The Strips That Won't Be Replaced

Shreeta Waldon, the executive director of the Kentucky Harm Reduction Coalition, got the email on the morning of April 25. It came from SAMHSA. Her organization was losing a $400,000 federal grant — one that had, in the first three months of fiscal year 2026 alone, put 48,465 fentanyl test strips into the hands of people using drugs in Kentucky. The message was terse and bureaucratic, as these things always are. It did not use the word “goodbye.” It didn’t need to.

By that weekend, Waldon had done the math. KHRC had roughly one month of operational reserves. After that, the strips — and the outreach workers who distributed them — would be gone. She told CBS News days later: “It doesn’t make sense. If we know this works, and we know people are dying, what is the argument?”

Nobody from SAMHSA called to explain.

The letter and what it said

The policy that ended Waldon’s grant had arrived one day before her email. On April 24, 2026, Christopher D. Carroll, SAMHSA’s acting principal deputy assistant secretary, sent a “Dear Colleague” letter to every organization receiving federal grants. The letter was a single page. It was unambiguous: effective immediately, federal dollars could not be used to purchase or distribute fentanyl test strips, xylazine test strips, medetomidine test strips, sterile syringes, or “any supplies that facilitate illegal drug use.”

Carroll cited President Trump’s executive order from July 2025, “Ending Crime and Disorder on America’s Streets,” which declared SAMHSA funding cannot support programs that “only facilitate illegal drug use.” The letter added a phrase worth reading twice: “This letter outlines the Agency’s clear shift away from harm reduction and practices that facilitate illicit drug use and are incompatible with Federal laws.”

One exception survived: test strips used by “public health officials, law enforcement, medical workers, and others who use them in professional settings” remained permissible. The strips could still exist in the hands of agencies and officials. They simply could no longer reach the people who use drugs — the people who die from undetected fentanyl.

Senator Edward Markey wrote to Carroll on May 8, asking for the evidence basis that informed the policy decision. As of this writing, SAMHSA has not publicly responded.

What test strips actually do

To understand what this policy removes, it helps to understand what a fentanyl test strip actually is. They are small, inexpensive paper strips — roughly the size of a home pregnancy test — that detect the presence of fentanyl in a drug sample. A person dissolves a small amount of residue in water, dips the strip, waits two minutes, and reads the result. One line: fentanyl present. Two lines: not detected.

In a drug supply where illicitly manufactured fentanyl contaminates not just heroin but cocaine, methamphetamine, counterfeit pills, and MDMA — any substance that passes through a supply chain — that two-minute result is the difference between a person making an informed decision and a person who dies without knowing what they took.

A 2023 study in the International Journal of Drug Policy followed 553 people who used test strips over six months. It found that 68% of those who received a fentanyl-positive result changed their behavior in response: they used less, used with someone present, used more slowly, or didn’t use at all. The strip did not stop the person from using. It gave them information. For a substantial share of them, that information kept them alive.

The administration’s framing — that test strips “facilitate illegal drug use” — is not supported by this evidence or by any other study in the literature. What the evidence shows is that test strips reduce overdose deaths among people who are already using, and who are going to continue using regardless of whether a strip is available. Maia Szalavitz, writing in Filter in early May, put the legal interpretation plainly: the executive order’s language requires that a program “only facilitate illegal drug use” to be disqualified. Test strips do not only do that. They save lives. An evidence-reading that ignores the life-saving function to reach the “facilitate” conclusion is not a policy analysis. It is a predetermined outcome dressed as one.

The administration’s framing — that test strips “facilitate illegal drug use” — is not supported by this evidence or by any other study in the literature.

Ohio: The first gap becomes visible

On June 5 — five weeks after Carroll’s letter — WOSU Public Media reported that Columbus Public Health, one of Ohio’s largest municipal public health agencies, was running low on the 50,000-plus fentanyl test strips it had distributed over the previous two years. Once the current inventory is gone, Columbus Public Health cannot order replacements under its affected federal grants. It is already stretching other public health budget lines to look for alternatives.

Columbus is not an anomaly. It is the first major agency to make visible what the April 24 letter is doing on the ground. SAMHSA’s policy took effect immediately; organizations that had existing strip inventories began burning through them. By late summer, dozens of programs across the country will be in the same position Columbus is in today: still open, still wanting to help, no longer able to distribute the tool that prevents overdose deaths.

