Indiana recently passed legislation allowing local governments to establish syringe exchanges. While the effectiveness of syringe exchange programming is established, there is a dearth of studies about associated policy adoption and implementation. This study documents the experiences of 24 Indiana counties engaged in the process of establishing syringe exchange programming under new state law. A mixed method, qualitative, exploratory case study was conducted from May 2015 to April 2016. We observed rapid and widespread policy adoption interest, and yet counties reported significant policy ambiguity, epidemiologic and resource capacity issues. The emergence of health commons involving information and tangible resource sharing networks allowed institutional rearrangement in the midst of resource scarcity; however, such rearrangement appeared to be a central threat to policy adoption and implementation given state structural barriers. The emerging commons could be a critical policy success factor, as it would achieve efficiencies not possible in the current resource environment, and can help achieve institutional rearrangement for the improvement of population health. Several recommendations for improvement are offered.