The Trump administration is doubling down on its opposition to harm reduction services for people who use illicit drugs.
In an open letter on April 24, the federal agency overseeing addiction and mental health policy warned its grantees against using federal funds to buy harm reduction supplies including sterile syringes and pipes, or to distribute test strips for common drug supply adulterants like fentanyl, xylazine, and medetomidine.
In a second letter bearing the same date, the Substance Abuse and Mental Health Services Administration also warned against using certain addiction medications without accompanying support services. It wrote that medications including methadone and buprenorphine, which are shown to vastly reduce opioid overdose deaths, should be used as “part of the pathway to long-term recovery” but “not as a default sentence to life-long medication use.”
The dual letters, signed by acting SAMHSA leader Chris Carroll, follow a year-plus of chaos and confusion at the agency. Over 15 months after taking office, the Trump administration has yet to appoint a director. Its head count, which stood at roughly 900 at the start of the Trump administration, is now less than half that total. Even before it abruptly terminated and then reinstated thousands of grants in January, SAMHSA had cancelled roughly $1.7 billion in block grant funding and cut another $350 million in addiction and overdose prevention funding.
SAMHSA’s actions represent a return to standard drug policy fare for the Trump administration: promoting abstinence-first interventions, opposing harm reduction strategies, and viewing law enforcement as a primary tool in reducing drug-related harms. But it represents a pivot from a flurry of actions one week earlier: a move to promote psychedelics as treatments for mental health conditions and to reclassify medical marijuana to a lower tier of scheduled substances.
The harm reduction letter, in SAMHSA’s own words, underscored the Trump administration’s “clear shift away from harm reduction and practices that facilitate illicit drug use and are incompatible with federal law.”
The letter also made clear that it is against administration policy to publicly distribute test strips used to detect fentanyl, xylazine, and medetomidine to the public. It stressed, however, that federal funds can still be used for test strips to be used by public health officials, law enforcement, medical workers, and others who use them in professional settings.
Also banned: funding for “overdose hotlines” that allow people using drugs to communicate remotely with staff who can call 911 if they stop responding; sterile water or saline distributed to help users inject drugs hygienically; and other forms of paraphernalia that, in the administration’s view, “promote or facilitate drug use.” The letter encourages federal funds be used for naloxone, the overdose-reversal medication; sharps disposal kits; and testing and vaccination for infectious diseases like hepatitis and HIV.
The test strip policy represents a major shift from the Biden administration, which pushed test-strip distribution enthusiastically. “This will save lives by providing tools to identify the growing presence of fentanyl in the nation’s illicit drug supply,” Tom Coderre, then SAMHSA’s interim leader, said in April 2021 in a statement announcing that federal funds could be used to buy test strips.
The agency’s second new letter warns stakeholders against the use of medications used to treat opioid addiction without accompanying services, like psychosocial counseling and other “recovery support services.”
While the letter does not cast doubt on the effectiveness of methadone or buprenorphine, it appears to echo a trope that use of the medications does not constitute “true recovery.” While many addiction clinicians might prefer to provide counseling alongside medication, current standards of care do not support withholding medication from patients who decline other services.
The letters were released as thousands of addiction providers and researchers gathered in San Diego for the American Society of Addiction Medicine’s annual conference. At one point, the letter cited ASAM practice guidelines regarding use of medications for opioid use disorder. The document cited, however, appears to contradict the letter, stating that a “patient’s decision to decline psychosocial treatment or the absence of available psychosocial treatment should not preclude or delay pharmacotherapy, with appropriate medication management.”
The letter also encourages clinicians to discuss “at least annually” with patients whether they’d like to remain on medication. While there is little conclusive, specific data on the relationship between mortality and long-term medication treatment, studies show that, in general, longer treatment durations yield better outcomes.
“ASAM is continuing to carefully review the new Dear Colleague letters from SAMHSA and is prepared to engage with federal partners to ensure that national policies reflect evidence-based practices in addiction medicine,” Stephen Taylor, an addiction physician currently serving as ASAM’s president, said in a statement. “This includes maintaining access to [medications for opioid use disorder] when clinically appropriate.”
STAT’s coverage of chronic health issues is supported by a grant from Bloomberg Philanthropies. Our financial supporters are not involved in any decisions about our journalism.