In 2022, physician Quang Pham approached the chief of medicine of a South Carolina hospital system with a logistical request. Could Pham’s friend, Marc Burrows, park his small white bus outside Pham’s clinic? Burrows, a licensed social worker, had made a name for himself dispensing clean syringes, naloxone and fentanyl test strips to drug users; his nonprofit Challenges Inc. effectively introduced harm reduction to the politically conservative Upstate.
Pham sensed a benefit in the bus’s proximity. Intravenous drug users could acquire “safer use supplies” from Burrows, who could point them to Pham for HIV and hepatitis C treatment. The idea was to parlay street outreach into clinical care — for viruses transmitted through shared needles and opioid use disorder.
It wasn’t an untested approach. Syringe programs can halve incidences of HIV and hepatitis C, per the federal Centers for Disease Control and Prevention. An oft-cited study shows new participants in such programs are five times more likely to enter drug treatment than nonparticipants.
Decades of research buttressed Pham’s proposal. But the chief of medicine denied his request.
Pham said the official feared incurring fines for associating with a syringe program. Such penalties are possible in South Carolina, where handing out clean needles as a harm-reduction tactic is neither explicitly outlawed nor expressly sanctioned. Per state law, possession and distribution of drug paraphernalia is a civil offense. Yet noticeably absent in the code’s list of outlawed devices — from bongs to roach clips to cocaine spoons — are syringes.
“It’s kind of a gray area,” Burrows said. “There’s nothing against it, and there’s nothing for it.”
Once mostly confined to the coasts, syringe programs have cropped up in the Palmetto State, where drug overdose deaths killed 2,168 people in 2021. Yet South Carolina’s silence on those programs’ legality can hamper harm reduction, providers say; it’s harder to recruit volunteers, score grants and expand services without a syringe law on the books, they argue, even as the stigma shrouding needle programs has partially thinned.
Burrows recently argued as much before the Senate Medical Affairs Committee. Dressed in a gray suit, seated before a panel of lawmakers, he endorsed a Republican-sponsored proposal to legalize safer syringe programs. The panel voted 5-2 on March 6 to send the bill to the full committee, though mere days remain in the 2024 legislative session.
The North American Syringe Exchange Network maintains a map of harm-reduction programs across the country. Sites proliferate in the Pacific Northwest, where activists began supplying syringes to drug users as early as 1988 to curtail the spread of AIDS. The Northeast and Appalachia, one epicenter of the opioid epidemic, are dotted with programs, too. Wide swaths of the Midwest, Southwest and Southeast are mostly absent of syringe programs.
Zoom in on South Carolina, and four harm-reduction organizations surface: two in the Upstate, two in Myrtle Beach. One of those coastal programs is Fyrebird Recovery, which founder A’zhane Powell describes as a one-stop shop for vulnerable people in Horry County. The coastal area led the state in overdose deaths in 2021. A year later, Powell formed Fyrebird, which provides everything from fresh produce to clean needles to treatment referrals.
Starting the organization wasn’t easy, she said. Powell watched one woman try to replicate her Philadelphia-based syringe program in Myrtle Beach, only to leave when opposition mounted. Powell’s windfall came in the form of 2,000 needles — old insulin syringes donated by a Virginia-based harm-reduction group. She bundled the sharps in tote bags, drove back to South Carolina and started distributing the supplies at a bus depot from the trunk of her car.
A wending line of people obtaining free syringes attracted considerable attention in the touristy Grand Strand, Powell recalled. But it wasn’t until Fyrebird moved into a storefront on Broadway Street that the group encountered serious challenges. A month and a half after opening, the city of Myrtle Beach mailed the organization a cease-and-desist letter, local outlets reported. At issue was an alleged zoning violation; according to a city official, Fyrebird was a “social welfare organization” in an area zoned for “art and innovation.” It needed to close immediately.
“We were targeted and had to shut down shop,” Powell said, adding that about 300 people patronized Fyrebird at the time. Maintaining connections with them — some regulars move every three days — while looking for a new place involved “a lot of scrambling,” she added.
The group eventually found an 1,800-square-foot space. It’s farther from a “hot spot” where drug users tend to congregate, so volunteers often visit encampments to hand out supplies — a cornerstone of what harm reductionists describe as “meeting people where they’re at.”
That might not mean treatment — at least not right now. Better to equip people with sterile supplies than impose care through the criminal justice system, some advocates argue. A body of evidence shows incarcerating people for low-level drug crimes doesn’t significantly slash substance abuse or overdose deaths.
Operating in South Carolina — one of six states with paraphernalia laws that are mum on needle distribution — means Powell must carefully navigate the practice’s legal gray area. That includes avoiding street names for supplies. It’s not uncommon for someone to ask for “rigs,” only for a volunteer to confirm that Fyrebird does carry “hypodermic needles.” Such wording choices can reduce the risk of recrimination, Powell said.
Despite the challenges, she’s a firm believer in harm reduction. She’s witnessed people flock to Fyrebird for syringes, then seek treatment for hepatitis C or get on PrEP to prevent HIV.
Burrows’ group has evolved, too, from an impromptu car operation to a fully stocked bus, with Prisma Health partnerships to boot. He recently applied for money from the South Carolina Opioid Recovery Fund — settlement money from opioid-related lawsuits dispensed to states for treatment and prevention. South Carolina’s arm of the initiative enumerates several approved uses for such funds. Among the greenlit approaches? Syringe service programs.
“It’s almost like the left hand isn’t talking to the right hand,” Burrows said of the discrepancy between syringe programs’ legal ambiguity and their approval for settlement fund recipients.
Resolving that contradiction is one reason Sen. Tom Davis sponsored a bill to formally authorize syringe programs. The Beaufort Republican said the benefits of these programs are threefold: They put recipients on a path to treatment, cut viral infection rates and slash overall health care costs.
But not all lawmakers agree with Davis, who’s also leading the effort to legalize medical marijuana. Sen. Richard Cash said he supports faith-based recovery programs; to the Anderson County Republican, syringe programs send a “mixed message.”
“To tell them drugs are poison, you shouldn’t be injecting it into your body, but here’s a clean needle if you’re going to do it: at best, that’s a mixed message,” Cash said. “At worst, it’s enabling someone to do something you’re trying to … help them not to do.”
Cash acknowledged that syringe programs have produced “success stories.” But he remains skeptical of initiatives that draw large numbers of drug users to one location. “You’re going to find out that nobody wants that in their backyard,” he said. Similar complaints have dogged harm-reduction centers in San Francisco, Portland and Vancouver, with some locations shutting down amid resident concerns about safety and scattered paraphernalia.
Pham, the physician, recently moved to Virginia, where state law explicitly authorizes syringe programs. It’s a different climate than South Carolina, where the chief of medicine forbade Challenges Inc. from setting up near Pham’s clinic, forcing Burrows to park his bus outside a hotel; that medical official, Pham recalls, told the physician that if he wanted a more convenient arrangement, he should go to the Statehouse and advocate for a syringe service law himself.
Pham has since moved, but Burrows recently traveled to Columbia to advocate for that proposal. It’s at least the third attempt to formally authorize syringe programs in South Carolina; similar bills introduced in 2020 and 2021 stalled in committee.
