The Strategy Says Test Strips Save Lives. The Letter Underneath It Says Don't Pay For Them.

Paul LaKosky has run needle exchanges long enough that he doesn’t lead with the needles anymore. “While syringe exchange is the basis of what we do, it’s the least of what good syringe exchange does,” LaKosky told Roll Call this July — the wound care, the naloxone kits pressed into someone’s hand on their way out the door, the referral that turns into a phone call that turns into a bed. LaKosky runs the Dave Purchase Project and the Tacoma Needle Exchange, and heads the North American Syringe Exchange Network. This year he’s spent as much time explaining why his program might not survive as he has running it.

If you have ever used a fentanyl test strip before you dosed, or watched someone hand one to a friend, you already know exactly what a program like his is worth. You do not need the modeling study to tell you. In harm reduction community threads this year, people who rely on programs like the Tacoma exchange describe the same thing over and over, in different words: the test strip that told them not to use alone that night, the syringe program worker who noticed a wound before it turned into an ER visit, the naloxone kit that sat in a bag for months until the one night it mattered. None of that shows up in a funding line item. All of it shows up in the mortality math below.

The federal government just spent $44 billion telling you these tools work, then made it harder for the people who hand them to you to keep the lights on.

That’s the sentence this week’s 2026 National Drug Control Strategy is built to avoid saying out loud, and it’s the sentence you need to understand if you work in this field, run a program in it, or are trying to stay alive inside it.

Two documents, five weeks apart, telling you opposite things

The Strategy, released by the Office of National Drug Control Policy — the office that coordinates $44 billion across 19 federal agencies — names naloxone distribution and drug-checking technology as core public health tools in the fight against overdose. Fentanyl test strips get an explicit nod. So does wider naloxone access. The document pairs that with an enforcement build-out: AI-assisted screening for illicit drugs at ports of entry, wastewater testing to track drug use nationwide, and a heavy emphasis on faith-based recovery programming.

Five weeks earlier, on April 24, SAMHSA sent grantees a letter with a different instruction. STAT News reported that the agency told programs receiving federal dollars they could no longer use that money to buy fentanyl, xylazine, or medetomidine test strips for people who use drugs — the exact tool the Strategy would go on to praise a month later. A second letter, issued the same day, warned grantees against supporting methadone and buprenorphine use without pairing it with other services, writing that medication for opioid use disorder should function as “part of the pathway to long-term recovery” and “not as a default sentence to life-long medication use” — a policy stance dressed up as clinical guidance, delivered to the people who prescribe FDA-approved medication every day. SSDP’s analysis of both letters calls it what it is: a “clear shift away from harm reduction,” in SAMHSA’s own words, arriving as formal guidance rather than legislation, which means it happened without a floor vote and can happen again just as fast.

Regina LaBelle watched both documents land. She ran the White House drug policy office under Biden and now directs the Addiction and Public Policy Initiative at Georgetown. Her read, given to KFF Health News: “It is the height of rhetoric over reality to champion a tool while simultaneously cutting off the funding used to acquire it.” Yngvild Olsen, a physician and former SAMHSA policy lead now consulting at Manatt Health, described the cumulative effect on providers as “whiplash” — a “sense of instability” so persistent that, she told KFF, it’s now “hard to really imagine when now people may have to pay for it themselves.” Libby Jones of the Global Health Advocacy Incubator was more direct about the through-line: there are pieces of the Strategy “we would agree with and that we fully support,” she said — the problem is the “disconnects in what the strategy says is important and then what they’re actually going to fund.”

She ran the White House drug policy office under Biden and now directs the Addiction and Public Policy Initiative at Georgetown.

The money backs up the disconnect. SAMHSA’s Center for Substance Abuse Prevention absorbed roughly a $220 million cut. The Drug-Free Communities program lost about $40 million. SAMHSA’s own workforce is down by roughly half from where it stood at the start of last year, and CDC’s overdose-response staff has shrunk by about a quarter. An agency that size, doing that much less, is the agency the Strategy is now asking to distribute more naloxone and more test strips than ever.

