The Policy Stack: How SAMHSA, the White House, and Louisiana Are Rewriting Drug and Homelessness Response

On April 24, 2026, the Substance Abuse and Mental Health Services Administration (SAMHSA) issued a Dear Colleague letter that withdraws federal funding eligibility from fentanyl test strips, sterile water, saline, ascorbic acid, sterile syringes, safer smoking supplies, and overdose hotlines. Signed by Principal Deputy Assistant Secretary Christopher Carroll, the letter operationalizes the July 2025 Executive Order directing the agency to defund what the order termed "so-called harm reduction" programs. This action arrives as Louisiana's House Bill 211 advances toward the state Senate, threatening fines and imprisonment for unauthorized public camping. Together, these federal and state moves construct a coordinated policy framework that abandons decades of evidence on what prevents HIV and HCV transmission, reduces overdose mortality, and connects people who use drugs to treatment.

For people living with HIV and HCV, people who inject drugs, and people experiencing homelessness, these are not parallel debates. They are the same policy question, asked at different levels of government.

What the Updated Guidance Actually Removes

The April 2026 letter preserves SAMHSA funding for naloxone and nalmefene, medication lock boxes, sharps disposal, wound care, FDA-approved home testing kits for HIV and viral hepatitis, navigation to PrEP and PEP, and condom distribution. It eliminates funding for fentanyl, xylazine, and medetomidine test strips intended for use by people who use drugs, alongside syringes, safer smoking supplies, sterile water, saline, ascorbic acid, and overdose hotlines that provide a remote companion to people while using.

This represents a significant retreat from the July 2025 SAMHSA guidance, which had preserved test strips even as it shifted the agency's overall framing. STAT News notes that the test strip policy reverses a position the federal government held since 2021. The carve-out permitting test strip purchases for law enforcement, emergency medical services, and healthcare professionals captures the structural problem: test strips work because they reach people before an overdose, not after. Each strip costs roughly one dollar. Rachel Winograd, who oversees Missouri's central warehouse for overdose prevention supplies, confirmed her usual order for 80,000 test strips on the afternoon the SAMHSA letter arrived in her inbox.

A second letter issued the same day warns grantees against medication-only treatment for opioid use disorder, encouraging clinicians to review continued use of methadone or buprenorphine "at least annually." As STAT observed, current standards of care do not support withholding medication from patients who decline psychosocial services, and the ASAM guideline the letter cites contradicts that framing.

The Evidence the Policy Discards

Syringe services programs (SSPs) are among the most studied public health interventions of the past three decades. A meta-analysis of more than 6,000 patients found a 58% HIV transmission risk reduction among SSP participants. High-coverage programs reduced HCV transmission by 52% in one UK meta-analysis and by 76% in a Cochrane review of nearly 2,500 patients. New York City saw a 29% reduction in HCV prevalence among people who inject drugs after SSP introduction. The economic case is equally clear: full harm reduction averts approximately 70 HCV treatments per 1,000 people who inject drugs, translating to roughly $2 million to $6.7 million in annual savings per 1,000 people based on direct-acting antiviral pricing.

The connection to current epidemiology is direct. HCV infections in the United States increased 124% between 2013 and 2020, largely driven by injection opioid use, and over 75% of overdose deaths in 2023 involved fentanyl. A meta-analysis published in Viruses demonstrated that combined harm reduction with medications for opioid use disorder reduced HCV transmission nearly fourfold compared to limited or absent access. The Department of Veterans Affairs, in its December 2025 analysis referenced in CANN's previous coverage, described SSPs as one of the most effective public health interventions ever devised, with reductions in new HIV and HCV cases of up to 67% and a five-fold increase in the likelihood of achieving abstinence among participants.

The evidence base is not contested in the medical literature. It is contested in federal policy.

The Executive Order's Architecture of Enforcement

The April 2026 SAMHSA letter does not stand alone. Section 4(a)(i) of Executive Order 14321, signed July 24, 2025, directed HHS to ensure SAMHSA grants "do not fund" harm reduction or safe consumption efforts. Section 3 instructs the Attorney General, HHS, HUD, and the Department of Transportation to prioritize discretionary grants for jurisdictions that enforce prohibitions on urban camping, loitering, and squatting, and that move people with mental health conditions or substance use disorder into treatment through civil commitment.

