More than test strips: what SAMHSA’s April 24 letter signals about the next chapter of harm reduction

On April 24, the Substance Abuse and Mental Health Services Administration sent grantees a single-page letter that does not change a law and does not rewrite a regulation, but does meaningfully alter what the federal government will pay for. Federally funded harm reduction programs may no longer use SAMHSA dollars to buy fentanyl, xylazine, or medetomidine test strips for distribution to people who use drugs; to provide sterile syringes, sterile pipes, sterile water, or saline; or to operate “overdose hotlines” — phone or text lines that someone can call before using alone, so a stranger on the other end can dial 911 if they go quiet.

A second paragraph in the same letter is getting less attention but is, in some ways, more consequential for the long arc. SAMHSA cautioned grantees that medications for opioid use disorder — methadone and buprenorphine — should not be a “default sentence to life-long medication use.” The agency framed MAT as part of a pathway to recovery, not as recovery itself. That is a posture, not a rule, but postures travel.

For organizations that already saw months of funding turbulence, the letter lands less like a surprise and more like a confirmation. The Kentucky Harm Reduction Coalition told CBS News that it lost a $400,000 grant and has roughly a month of test strip supply left at current distribution rates — 48,465 strips moved in the first quarter of fiscal year 2026 alone.

What the letter actually does — and does not — change

The letter is guidance to grantees about allowable uses of federal funds. It does not make any of these supplies illegal. State and local governments can still buy and distribute them, and many already do. Naloxone funding is explicitly preserved.

What changes is who pays. Programs operating on a SAMHSA grant or its state pass-through can no longer use those dollars for the listed items. They have to source another stream — opioid settlement money, county appropriation, state general funds, or philanthropy — to keep the same services running. In states with active settlement deployment and engaged county health departments, that backfill is more likely. In states without those infrastructures, the gap is harder to close.

Federal funds may also still be used for test strips when they are used by public health officials, law enforcement, medical workers, or “others who use them in professional settings” rather than by people who use drugs themselves. In practice, that distinction matters — a strip in a clinic supply closet does not have the same overdose-prevention impact as a strip in someone’s pocket — but it does keep some surveillance and clinical use cases funded.

Why this matters now, specifically

The letter arrives at a moment when the supply itself is becoming more dangerous, not less. The CDC’s April 2 health advisory on medetomidine — a veterinary tranquilizer 200 to 300 times more potent than xylazine — describes a contaminant whose opioid-mixed overdoses do not fully reverse with naloxone, and whose withdrawal is now severe enough that New York City issued a separate health advisory on the withdrawal syndrome alone. Detections of medetomidine in the National Forensic Laboratory Information System rose from 247 reports in 2023 to 8,233 in 2025 — a 33-fold increase in 24 months. Drug-checking tools are how people, programs, and clinicians find out what is in the supply.

At the same time, the overall overdose picture is improving. The CDC’s most recent provisional release puts U.S. overdose deaths at 70,231 for the 12 months ending November 2025 — a 15.9% year-over-year decline and the largest sustained drop in over a decade. Researchers debate the drivers; harm reduction infrastructure built and refined over the past five years is on most short lists.

overdose deaths at 70,231 for the 12 months ending November 2025 — a 15.9% year-over-year decline and the largest sustained drop in over a decade.

The risk of the present moment is that the supply shifts faster than the safety net.

What programs are doing on the ground

In Travis County, Texas, Central Health is expanding its naloxone vending machine network to 45 anonymous, 24-hour units between April and September, paid through county funds and opioid settlement dollars rather than SAMHSA grants. That model — local money, low-barrier access — is increasingly the template programs are pointing to.

In California, the CalRx state-pharmacy program continues to make naloxone available over the counter for $19 per twin-pack, reducing the per-dose cost and the dependency on grant pipelines.

In Arizona, the next Hikma settlement naloxone shipment — 6,599 units totaling 13,198 doses — is scheduled for September. AHCCCS continues its $776 million annual SUD allocation. Both of those streams are state-controlled and are not affected by the SAMHSA letter. The exposure is more pointed for harm-reduction programs that depend on State Opioid Response pass-through dollars to buy strips, syringes, and hotline staffing.

The MAT framing question

The “not a default sentence to life-long medication use” line in the SAMHSA letter is the part of this story that families are asking about. It does not change the DEA and HHS final rule extending telehealth buprenorphine prescribing through December 31, 2026. It does not change Medicaid reimbursement for methadone or buprenorphine. It does not change clinical guidelines from ASAM, SAMHSA’s TIP-63, or the WHO. What it changes is the rhetorical environment around long-term MAT, and that environment is what a person on bup for ten years hears when they read coverage of a federal letter.

For families: methadone and buprenorphine remain the most evidence-supported treatments for opioid use disorder. The relapse and mortality data on stopping them, especially abruptly, is consistent and stark. If a loved one is on either medication and stable, the right conversation to have is between them and their prescriber — not a conversation triggered by a federal posture statement.

Why this matters for people in recovery

Harm reduction is not separate from recovery. For many people, the small steps — knowing what is in front of them, having clean supplies, having someone to call before they use alone, having naloxone in the bathroom drawer — are the steps that keep them alive long enough to want something different. That is not contested in the clinical literature. What is being contested in 2026 is who pays for it.

If you are using right now and need test strips, sterile supplies, or naloxone, your local syringe service program, county public health department, or 211 line is the fastest route to what is available in your area. If you are a family member, the questions worth asking your loved one’s program right now are: where do you get your test strips from, who pays for them, and what is your plan if that source goes away?

We will continue tracking the federal funding picture — and the state and local responses backfilling it — as it develops.

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If you or someone you love is in immediate danger, call or text 988 (Suicide & Crisis Lifeline) or 911. If a loved one may be experiencing an overdose, call 911 and use naloxone if available. Naloxone is now available over the counter at most pharmacies.