The harm reduction infrastructure built over the last decade — funded largely through SAMHSA’s State Opioid Response grants, which distributed $1.575 billion in FY 2026 — did not happen overnight. It took years to build trust with communities that had every reason to be suspicious of the healthcare system, years to train staff and develop distribution networks, years to reach the populations most at risk. Defunding that infrastructure does not leave a neutral baseline. It leaves a hole. And holes in harm reduction infrastructure are measured in deaths.

What this means for Arizona

Arizona is not insulated from this shift. Maricopa County, which accounts for the majority of the state’s roughly 2,664 annual overdose deaths, recently committed $2 million in opioid settlement funds to 12 local organizations expanding harm reduction programs. AHCCCS has funded a naloxone and fentanyl test strip awareness campaign through its Substance Abuse Block Grant supplemental dollars. These programs are real. They matter.

They also exist alongside federal funding, not instead of it. Arizona consistently ranks 49th out of 51 jurisdictions for behavioral health access. The organizations distributing test strips in Phoenix, Tucson, and Flagstaff are not bureaucracies with cushion to absorb a federal funding loss. They are understaffed nonprofits that often depend on a single major grant for operational continuity. SAMHSA’s SOR grant program — the precise program SAMHSA is now restricting — is the backbone of this infrastructure.

Arizona’s $1.215 billion in opioid settlement funds was designed to expand access. It was not designed to replace the federal government. Asking it to cover SAMHSA grant losses is asking it to do two jobs at once. At minimum, one of those jobs gets done less well. At worst, organizations that lose federal grants fold before the settlement money reaches them — because settlement distribution operates on multi-year timelines, and nonprofits run on annual budgets.

States like California, Nevada, and New York have maintained or expanded state-level harm reduction programs insulated from the federal change. Arizona is not among them. This is the consequence of years of underinvestment in public behavioral health infrastructure, now colliding with a federal policy decision that removes the support those programs depended on.

The logic failure at the center of this policy

The administration’s position has a clean internal logic: test strips allow someone to use drugs with less risk; therefore they “facilitate” drug use; therefore they violate an executive order prohibiting federal funding for drug-facilitation programs.

This reading is not wrong as far as it goes. It treats facilitation as the end of the analysis rather than the beginning. The meaningful question is not whether test strips reduce the danger of individual drug use episodes. It is whether, compared to the alternative — a person using drugs without knowing whether fentanyl is present — distributing test strips leads to better or worse population-level outcomes.

The meaningful question is not whether test strips reduce the danger of individual drug use episodes.

The evidence answers this question. Better outcomes. Consistently. Across settings and populations.

The secondary claim embedded in this policy — that removing test strips will reduce drug use by making it more dangerous — is not supported by credible evidence in the addiction literature. People who are physiologically dependent on substances do not stop using when the risk increases. They continue using and die at higher rates. This is not a moral judgment. It is a clinical observation documented across decades of research.

The argument that harm reduction “sends a message” that drug use is acceptable is a moral claim, not an empirical one. It trades lives for messaging. That trade is a choice the administration is entitled to make. It should be made transparently, with the expected consequences stated openly — not laundered through the language of “facilitation.”

What comes next

Organizations like KHRC are not going quietly. Several are pursuing emergency bridge funding through state health departments, private foundations, and direct donor solicitation. Advocacy organizations have filed formal comment letters. Senator Markey’s May 8 inquiry sits unanswered at SAMHSA headquarters.

The trajectory of the overdose crisis makes the timing of this policy particularly difficult to explain. Drug overdose deaths fell 14% in 2024 and continued falling through 2025, with CDC provisional data projecting 69,973 deaths — the lowest annual total since 2016. Public health researchers credit multiple converging factors: expanded naloxone access, broader buprenorphine prescribing following the 2023 X-waiver elimination, opioid settlement funding flowing to treatment programs, and harm reduction infrastructure including widespread test strip distribution.

The administration is now defunding one of the tools credibly associated with that decline. It is doing so at the moment the decline is accelerating — not despite the progress, apparently, but indifferent to it.

Waldon’s strips will run out. Columbus Public Health’s supply will run out. Programs in Phoenix and Tucson will reach the bottom of their current inventory and find nowhere to turn. When the next person dies from fentanyl they didn’t know was in their drugs — in Ohio, in Kentucky, in Maricopa County — the policy responsible will have a date on it.

April 24, 2026.