Harm reduction strategies for addiction ‘incompatible with federal law’

The Trump administration is intensifying its stance against harm reduction services for individuals using illicit drugs.

In an open letter dated April 24, the federal agency managing addiction and mental health policies cautioned its grantees against utilizing federal funds to purchase harm reduction supplies, such as sterile syringes and pipes, or distributing test strips for common drug contaminants like fentanyl, xylazine, and medetomidine.

A second letter issued on the same day by the Substance Abuse and Mental Health Services Administration (SAMHSA) advised against using certain addiction medications without supplementary support services. The letter indicated that medications such as methadone and buprenorphine, which significantly decrease opioid overdose deaths, should be part of a long-term recovery strategy, rather than a lifelong dependency.

These letters, signed by acting SAMHSA leader Chris Carroll, come amid ongoing disorder at the agency. Over 15 months into the Trump administration, a director has yet to be appointed. The agency’s workforce, initially around 900, has been reduced to less than half. Prior to the abrupt termination and subsequent reinstatement of thousands of grants in January, SAMHSA canceled approximately $1.7 billion in block grant funding and reduced addiction and overdose prevention funding by another $350 million.

SAMHSA’s recent actions align with the Trump administration’s conventional drug policy: prioritizing abstinence-first approaches, opposing harm reduction strategies, and emphasizing law enforcement as a primary means of reducing drug-related issues. This marks a shift from actions taken a week earlier that aimed to promote psychedelics for mental health treatment and reclassify medical marijuana to a lower tier of controlled substances.

The harm reduction letter explicitly highlighted the administration’s “clear shift away from harm reduction and practices that facilitate illicit drug use and are incompatible with federal law.”

The letter also clarified that distributing test strips for detecting fentanyl, xylazine, and medetomidine to the public is against the administration’s policy. However, federal funds can still support the use of these test strips by public health officials, law enforcement, medical workers, and other professionals.

Additionally, funding for “overdose hotlines” that allow drug users to remotely contact staff who can call 911 if they stop responding is prohibited. The distribution of sterile water or saline for hygienic injection practices and other paraphernalia viewed as facilitating drug use is also banned. Conversely, federal funds are encouraged for use on naloxone, the overdose-reversal medication; sharps disposal kits; and testing and vaccinations for infectious diseases like hepatitis and HIV.

This policy on test strips marks a significant shift from the Biden administration’s approach, which strongly supported test-strip distribution. “This will save lives by providing tools to identify the growing presence of fentanyl in the nation’s illicit drug supply,” stated Tom Coderre, then SAMHSA’s interim leader, in April 2021, when announcing that federal funds could be used to purchase test strips.

The second letter from the agency cautioned against using medications for opioid addiction treatment without accompanying services, such as psychosocial counseling and other recovery support services.

Although the letter does not question the effectiveness of methadone or buprenorphine, it seems to imply that using these medications alone does not equate to “true recovery.” While many clinicians prefer to offer counseling alongside medication, current care standards do not support withholding medication from patients who decline additional services.

These letters were released as thousands of addiction specialists and researchers met in San Diego for the American Society of Addiction Medicine’s annual conference. The letter cited ASAM practice guidelines on opioid use disorder medications, although the referenced guidelines contradict the letter by stating that a “patient’s decision to decline psychosocial treatment or the absence of available psychosocial treatment should not preclude or delay pharmacotherapy, with appropriate medication management.”

The letter also advises clinicians to discuss annually with patients whether they wish to remain on medication. Though specific data on the correlation between mortality and long-term medication treatment is inconclusive, studies indicate that generally, longer treatment durations lead to better outcomes.

“ASAM is 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,” stated Stephen Taylor, president of ASAM. “This includes maintaining access to medications for opioid use disorder when clinically appropriate.”

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