SAMHSA Killed Test-Strip Funding on the One Day We're Supposed to Count the Dead

Every county in North Carolina where Elyse Powell’s organization works, a strip that turns purple when it touches fentanyl costs about thirty-five cents. A strip that catches medetomidine — the veterinary sedative now cutting through the illicit opioid supply in her state faster than anything the UNC Street Drug Analysis Lab has tracked before — costs closer to two dollars. The NC Harm Reduction Coalition, which Powell directs, serves more than 5,000 people a year. As of April 24, 2026, it is against federal rules for her to buy either strip with a federal harm-reduction dollar.

That is not hyperbole and it is not a future risk. It is the plain text of a SAMHSA guidance letter, issued in the spring and still reshaping county budgets today, that bars grantees from using federal harm-reduction money to purchase fentanyl test strips, sterile syringes, or “any other substance test kits, including xylazine and medetomidine test strips.” It cites a July 2025 executive order against programs that “facilitate illegal drug use.” A Kentucky harm-reduction coalition told CBS News it lost $400,000 in a single stroke of a signature. A South Carolina nonprofit lost $4,000 — small on paper, and the whole operating margin for a program running on volunteers.

A federal agency just made it cheaper to overdose blind than to know what’s in your drugs, on the one day of the year we set aside to count the people who didn’t survive not knowing.

Today is International Overdose Awareness Day. Boston marked it Friday by reporting a 29% drop in overdose deaths in 2025 — the city’s fewest in a decade — and crediting the exact toolkit SAMHSA just defunded nationally: syringe exchange, naloxone kiosks, drug-checking. If you have ever dipped a strip into a cooker before you used, or watched someone else do it, you already know what thirty-five cents buys and what its absence costs. This piece is for you as much as for anyone who writes policy about you.

The order arrived as a letter, not a headline

Federal harm-reduction policy rarely changes with a press conference. It changes with a memo that county health directors forward to each other, and this one moved fast. The April 24 letter — confirmed independently by CBS News and by the National Association of Counties, which represents the county governments that actually administer most of this funding — updates a directive issued under the same executive order eleven months earlier. It doesn’t zero out SAMHSA’s harm-reduction grant line item entirely. It narrows what the money can buy, and drug-checking supplies — the strips, the kits, the tools that tell a person what is actually in the substance they’re about to use — are explicitly excluded.

The timing compounds the irony. Seventeen days after the letter, SAMHSA’s own data — provisional but consistent across two separate releases this year — showed the dozen months ending in February 2026 recorded 68,641 overdose deaths nationwide, a 12.1% decline from the year before. That’s real progress, the third straight year of it, down from a 2023 peak north of 110,000. The administration has been eager to claim credit, and on August 21 the DEA marked its fifth annual National Fentanyl Prevention and Awareness Day, noting fentanyl remains the leading cause of death for Americans 18 to 45 even as the national trend improves. Ten weeks later, the same federal government made it structurally harder for the people doing the ground-level work behind that trend to keep doing it.

Here is the layman version, because the jargon matters and so does stripping it away: a test strip is not a tool that helps someone use drugs. It’s a tool that tells someone what’s actually in the drugs they already have — because today’s illicit supply is not what it says on the bag. Powell’s coalition, and hundreds like it, hand out strips so a person can find out, in thirty seconds, whether what they’re about to use contains fentanyl or one of its newer, harder-to-reverse cousins, before it’s in their bloodstream instead of a test tube.

It’s a tool that tells someone what’s actually in the drugs they already have — because today’s illicit supply is not what it says on the bag.

Medetomidine didn’t wait for a press release

The drug supply doesn’t pause for federal guidance letters, and North Carolina is the clearest evidence of that this year. Nabarun Dasgupta, who directs the UNC Street Drug Analysis Lab, has logged more than 536 unique substances across over 23,000 drug samples his lab has tested. His data shows medetomidine — a veterinary alpha-2 sedative, meaning it works on the same nervous-system receptors as xylazine but hits harder and knocks a person out longer — has now surpassed xylazine as the dominant tranquilizer adulterant in parts of the state’s illicit supply. It doesn’t respond to naloxone. It causes withdrawal severe enough to sometimes require ICU-level care.

This is where the funding cut stops being an abstraction and starts compounding itself. A fentanyl strip runs about thirty-five cents per unit. A medetomidine strip, per WUNC’s reporting, costs roughly $200 for a box of 100 — nearly six times as much per test. Powell’s coalition and organizations like it were already stretching grant dollars to cover the newer, pricier strips as the supply shifted. Now federal rules forbid spending grant dollars on either kind, at the exact moment the thing people need to test for got more dangerous and more expensive to detect.

There’s a peer-reviewed reason to expect this pattern to repeat. A study published in the International Journal of Drug Policy by David Zhu of Virginia Commonwealth University and Sehun Oh of Ohio State compared nine states that formally scheduled xylazine as a controlled substance against five that only criminalized its use. States that scheduled it saw roughly 1,500 additional medetomidine detections per 100,000 drug samples — a measurable substitution effect. Drug policy researchers have a decades-old name for this pattern: the iron law of prohibition — crack down on one substance and the market doesn’t shrink, it mutates toward whatever’s harder to detect and regulate. Cutting the tools that detect the new substance doesn’t slow that mutation. It just means fewer people find out about it before it’s too late.

