SAMHSA Made It Cheaper to Die Than to Know What You're Dying From

On the morning of April 25, 2026, Shreeta Waldon opened an email that told her the $400,000 federal grant her organization had relied on for a year was gone. The Kentucky Harm Reduction Coalition had spent the first three months of fiscal year 2026 distributing 48,465 fentanyl test strips — strips that cost about a dollar each and let people know whether the drugs in their hands contain a substance fifty to one hundred times more potent than morphine. The strips had been working. Now those funds were cut off.

The day before, acting SAMHSA administrator Chris Carroll had signed two directives that rewrote the rules for every organization receiving federal behavioral health grants. The directives told grantees they could no longer use SAMHSA money to buy fentanyl test strips, xylazine and medetomidine test strips, sterile syringes, sterile smoking pipes, or sterile water. A companion letter urged providers to treat buprenorphine and methadone — the most effective medications for opioid use disorder — not as long-term treatment but as transition steps toward abstinence.

Two months later, Waldon has spent her operational reserves and begun laying off staff.

SAMHSA just made it cheaper to die than to know what you’re dying from.

The directive landed on programs already cut to the bone

The April 24 guidance did not arrive in a vacuum. It came after months of aggressive SAMHSA staff reductions, with the agency losing dozens of program officers who had built relationships with grantees across the country. It came as opioid settlement funds — theoretically a lifeline for states and counties — remained tied up in slow-moving disbursement processes. It came, in short, at the worst possible moment for the organizations that have spent a decade building the harm reduction infrastructure that helped bend the overdose curve downward.

That curve is real. New data from the CDC’s National Center for Health Statistics shows that drug overdose death rates dropped 26.2% between 2023 and 2024 — from 31.3 deaths per 100,000 to 23.1. Synthetic opioid deaths fell 35.6% in the same period. After years of watching the numbers climb, this decline is the first real evidence that the public health response was working. Fentanyl test strips were part of that response. Naloxone was part of it. Syringe service programs were part of it. Medication-assisted treatment expansion was part of it.

The April directives cut directly at three of those four pillars.

What the ban actually prohibits — and what it signals

Reading the SAMHSA directive carefully, as KFF Health News laid out in its policy tracker, the prohibited supplies include more than just fentanyl strips. Gone from federally funded programs:

• Drug checking equipment of any kind — meaning organizations can no longer test supplies for adulterants, regardless of what substance is being checked
• Sterile syringes and pipes distributed as harm reduction supplies
• Sterile water or saline intended to support safer injection practices
• Naloxone kits provided through overdose prevention programs (the companion letter’s chilling effect extends here, though naloxone itself is not named in the prohibition)

The companion letter on medications is potentially even more damaging. It frames buprenorphine and methadone — both classified as Schedule III and Schedule II controlled substances, both with decades of evidence demonstrating their effectiveness at reducing overdose deaths — as stepping stones to abstinence rather than legitimate long-term treatment in their own right. The American Society of Addiction Medicine and virtually every major clinical organization have moved away from that framing since at least 2011. SAMHSA just moved back.

Tom Kraus, vice president of government relations at the American Society of Health-System Pharmacists, was direct when he responded to the directives: “Pharmacists should not be prevented from providing access to harm-reduction tools that reduce the risk of overdose.” His organization’s statement went further, noting that the restrictions conflict with evidence-based clinical practice and the professional judgment of pharmacists and providers.

The 1988 playbook, restaged for fentanyl

We have watched a government decide that a cheap thing that keeps people alive sends the wrong message before.

In 1988, Congress banned federal funding for needle exchange programs on the grounds that distributing clean syringes encouraged injection drug use. The ban held for 21 years. During that time, HIV spread rapidly through networks of people who inject drugs — and the research showing that syringe exchanges reduced HIV transmission without increasing drug use accumulated, quietly, in public health journals that nobody in Congress appeared to be reading. When Congress finally lifted the ban in 2009, the Centers for Disease Control estimated that HIV among injection drug users could have been reduced by as much as a third had the evidence-based programs been allowed to operate with federal support from the beginning.

In 1988, Congress banned federal funding for needle exchange programs on the grounds that distributing clean syringes encouraged injection drug use.

The fentanyl test strip debate is the same argument in new clothes. The evidence that test strips reduce overdose risk is robust and peer-reviewed: people who use drugs are more likely to use more slowly, use with others present, or not use at all when they know their supply contains fentanyl. The strips don’t encourage drug use. They give people information about what they are already going to take. The directive doesn’t engage with that evidence. It doesn’t cite any countervailing studies. It cites a policy preference.

The 1988 ban is remembered now as one of the more costly errors in federal public health history. History may not be generous about this one either.

You don’t need me to tell you what a dollar buys

If you have ever held a test strip in your hands — if you have ever dipped one into the rinse water from a cooker and watched the lines appear or not appear — you already know what this policy costs. Not in dollar terms. In terms of what you knew and what you did next.

The strip is not magic. It does not make fentanyl disappear. It does not guarantee safety. What it gives you is information at the moment you most need it: before, not after. Programs like Waldon’s have spent years teaching people who use drugs how to use them. Not because drug use is good. Because the people in those programs are alive, and dying of fentanyl is easy, and the goal is to keep them alive until they decide they want something different.

That decision — the one that leads to treatment, or to leaving, or to a life that looks like anything other than managing addiction — requires being alive to make it.

The directive doesn’t grapple with that logic. It assumes that withholding information produces abstinence. The evidence, accumulated across multiple countries and decades, is that withholding information produces preventable deaths.

What providers can do right now

If your harm reduction program received federal SAMHSA grant funds, the directive is in effect and compliance is not optional. But several paths remain:

State and local funding. Roughly half of U.S. states have independently legalized fentanyl test strips, and many state health departments maintain their own harm reduction budgets that do not flow through SAMHSA. Check whether your state health department or county behavioral health authority has programs that can fill the gap. SAMHSA’s directive governs federal funds, not state funds.

Private foundation support. The Robert Wood Johnson Foundation, the Bloomberg Philanthropies, and several regional health foundations have historically funded harm reduction directly. Contact them now, before your operational reserves run out. Do not wait.

Coalition consolidation. Smaller harm reduction programs that cannot sustain independent operations may be able to fold into larger organizations that maintain a larger financial buffer. This is a loss of local presence and trust — the human relationships that make harm reduction work are not transferable assets — but it is better than shutting down.

Documentation. If you serve communities where the SAMHSA directive is causing measurable harm — where you can tie specific overdose deaths to the absence of test strips or to patients who could not get buprenorphine because a provider trimmed their program in response to the guidance — document it. The litigation against this directive, when it comes, will need evidence. The historical record will need it too.

The overdose decline is real. So is the threat to it.

The 13% drop in overdose deaths over the last two years is the first meaningful evidence in a decade that the public health response was working. Research published in Drug and Alcohol Dependence Plus has identified several drivers: changes in fentanyl market dynamics, increased naloxone availability, expanded MAT access, and — directly relevant here — widespread adoption of harm reduction practices including drug checking.

Dismantling those practices does not lock in the decline. It risks reversing it.

The ASHP has opposed these restrictions. The Drug Policy Alliance has called them a threat to the gains of the last decade. Every major addiction medicine organization in the country has supported fentanyl test strips as an evidence-based tool. The only thing that has changed is the name on the door at HHS.

Waldon is still running her organization, on fumes, calling every foundation she knows. On the day the directive came out, she wrote down the name of a person she had served who tested positive for fentanyl in their supply the week before, adjusted how they used, and survived. She has not written that name down since. She doesn’t know what happened to them.

She’s trying not to.