Background: Opioid use has reached epidemic proportions in rural communities in the United States and injection of drugs is commonly used. As a result of shared or reusing needles and syringes, the risk for contracting blood-borne diseases is significantly increased. Rural areas face many social and attitudinal barriers regarding syringe exchange programs (SEPs). Objective: This article describes national trends for drug injection problems in rural areas and discusses effectiveness of needle and SEPs as a harm reduction healthcare policy. Ethical and practical considerations in the implementation of SEPs are also presented. Method: The rehabilitation literature was reviewed on trends in substance abuse and intravenous (IV) drug use in rural areas to identify the status and need for SEPs to address risk factors of infectious diseases resulting from needle sharing and reusing of needles. Findings: IV drug use in rural communities has reached epidemic proportions with resulting dramatic increases in hepatitis C and B and incidence of HIV. Yet, many rural communities continue to object to the implementation of SEPs due to fears that such programs will increase drug use and crime in the community. Conclusion: IV drug use is a critical public health issue for users and non-IV users in rural communities, and is increasingly becoming an issue about which rural rehabilitation counselors will need to be informed. For the sake of public health, SEPs should be recognized as an economical, ethical, and effective factor in the larger response to the epidemic of IV drug use in rural America.