We have watched a government decide that a cheap thing keeping people alive sends the wrong message before, and it took over two decades to reverse course last time. In 1988, Congress banned the use of federal funds for the syringe exchanges that were, at that point, the single most effective tool slowing HIV transmission among people who inject drugs. The ban held for 21 years, through a public-health emergency that killed hundreds of thousands of Americans, before Congress lifted it in 2009. Public-health researchers spent that entire period producing study after study showing syringe exchanges did not increase drug use and did prevent HIV. The evidence didn’t move the policy. Politics did, eventually, and only after a body count nobody could keep arguing around.

”Treatment-first” is a toolkit, not a treatment plan

Eight days after the DEA’s fentanyl-awareness observance, HHS released a new resource for addressing addiction and homelessness, and its framing tells you where the administration wants the conversation to go next. STAT News, which obtained and reviewed the toolkit, reports it emphasizes faith-based interventions, abstinence, and structured daily routines, explicitly moving away from the Biden-era “Housing First” model — citing a study of rising overdose deaths among veterans in supportive housing as justification. HHS Secretary Robert F. Kennedy Jr. and HUD Secretary Scott Turner are both quoted promoting the shift.

To its credit, the toolkit does endorse contingency management — the practice of paying people modest incentives for verified drug-free test results, which has real trial evidence behind it. But STAT’s reporting notes it gives only passing mention to methadone and buprenorphine, the two medications with the strongest evidence base for treating opioid use disorder, the same medications a new CDC report published August 27 shows are still desperately underused in the places that need them most. That report found only 10.3% of rural emergency departments had started administering buprenorphine to overdose and opioid-use-disorder patients by 2025, compared with 31.4% of urban EDs — a gap that has held steady across the entire 2019-to-2025 period the CDC studied. If you run a small ED and are looking for a concrete move this week: that MMWR report is a ready-made case to bring to your medical director for adding buprenorphine induction to your overdose-response protocol, and it costs nothing to ask.

A toolkit that leans on faith and structure while treating the two most effective medications for opioid addiction as an afterthought isn’t neutral. It’s a bet — that willpower and routine will outperform pharmacology and drug-checking for people whose brains have been remodeled by sustained opioid exposure, a bet the last several decades of addiction science have not been kind to.

A toolkit that leans on faith and structure while treating the two most effective medications for opioid addiction as an afterthought isn’t neutral.

What the decline doesn’t include yet

Boston’s numbers are the clearest counter-argument sitting in plain sight. The city’s 29% year-over-year drop in overdose deaths — its lowest total in ten years — didn’t happen because people simply decided to stop. Mayor Michelle Wu’s office and Public Health Commissioner Dr. Bisola Ojikutu credit a specific, funded infrastructure: the AHOPE syringe-exchange and naloxone program, the PAATHS withdrawal-management and medication-assisted-treatment pathway, sixteen naloxone kiosks and seven public-health vending machines placed around the city, and more than 600 residents trained in overdose response this year alone. Nearly 3,000 Boston residents have died in the opioid crisis since 2015; the city is not declaring victory, it’s pointing at what’s working and asking to keep doing it.

That’s the trap in celebrating a national overdose decline while defunding the exact category of program several cities credit for their local version of it. The national numbers are aggregate and lagging — they reflect what harm-reduction infrastructure, expanded naloxone access, and buprenorphine prescribing built over the past three years, not what federal policy is doing to that infrastructure this month. Nationally, over-the-counter naloxone access did expand this year: in June, the FDA approved Rextovy, a second over-the-counter naloxone nasal spray alongside Narcan, now available at pharmacies and convenience stores without a prescription. That access is still real and it is still yours, wherever you are reading this — this is the one piece of the harm-reduction toolkit the funding cuts haven’t touched. But naloxone reverses an overdose already happening. Test strips are supposed to prevent one from starting. Cutting funding for the second while expanding access to the first is treating the symptom you can see and defunding the intervention you can’t easily photograph for a press release.

This isn’t an abstraction for the people the strips are for, either. Writing in Filter this month, harm-reduction journalist and former syringe-program peer worker Kastalia Medrano described years of daily methamphetamine use in blunt, unsentimental terms — “it made a lot of things in my life harder” but “I’m not sure how else I could have managed the things it made easier.” People who use drugs are not a hypothetical constituency lawmakers are debating in the abstract. They are the actual population a thirty-five-cent strip is for, and they are the ones deciding, tonight, whether to use something without knowing what’s in it.

Powell’s coalition will keep operating on whatever combination of state money, private donations, and stretched volunteer hours it can piece together, because that’s what harm-reduction organizations have always done when federal support disappeared — the 1988 syringe-exchange generation did the same thing for 21 years. The difference this time is the drug supply isn’t waiting two decades for the policy to catch back up. Medetomidine is already here. The next thing after it will not announce itself with a press release either, and the question this April letter answers is whether the people most likely to notice first will still have thirty-five cents’ worth of federal support to tell you before you find out the hard way.

Read more on Rize’s harm reduction coverage, our ongoing tracking of opioid policy, and yesterday’s contingency management coverage on what federal Medicaid dollars are funding instead.