The order's foundational claims warrant examination. It asserts that the "overwhelming majority" of unhoused people are addicted to drugs or have a mental health condition. The data tell a different story: roughly one-third of people experiencing homelessness have a substance use disorder, and roughly one-third have a mental health condition. Penn LDI's Dennis Culhane has observed that housing affordability is the primary explanatory variable in modeling homelessness rates by city or county, and that 84% of households in shelters do not receive Housing First or rental assistance to exit homelessness. The Department of Veterans Affairs implementation of Housing First reduced veteran homelessness by 55%, and the administration has not modified that program.

A federal appeals court ruled on March 31, 2026 that HUD's attempt to cap permanent housing spending at 30% of grants was unlawful, describing the policy as a slapdash imposition of political whims. The administration must now go to Congress to alter that framework.

Louisiana HB 211: The Cascade in Practice

Louisiana's House Bill 211, authored by Representative Debbie Villio, criminalizes unauthorized public camping with fines up to $500 and six months imprisonment for a first conviction, escalating to $1,000 and one to two years with hard labor for subsequent convictions. The bill passed the Louisiana House in April 2026 and awaits action in the Senate Judiciary C Committee.

State officials have acknowledged that supporting the bill could improve Louisiana's standing with the Trump administration when discretionary federal grants are awarded. This is the EO's incentive structure functioning as designed. The downstream context matters: Louisiana has the nation's highest poverty rate and the highest incarceration rate in the Western world. About 60% of Louisiana's unhoused population is Black despite the state being 30% Black. Roughly one in three Louisiana households are extremely low income, and the National Low Income Housing Coalition estimates a shortage of more than 100,000 affordable homes for those families. New Orleans Councilmember Lesli Harris compared the bill to internment camps and warned it would produce no lasting housing or services.

The Homelessness Court program created by HB 211 allows participants to have charges dismissed upon successful completion, but defendants may be required to pay for treatment costs, with courts authorized to mandate unpaid labor when payment is impossible. Pastor Jeremy Babineaux, quoted in KPLC's coverage, asked the question that the bill's text does not answer: how do unhoused people pay fines and program fees when they cannot afford housing in the first place?

Where the Syndemics Compound

Harm reduction defunding does not happen in a vacuum. Encampment sweeps, civil commitment mandates, and treatment-first housing conditions interact with the loss of test strips, sterile supplies, and overdose hotlines to produce harms that exceed the sum of their parts. For people who inject drugs and live with or are at risk for HIV or HCV, the result is a policy environment that systematically severs the connections that public health depends on.

Sweeps and criminalization disrupt continuity of care in concrete, documented ways. Research compiled by the National Alliance to End Homelessness finds that enforcement actions cause loss or destruction of legal documents, medical equipment, prescriptions, and personal effects, while displacing people from the locations where outreach workers and providers know to find them. People moved from one public area to another lose contact with street medicine teams, syringe services, and the case managers who help them apply for Medicaid or get on antiretroviral therapy. Those connections are how the Ending the HIV Epidemic and HCV Elimination plans actually reach the populations that drive ongoing transmission.

The economics are not subtle. Chronic homelessness costs taxpayers approximately $31,000 per person per year under enforcement-driven approaches, while permanent supportive housing with case management costs roughly $10,000 per year. The U.S. Interagency Council on Homelessness has documented that anti-homeless enforcement can cost three times more than housing the same people. Housing First programs, when compared to treatment-first models, reduce homelessness by 88% and, among people living with HIV, decrease emergency department visits by 41%, hospitalizations by 36%, and mortality by 37% within two years, according to research summarized in the AMA Journal of Ethics.

The convergence is what makes the compounding harm difficult to undo. A person who loses access to sterile syringes is more likely to acquire HCV. A person whose encampment is swept loses the ID required to enroll in Medicaid coverage for direct-acting antivirals. A person facing civil commitment or a camping conviction acquires a record that disqualifies them from future housing applications. Each link in the chain, individually defensible to its proponents, produces a population less reachable by the public health system than it was a year ago.

Specific Actions for Advocates

The federal policy framework can be challenged at multiple points. The April 2026 SAMHSA guidance is administrative, not statutory, and Congress retains appropriations authority. The FY2026 Labor-HHS package, as we previously reported, already includes structural protections requiring advance notice before HHS reorganizations and grant terminations. The FY2027 cycle is the next opportunity to direct SAMHSA on allowable harm reduction expenses and to push back on the medication-only treatment framing in the second April 24 letter.

