Federal Grantees Have Thirty Days

Shreeta Waldon, executive director of the Kentucky Harm Reduction Coalition, learned on April 25 that her organization was losing a $400,000 federal grant. The day before, the Substance Abuse and Mental Health Services Administration had sent a letter to every organization it funds. Acting Administrator Chris Carroll’s signature sat at the bottom. The letter said that federal dollars could no longer be used to distribute fentanyl test strips “to the public.”

In the first quarter of fiscal year 2026, KHRC had distributed 48,465 fentanyl test strips — roughly 16,000 per month, about 530 a day. After the letter, Waldon estimated the coalition had roughly 30 days of supply left before what she described as a “full-blown crisis.” In South Carolina, Fyrebird Recovery lost a $4,000 grant. Across the country, programs doing this work began counting not weeks, but days.

This is what the policy looks like in practice: specific organizations, specific dollar figures, a specific countdown. What it looks like in theory — a “clear shift away from harm reduction,” as Carroll described it — is more contested. It may also be illegal.

The letter said something precise, and that precision matters

The April 24 guidance, surfaced publicly by STAT News three days after it was sent, contained a carve-out that was designed to make the policy sound measured. Federal funds CAN still be used for fentanyl test strips, it explained. They can be used by “public health officials, law enforcement, medical workers, and others who use them in professional settings.” What they cannot do is reach “the public.”

This distinction is not administrative fine print. A fentanyl test strip works at one specific moment: when someone who is about to use a drug — or someone who is with them — dips the strip in a diluted sample and reads the result before they use. The strip’s entire value is tied to that transaction. Clinical professionals who work in hospitals and public health departments have access to comprehensive toxicology testing. They do not need a test strip that costs about 40 cents. The 48,465 people KHRC reached in one quarter did.

The guidance also prohibited the use of federal funds for sterile syringes and pipes for “illicit drug use,” and for test strips detecting xylazine and medetomidine. Xylazine is a veterinary tranquilizer, not reversible by naloxone, now present in the fentanyl supply in more than 20 states. Medetomidine is another veterinary sedative that began appearing in Chicago toxicology reports in 2023 and has spread since. The DEA issued a multi-state advisory about medetomidine-fentanyl combinations in early 2026 — the combination is unusually dangerous and, like xylazine, cannot be reversed with standard overdose medications.

One week after the DEA warned that medetomidine was spreading in the supply, SAMHSA’s guidance told funded organizations they can no longer test for it in public settings.

The science doesn’t work the way the policy assumes

Fentanyl test strips are not harm reduction ideology. They are among the most rigorously validated tools in overdose prevention.

A 2022 study in the International Journal of Drug Policy found that people who used fentanyl test strips were more than twice as likely to take protective measures when the result came back positive — using less, using more slowly, not using alone. In a drug supply where fentanyl is present in roughly 70% of substances submitted for analysis, and where a single unexpected fentanyl-positive can kill someone who hasn’t built tolerance, the strip’s function is not theoretical. It changes behavior in ways that keep people alive.

The xylazine test strip works on the same principle: knowing what’s in the supply changes what someone does with it. A person who knows their supply contains xylazine needs a different overdose response than one who doesn’t — more time, more monitoring, wound care for the distinctive skin ulcers that xylazine causes. Without the strip, they’re making a high-stakes decision without information they could have had for less than a dollar.

Without the strip, they’re making a high-stakes decision without information they could have had for less than a dollar.

The April 24 guidance’s language — “practices that facilitate illicit drug use and are incompatible with federal law” — characterizes providing test strips as facilitation of drug use. The evidence says something different. The people using test strips were already using. They used the strip before they used the drug. The causal chain runs toward prevention of death, not toward initiation of use. This is not a subtle distinction.

The institutions that said so

The American Society of Addiction Medicine responded within 48 hours of the guidance becoming public. Its president, Dr. Stephen Taylor, said the organization was “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.”

That sentence is written in the careful register of an organization that has to keep working with the agency it disagrees with. ASAM represents the nation’s addiction medicine specialists — the physicians who treat the patients who end up in emergency rooms when harm reduction fails. Taylor’s statement is diplomatic language for: we think this is wrong.

