The Trump administration has increasingly opposed harm reduction services for illegal drug users.
In an April 24 open letter, the federal agency that oversees addiction and mental health policy warned grant recipients not to use federal funds to purchase harm reduction supplies such as sterile syringes and pipes or to distribute test strips for common drug supply contaminants such as fentanyl, xylazine and medetomidine.
In a second letter dated the same day, the Substance Abuse and Mental Health Services Administration also warned against the use of certain addiction medications without support services. The report writes that medications such as methadone and buprenorphine, which have been shown to significantly reduce deaths from opioid overdose, should be used “as part of a path to long-term recovery,” but “not as a default sentence to lifelong drug use.”
The double letter, signed by SAMHSA Acting Leader Chris Carroll, follows more than a year of confusion and turmoil within SAMHSA. More than 15 months after taking office, the Trump administration has yet to appoint a board member. The number of employees at the agency was about 900 at the start of the Trump administration, but that number is now less than half that number. Even before it abruptly ended thousands of grants in January and then reinstated them, SAMHSA had canceled about $1.7 billion in block grants and cut funding for addiction and overdose prevention by an additional $350 million.
In SAMHSA’s own words, the harm reduction letter emphasized that the Trump administration has “clearly distanced itself from harm reduction and practices that promote illegal drug use and are inconsistent with federal law.”
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The letter also made it clear that it is against administrative policy to publicly distribute test strips used to detect fentanyl, xylazine, and medetomidine. But he stressed that federal funds will continue to be available for test strips used by public health officials, law enforcement, health care workers and others who use test strips in professional settings.
Also prohibited: Funding for an “overdose hotline” that would allow drug users to communicate remotely with staff who could call 911 if they stopped responding. Sterile water or saline solution distributed to allow users to hygienically inject medications. and other forms of paraphernalia that, in the government’s view, “facilitate or facilitate drug use.” The letter encourages federal funds to be used for naloxone, a drug that reverses overdoses. Sharps disposal kit. Tests for infectious diseases such as hepatitis and HIV and vaccinations will also be performed.
This test strip policy marks a major shift from the Biden administration, which has enthusiastically promoted test strip distribution. “This will save lives by providing a tool to identify the growing presence of fentanyl in the nation’s illicit drug supply,” Tom Coderre, then interim SAMHSA leader, said in a statement in April 2021 announcing that federal funds could be used to purchase the test strips.
The agency’s second new letter warns officials against using drugs used to treat opioid addiction without accompanying services such as psychosocial counseling or other “recovery support services.”
While the letter does not question the effectiveness of methadone or buprenorphine, it appears to repeat the metaphor that drug use does not lead to “true recovery.” Although many addiction clinicians may prefer to provide counseling alongside medication, current standards of care do not support withholding medication from patients who refuse other services.
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The letter was released as thousands of addiction providers and researchers gathered in San Diego for the American Society of Addiction Medicine’s annual conference. At one point, the letter cited ASAM’s practice guidelines on medication use for opioid use disorder. However, the cited document appears to contradict the letter, stating that “a patient’s decision to refuse psychosocial treatment, or the absence of psychosocial treatment available, should not prevent or delay drug treatment with appropriate medication management.”
The letter also encourages clinicians to discuss with patients “at least once a year” whether they wish to continue taking the medication. Although there is little conclusive, specific data on the relationship between mortality and long-term drug treatment, studies have shown that longer treatment periods generally result in better outcomes.
“ASAM continues to carefully review the new Dear Colleague letter from SAMHSA and stands ready to work with our federal partners to ensure national policy reflects evidence-based practices in addiction medicine,” said addiction physician Steven Taylor, who currently serves as ASAM president, in a statement. “This includes maintaining access (to medications to treat opioid use disorder) when clinically appropriate.”
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