For people working in HIV and HCV care, the most immediate action is documentation. State health departments and Ryan White grantees should be tracking, in real time, the gaps that emerge as SAMHSA-funded programs lose access to test strips and sterile supplies. Quantifying lost services and projected transmission impacts gives appropriators and oversight committees the data they need to act. Sharing that documentation with state public health officials, congressional staff, and the press converts administrative changes into a public record.

For Louisiana readers, HB 211 sits before the Senate Judiciary C Committee. The cost-effectiveness data is unambiguous, and the bill's own structure invites scrutiny: a program that requires payment from people who cannot afford housing, with unpaid labor as the alternative, will not produce the rehabilitative outcomes its sponsors claim. Constituent contact with committee members, paired with testimony from clinicians and people with lived experience, is the most direct lever. The state's existing crisis with HIV transmission and HCV in rural and Delta communities makes the public health case immediate.

At the federal level, Representative Rashida Tlaib's Unhoused Persons Bill of Rights, reintroduced April 30, 2026, calls on HHS to declare the unhoused crisis a public health emergency and proposes universal housing vouchers, expanded rental assistance, and non-carceral approaches to unsheltered homelessness. The resolution will not pass the current Congress, but its cosponsors are the policymakers most likely to move incremental protections through appropriations and oversight.

The Pridgen et al. review published in Harm Reduction Journal in June 2025 outlines additional federal and state actions worth pursuing: amending 21 U.S.C. 863 to decriminalize syringes and drug-checking equipment; protecting Medicaid coverage of PrEP in light of the Braidwood litigation; expanding scope of practice for nurse practitioners and physician assistants to prescribe PrEP; and opposing Medicaid lockouts based on substance use. None of these require the current administration's cooperation. All of them require sustained engagement from the advocacy community.

The Cost of Choosing Ideology Over Evidence

The federal government has, simultaneously, committed to ending the HIV epidemic, eliminating hepatitis C as a public health threat, and reducing overdose mortality. Yet, achieving any of those goals requires reaching the populations whose injection drug use, housing instability, and disconnection from systems of care drive ongoing transmission and death. The April 24, 2026 SAMHSA guidance, the July 2025 Executive Order, and state bills like Louisiana HB 211 move in the opposite direction. They withdraw the tools that connect public health systems to the people they are meant to serve, and they create incentives for jurisdictions to use enforcement against the populations the federal government has committed to helping.

The evidence on syringe services programs, fentanyl test strips, Housing First, and medications for opioid use disorder is not preliminary. It spans decades, multiple meta-analyses, and the operational experience of the Department of Veterans Affairs, which the current administration has chosen to leave intact. The contradiction is the policy.

For us, the path forward is to keep the evidence in front of the people making decisions: appropriators, state legislators, Medicaid directors, hospital systems, and the press. Public health goals like ending the HIV epidemic and HCV elimination are not abstract aspirations. They depend on specific tools, specific funding streams, and specific connections to the populations most at risk. Each test strip removed, each encampment swept, each treatment-first mandate imposed represents a measurable cost to those goals.

Patients deserve policy grounded in what works. The administrative and legislative actions of the past nine months have moved in a different direction. We have the data, the clinical experience, and the cost analyses to make the case for course correction. The work now is to make that case loudly enough, often enough, and to the people with the authority to act.

The Great American Recovery Needs More Than a Slogan

On February 2, 2026, Health and Human Services Secretary Robert F. Kennedy Jr. took the stage at SAMHSA's Prevention Day to announce a $100 million pilot program addressing homelessness and addiction, alongside a meaningful expansion of medication access for families affected by opioid use disorder. In the same speech, Kennedy characterized harm reduction as a "non-effective intervention" that "enabled future drug use." The contradiction captures the current state of American addiction policy: genuine progress on biomedical treatment access undermined by ideological rejection of the evidence-based strategies needed to keep people alive long enough to access that treatment.

The scope of the crisis is not in dispute. According to the White House fact sheet accompanying the Great American Recovery Initiative, 48.4 million Americans, or 16.8% of the population, live with substance use disorder. Nearly eight in ten did not receive treatment in 2024. These numbers should focus policymakers on removing every barrier between people and care. Instead, the administration is simultaneously expanding some pathways while actively dismantling others.