What “policy whiplash” costs, counted in bodies

It would be easy to read all of this as a Washington paperwork story — two offices not talking to each other, a contradiction that gets ironed out in the next budget cycle. It isn’t. In June, researchers led by Kirk Fetters modeled what happens to the roughly 3.7 million people in the U.S. who inject drugs under different federal funding-disruption scenarios for syringe service programs, publishing in JAMA Network Open. In their mildest disruption scenario, they projected about 1,100 additional deaths from all causes and 500 excess overdose deaths over five years. In their worst-case scenario — the one that assumes the kind of abrupt, sustained funding collapse the past eight months have made look plausible rather than hypothetical — the number climbs to roughly 39,600 excess deaths, including 5,600 from overdose alone. That’s not a projection about test strips in isolation; syringe service programs are usually the only point of contact many people who inject drugs have with any part of the health system, the place where an HIV test happens, where a wound gets looked at before it becomes sepsis, where naloxone actually reaches a pocket instead of a supply closet.

Joshua Barocas, an infectious disease physician who studies these programs at the University of Colorado, put it plainly to Psychiatric News: “These harm-reduction services help keep people alive so they can enter treatment or recovery. Without them, more people die.” That is not an opinion competing with another opinion. It’s the finding.

Drew Gibson, who directs advocacy at AIDS United, described what that funding uncertainty looks like inside the programs themselves: staff who are, in his words, “really wondering how it is they’re going to be able to keep their doors open.” Programs don’t close all at once when this happens. They close a service line, then a satellite site, then their weekend hours, then their outreach van — each cut small enough that no single headline captures it, each cut removing one more reason for someone to come back next week.

We have watched this exact fight before

We have watched a government decide that a cheap thing keeping people alive sends the wrong message before, and we know how the story ends when the decision holds. In 1988, at the height of the AIDS epidemic, Congress banned the use of federal money to fund syringe exchange programs — the same year Dave Purchase, working without federal or state funding, without institutional backing, set up an unsanctioned table on a street corner in Tacoma and started handing out clean needles anyway, because he’d watched people around him die and decided the ban didn’t have to be the last word. That ban on federal dollars, in one form or another, held for the better part of three decades. Public health researchers spent those decades producing the same evidence, over and over, that syringe access reduces HIV and hepatitis C transmission without increasing drug use — evidence the federal funding rules simply declined to act on. The program Dave Purchase started with no money is the same organization Paul LaKosky now runs, and the argument he’s making in 2026 is, in its bones, the same argument Purchase was making in 1988: that people who use drugs deserve to survive long enough to have a chance at something else, and that withholding a cheap tool that keeps them alive because it might “send the wrong message” is a policy choice with a body count, not a neutral one.

That ban on federal dollars, in one form or another, held for the better part of three decades.

If you are reading this because you run a program, work the front desk of one, or are the person a program like this exists for, the practical floor under all of this has not moved: naloxone remains federally funded and legal to distribute in every state, fentanyl test strips are still legal to possess and distribute in the overwhelming majority of states even where federal dollars can no longer buy them, and syringe service programs that predate this funding fight — like LaKosky’s — are still open right now. If you run a treatment program and are weighing how to talk to your team about this, the plain-language version for a staff meeting is: the federal instruction has changed on what federal money can buy, not on what is legal, evidence-based, or clinically appropriate to do with other funding sources — worth confirming explicitly with your state health department this week, because “no longer federally reimbursable” gets misheard as “no longer allowed” inside organizations fast, and that misreading costs lives on its own.

The strategy document will get updated. The people it’s about won’t get a second draft.

Strategy documents get revised every few years, and this one likely will too, once the funding math becomes politically impossible to ignore or once the mortality data forces the next administration’s hand — it usually takes both. What doesn’t get revised is the person who needed the test strip on the specific day their program didn’t have one, or the syringe exchange that closed its outreach van in the gap between one guidance letter and the next Strategy release claiming to champion the thing it just definanced. Paul LaKosky is still showing up. The question this Strategy actually answers, whether or not it means to, is how much longer the federal government expects people like him to keep showing up without it.