance for healthy children
Previously, the CDC’s guidance was simple: everyone ages 6 months and up should get an updated COVID vaccination. The most recent version was unveiled in September, and is officially known as the 2024-25 COVID-19 vaccine.
As of Thursday, the CDC, on its pediatric immunization schedule page, says that for healthy children — those age 6 months to 17 years — decisions about COVID vaccination should come from “shared clinical decision-making,” which is “informed by a decision process between the healthcare provider and the patient or parent/guardian.”
“Where the parent presents with a desire for their child to be vaccinated, children 6 months and older may receive COVID-19 vaccination, informed by the clinical judgment of a healthcare provider and personal preference and circumstances,” the CDC says.
The vaccine-skeptic secretary of Health and Human Services, Robert F. Kennedy Jr., contended in a video posted on Tuesday there was a “lack of any clinical data to support the repeat booster strategy in children.”
However, an earlier presentation by CDC staff said that, in general, getting an updated vaccine provides both children and adults additional protection from COVID-related emergency room and urgent care visits.
Dr. Peter Chin-Hong, a UC San Francisco infectious diseases expert, said he would have preferred the CDC retain its broader recommendation that everyone age 6 months and up get the updated vaccine.
“It’s simpler,” Chin-Hong said. He added there’s no new data out there that to him suggests children shouldn’t be getting the updated COVID vaccine.
A guideline that involves “shared decision-making,” Chin-Hong said, “is a very nebulous recommendation, and it doesn’t result in a lot of people getting vaccines.”
Kressly, of the American Academy of Pediatrics, said the shared clinical decision-making model is challenging to implement “because it lacks clear guidance for the conversations between a doctor and a family. Doctors and families need straightforward, evidence-based guidance, not vague, impractical frameworks.”
Some experts had been worried that the CDC would make a decision that would’ve ended the federal requirement that insurers cover the cost of COVID-19 vaccines for children. The out-of-pocket cost for a COVID-19 vaccine can reach around $200.
New vaccine guidance for pregnant women
In its adult immunization schedule for people who have medical conditions, the CDC now says it has “no guidance” on whether pregnant women should get the COVID-19 vaccine.
In his 58-second video on Tuesday, Kennedy did not explain why he thought pregnant women should not be recommended to get vaccinated against COVID-19.
Chin-Hong, of UCSF, called the decision to drop the vaccination recommendation for pregnant women “100%” wrong.
Pregnancy brings with it a relatively compromised immune system. Pregnant women have “a high chance of getting infections, and they get more serious disease — including COVID,” Chin-Hong said.
A pregnant woman getting vaccinated also protects the newborn. “You really need the antibodies in the pregnant person to go across the placenta to protect the newborn,” Chin-Hong said.
It’s especially important, Chin-Hong and others say, because infants under 6 months of age can’t be vaccinated against COVID-19, and they have as high a risk of severe complications as do seniors age 65 and over.
Not the worst-case scenario for vaccine proponents
Earlier in the week, some experts worried the new rules would allow insurers to stop covering the cost of the COVID vaccine for healthy children.
Their worries were sparked by the video message on Tuesday, in which Kennedy said that “the COVID vaccine for healthy children and healthy pregnant women has been removed from the CDC recommended immunization schedule.”
By late Thursday, the CDC came out with its formal decision — the agency dropped the recommendation for healthy children, but still left the shot on the pediatric immunization schedule.
Leaving the COVID-19 vaccine on the immunization schedule “means the vaccine will be covered by insurance” for healthy children, the American Academy of Pediatrics said in a statement.
How pharmacies and insurers are responding
There are some questions that don’t have immediate answers. Will some vaccine providers start requiring doctor’s notes in order for healthy children and healthy pregnant women to get vaccinated? Will it be harder for children and pregnant women to get vaccinated at a pharmacy?
In a statement, CVS Pharmacy said it “follows federal guidance and state law regarding vaccine administration and are monitoring any changes that the government may make regarding vaccine eligibility.” The insurer Aetna, which is owned by CVS, is also monitoring any changes federal officials make to COVID-19 vaccine eligibility “and will evaluate whether coverage adjustments are needed.”
Blue Shield of California said it will not change its practices on covering COVID-19 vaccines.
“Despite the recent federal policy change on COVID-19 vaccinations for healthy children and pregnant women, Blue Shield of California will continue to cover COVID-19 vaccines for all eligible members,” the insurer said in a statement. “The decision on whether to receive a COVID-19 vaccine is between our member and their provider. Blue Shield does not require prior authorization for COVID-19 vaccines.”
Under California law, health plans regulated by the state Department of Managed Health Care must cover COVID-19 vaccines without requiring prior authorization, the agency said Friday. “If consumers access these services from a provider in their health plan’s network, they will not need to pay anything for these services,” the statement said.
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