Washington Built the Playbook That Cut Overdose Deaths. It Just Told States to Stop Using It.

Shreeta Waldon found out on a Saturday. April 25, an email from a SAMHSA program office, six sentences long, the kind that arrives without a phone call first. The $400,000 grant that funded most of what the Kentucky Harm Reduction Coalition does — in the first quarter of this fiscal year alone, that grant put 48,465 fentanyl test strips into the hands of people who wanted to know what was actually in the bag before they used it — was gone. Not reduced. Gone, the same week SAMHSA told every one of its grantees nationally that federal money could no longer pay for test strips, syringes, safer-smoking supplies, or overdose-prevention hotlines, because, in the agency’s own words, harm reduction “only facilitate[s] illegal drug use and its attendant harm.”

Waldon runs an organization, and running an organization means the email lands on her desk, not on the person standing in line for a strip at a mobile unit in Louisville. But multiply her Saturday by every harm reduction group in the country that took SAMHSA money — and then read the second announcement, the one HHS Secretary Robert F. Kennedy Jr., ONDCP Director Sara Carter, and HUD Secretary Scott Turner made three and a half months later at the San Diego Rescue Mission — and a pattern comes into focus that is bigger than one coalition’s budget.

The government just spent four years citing a real, measurable decline in overdose deaths as vindication of its approach. It is now dismantling the specific tools most closely associated with that decline, and calling the replacement a return to seriousness — the latest turn in a fight over how treatment and recovery systems in this country are supposed to work.

The government is taking credit for a decline it built with tools it just defunded.

The number everyone is citing is a harm-reduction number

Start with the number, because both sides of this fight are citing the same one and drawing opposite conclusions from it. Drug overdose deaths have been falling since their 2023 peak of roughly 107,000 — CDC’s National Center for Health Statistics has tracked the decline across successive 12-month reporting windows, and every public accounting of it — from Rize’s own market research to the administration’s own talking points — treats the drop as real and as the best news the overdose crisis has produced in a decade.

What almost nobody disputes, including researchers inside HHS’s own orbit, is why the number moved. Naloxone went over the counter. States saturated their communities with it through standing orders. Syringe service programs expanded into places that had never had them. Fentanyl test strips, once a novelty distributed by a handful of underground operations, became a mainstream public health tool that let a person check a bag before they put it in their body — not to make using safer in some abstract sense, but to make the specific difference between a dose someone could handle and a dose that would kill them. Kentucky, one of the states that leaned hardest into this model, reported a 22.9% decline in overdose deaths in 2025 — its fourth consecutive year of improvement — and the state’s own public health officials credited exactly the tools SAMHSA just defunded. This isn’t isolated to Kentucky, either — SAMHSA’s own naloxone funding shifts this week show the same restructuring reaching a second pillar of the fentanyl response at once.

This is not the first time the federal government has tried to unwind harm reduction infrastructure at the moment it was working. In 1988, with the AIDS epidemic tearing through people who inject drugs, Congress banned federal funding for syringe exchange programs outright — over the objections of researchers who already had data showing exchanges slowed HIV transmission without increasing drug use. The ban held, with one brief exception, from 1988 until 2015. Twenty-seven years, minus a two-year window Congress opened in 2009 and then closed again in 2011 under budget pressure. The public health case against the ban never changed in that time. The politics did, repeatedly, in both directions, and the people who paid for the gap were the ones the studies had already told everyone how to protect. If you want the shape of what’s happening in 2026, that’s it: the evidence holds still while the funding lurches, and the lurching has a body count.

The public health case against the ban never changed in that time.

”Treatment First” names its enemy

The toolkit HHS, ONDCP, and HUD released on August 12 doesn’t hide what it’s replacing. Kennedy, Carter, and Turner framed it as a correction — “Treatment First” instead of the Biden-era “Housing First,” coordinated and accountability-driven engagement with treatment instead of what the toolkit characterizes as a model that let people stay housed and using indefinitely. Kennedy’s language was direct: “Treatment must come first. Recovery begins when we connect people with effective care, not leave them trapped in addiction.” Turner added the housing half of the argument: “Housing is essential, but housing alone is not enough. This toolkit gives communities a practical playbook.” The stats the toolkit leads with are stark by design — 75% of homeless Americans struggle with drug addiction, 78% experience mental illness — numbers meant to justify urgency, not nuance.