The American Society of Health-System Pharmacists was less careful. On April 30, ASHP issued a formal statement opposing the restrictions on fentanyl test strips, describing the policy as contrary to evidence and harmful to patient safety. ASHP represents the hospital and health-system pharmacists who work in exactly the clinical settings the SAMHSA carve-out claims to still serve. Their opposition undermines the framing that the guidance is about directing tools toward professionals rather than removing them from people who need them.

The Faces & Voices of Recovery, documenting cumulative federal actions in its May 2026 Monthly Policy Update, placed the test strip ban in a pattern that has now cut more than $2 billion from behavioral health programs since January. The Drug Policy Alliance’s running tracker tells the same story: $1.7 billion in SAMHSA block grant funding cancelled (briefly reversed after backlash, then re-cancelled), $350 million in addiction and overdose prevention programs cut, and SAMHSA’s own workforce reduced from approximately 900 employees to fewer than 450.

The workforce reduction matters here in a specific way: the staff who were designing and overseeing harm reduction grant programs, who understood which grantees were doing the work and what outcomes they were producing, are largely gone. The surveillance infrastructure that tracked overdose trends at the state and local level — the Overdose Data to Action program, the Opioid Overdose Prevention and Surveillance program — was among the programs cut. The administration is now making policy about harm reduction with less capacity to know whether it’s working.

The legal question no one has asked loudly yet

The SUPPORT Act, passed by Congress in 2018 and reauthorized in 2025, explicitly authorized the use of federal funds for harm reduction services. Amendments added in subsequent appropriations cycles specifically protected the use of federal funds for fentanyl test strip distribution in states where the strips were legal.

The April 24 SAMHSA guidance tests the boundary of that legislative authorization in a way that has not yet been litigated. Administrative law organizations that work with harm reduction programs have raised the question: can the executive branch direct an agency to refuse to spend funds that Congress has authorized? The short answer is complicated. Agencies have substantial discretion in implementing grants. But instructing grantees to refuse to spend funds on specifically authorized activities, while still technically maintaining the grants, is a different legal question than standard implementation discretion.

No formal challenge had been filed as of the close of this reporting. The organizations best positioned to file one — the Drug Policy Alliance, the National Harm Reduction Coalition, the ACLU’s drug policy project — are aware of the issue.

The organizations best positioned to file one — the Drug Policy Alliance, the National Harm Reduction Coalition, the ACLU’s drug policy project — are aware of the issue.

What it means for the numbers

The CDC counted approximately 70,000 overdose deaths for the 12 months ending December 2025, a 13.9% decline from the previous year and a 35% decline from the 2022 peak of 108,000. That decline is real. It was not inevitable.

Researchers who have studied what drove it point to a combination of factors: expanded naloxone distribution, broader buprenorphine access under telehealth flexibilities, harm reduction services including test strip distribution, and in some markets a modestly less potent fentanyl supply. These factors are not fully separable in the data, but test strips appear in every credible analysis of what contributed to fewer deaths.

The April 24 guidance removes one of those factors in every state where SAMHSA-funded organizations were the primary distributor. Some states — California, Nevada — have state-level programs and may be able to absorb some of the gap. Most of the country cannot. For organizations like KHRC, the federal grant was not a supplement to other funding. It was the program.

Thirty days

If no alternative funding materializes before Shreeta Waldon’s deadline, the Kentucky Harm Reduction Coalition will distribute its last box of fentanyl test strips sometime in late May or early June. Workers who have been reaching 530 people a day will stop. The 530 people will use without knowing what they’re using.

The administration’s April 24 letter described test strips as practices that “facilitate illicit drug use.” Waldon’s coalition facilitated nothing — it was trying to keep people who were already using alive long enough to get to treatment. The word “facilitate” is doing enormous work in that sentence. So is the absence of any accounting for what the alternative looks like.

The strips are not magic. They don’t stop anyone from using. They give someone a piece of information they didn’t have — and in a drug supply where what you think you’re using and what you’re actually using can be separated by the difference between alive and dead, a piece of information is not nothing.

In thirty days, those pieces of information will stop flowing. The overdose death data that the CDC will publish twelve months from now will reflect what happened when they did.