Here’s the layman version of what “harm reduction” actually means, because the toolkit’s framing depends on the reader not knowing: it is not a philosophy that drug use is fine. It is the specific, boring, well-evidenced practice of keeping someone alive and reachable between the moment they’re using and the moment — if it comes — they’re ready for treatment. A test strip doesn’t make anyone use. It tells someone what’s in the bag they already decided to use. A syringe program doesn’t recruit new injectors. It keeps the ones who already exist from getting HIV or endocarditis from a shared needle. STAT News’s reporting on the toolkit noted what the administration left unsaid in its own announcement: the toolkit doesn’t argue harm reduction doesn’t work. It argues the government shouldn’t be the one paying for it, on the theory that funding it signals acceptance of ongoing use rather than urgency toward treatment.

That’s a coherent moral argument. It is also a bet that the country can afford the gap between “no longer using” and “in treatment” to go unmanaged — the exact gap harm reduction exists to cover, and the exact gap that killed people during the 1988-to-2015 stretch when the federal government made the same bet the last time.

Baltimore is what the gap looks like in real time

If you want to see what happens when that gap opens somewhere that was already leaning on the infrastructure now being pulled, look at Baltimore’s Penn North neighborhood. Baltimore’s overall overdose deaths have fallen more than 40% since 2023 — one of the steepest declines of any major city, driven in large part by an aggressive harm reduction buildout the city credits by name. And Penn North still had three mass overdose incidents in three months in 2025, one of them hospitalizing more than 27 people in a single event after a contaminated batch hit the street. Candy Kerr, who works with the Baltimore Harm Reduction Coalition, put the underlying problem in the plainest terms available: “Nobody really knows what they’re getting whenever they’re getting stuff off the street.” That’s not a philosophical statement. It’s a description of the actual, physical uncertainty a fentanyl test strip exists to resolve, in a city where SAMHSA’s new restrictions now sit directly on top of a neighborhood that has needed exactly that tool three times in three months.

Yngvild Olsen, who used to oversee SAMHSA’s own Center for Substance Abuse Treatment, described what the tools actually do for the people using them in terms the toolkit’s framing skips past entirely: some people decide not to use at all once they know what’s in the bag; others decide to use less. Both outcomes point toward the treatment system Kennedy says he wants to strengthen — they just don’t require a bed to be available on the specific day someone is ready to walk through the door, which is the part “treatment first” tends to leave out of the sentence.

If you’ve done this work, you already know the “you”

If you have ever worked a needle exchange table, staffed a warmline at 2 a.m., or handed someone a strip because you’d already been the person deciding whether tonight’s bag was safe — you don’t need this article to explain what’s being taken away. You already know the difference between “get treatment” as a sentence a policymaker says at a podium and “get treatment” as a thing that has to be available, funded, and staffed on the exact day a specific person is ready, which is not a day anyone can schedule in advance.

That gap between the two is where peer workers have always lived, and a 2026 study out of UNSW, led by Professor Loren Brener and published in the International Journal of Drug Policy, is one of the first to actually document what that costs the people doing the work. Researchers interviewed workers with lived and living experience of substance use across Australia’s drug and alcohol sector and found something the toolkit’s framing has no room for: peer workers described navigating their own triggers in real time while sitting across from a client living through the same fear they once carried themselves, and doing it precisely because that shared history is what let the person across the table trust them enough to stay in the room. That trust is not a soft benefit. It is the mechanism. Cut the infrastructure that gets someone to the table in the first place — the test strip, the syringe, the hotline, the low-barrier contact point — and you don’t just lose a service. You lose the room where that trust had any chance to start.

You lose the room where that trust had any chance to start.

What’s still yours, tonight

None of this means the tools disappeared everywhere overnight. Naloxone is still available over the counter nationwide, and most state standing orders that let pharmacies dispense it without a prescription are still in effect — that access didn’t come from the SAMHSA grants that just got cut, and it isn’t going anywhere with this policy. If you’re carrying it, or you can get to a pharmacy that stocks it, that part of the safety net is still yours tonight, regardless of what happens to test strip funding in your state.

If you’re a case manager or a program director reading this instead of living it, the concrete move this week is not philosophical: pull your organization’s SAMHSA grant terms and check line-by-line whether test strips, syringes, or hotline staffing sit inside the restricted categories in the April 24 guidance — several coalitions found out by surprise email, and yours doesn’t have to.

What the “Treatment First” toolkit gets right is that treatment access in this country is a real and unacceptable bottleneck — that part isn’t propaganda. What it gets backward is the idea that you fix a bottleneck by draining the reservoir that was keeping people alive long enough to reach it. Shreeta Waldon’s coalition is still operating in Kentucky, on a budget that just lost its largest line item, distributing whatever test strips it has left until it doesn’t. The toolkit calls what she does the old model. Her state’s own overdose numbers, four years running, call it the thing that’s been working. Somebody in Washington is going to have to explain, eventually, what happens to the fifth year.