The Biomedical Frontier

One area of genuine scientific promise involves glucagon-like peptide-1 (GLP-1) receptor agonists, medications originally developed for diabetes and obesity that are showing unexpected potential for treating addiction. These drugs target the brain's mesolimbic reward pathways, and emerging research indicates they may modulate the dopamine neurotransmission involved in addictive behaviors.

The implications are significant. As the British Journal of Pharmacology notes, no FDA or EMA-approved medications currently exist for cocaine or stimulant use disorders. This treatment gap disproportionately affects marginalized communities, including LGBTQ populations where methamphetamine use remains a significant concern intersecting with HIV and HCV transmission.

Early evidence is encouraging. A large observational study using the VA database found that people with alcohol use disorder who used GLP-1 medications had a 50% lower rate of alcohol bingeing compared to those not on the medications. People with opioid use disorder on these medications had a 40% lower rate of overdose. Clinical trials are now underway for multiple substance use disorders, including a trial specifically enrolling people with both cocaine use disorder and HIV.

"This research is very important because alcohol and drug addiction are major causes of illness and death, yet there are still only a few effective treatment options," Dr. Lorenzo Leggio of the National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism noted in October 2025.

The critical question is access. As Penn Medicine researchers have observed, "many who struggle with addiction are multiply marginalized, making access to these medications a potential concern." The VA study data came largely from older white males, and robust research across demographics remains necessary. Breakthrough treatments mean little if the people who need them most cannot obtain them.

Meaningful Progress

Credit where due: the administration has taken concrete steps to expand medication access for opioid use disorder. On February 2, the Administration for Children and Families announced that buprenorphine, methadone, and naltrexone now qualify as prevention services eligible for Title IV-E funding. States and tribes can receive a 50% federal match to provide these medications to parents when children are at imminent risk of entering foster care. The policy reflects sound reasoning: keeping families together through effective treatment generally serves children better than separation.

The December 2025 reauthorization of the SUPPORT Act extended substance use disorder programs through fiscal year 2030 after the original legislation had languished since its 2023 expiration. The bill passed with strong bipartisan support, 366-57 in the House and by unanimous consent in the Senate.

There is also useful historical precedent from the first Trump administration. In May 2020, HHS Office for Civil Rights Director Roger Severino secured an agreement with West Virginia establishing that people in recovery using medication-assisted treatment are entitled to ADA protections. "People in recovery from opioid use disorder should never be stigmatized for seeking appropriate medical treatment that can save their lives," Severino stated at the time. That principle should guide current policy.

Where Policy Contradicts Evidence

Against these advances stands a pattern of actions that undermine the stated goal of connecting people with treatment.

The Substance Abuse and Mental Health Services Administration has lost approximately one-third of its roughly 900 employees over the past year. In January 2026, the administration briefly cancelled nearly $2 billion in SAMHSA grants before bipartisan backlash forced a reversal within 24 hours. Providers report an environment where planning for the future feels impossible.

The administration proposed folding SAMHSA into a new "Administration for a Healthy America." Congress rejected this in the FY2026 LHHS appropriations package and added structural protections requiring 60 days' advance notice before HHS reorganizations affecting CDC functions and three days' notice before grant terminations. These guardrails exist because they proved necessary.

On harm reduction, the gap between evidence and policy is particularly troubling. The July 2025 executive order "Ending Crime and Disorder on America's Streets" directed SAMHSA to defund "so-called harm reduction" programs. A subsequent SAMHSA letter drew an explicit line between acceptable overdose reversal tools like naloxone and the "ideological concept of harm reduction."

This framing ignores the government's own evidence. In December 2025, the VA published an analysis of its harm reduction programs describing syringe services programs as "one of the most effective public health interventions ever devised." The data: SSPs decrease new HIV and HCV infections by up to 67%, increase the likelihood of achieving abstinence five-fold, and "do not enable or increase drug use, nor do they cause increases in crime."

The FY2026 appropriations bill maintains Section 525, the longstanding prohibition on using federal funds for sterile needles or syringes outside narrow outbreak exceptions. Report language frames harm reduction through an abstinence-first lens, treating harm reduction and recovery as opposing forces when the evidence shows they are complementary. Meeting people where they are is how you eventually connect them with treatment.

The Syndemic Reality

These policy contradictions have real consequences for communities facing intersecting epidemics. Syringe services programs are foundational infrastructure for preventing HIV and HCV transmission among people who inject drugs. Cutting STI prevention funding by $10 million while syphilis and congenital syphilis remain at historically high levels makes no public health sense.

The approach to homelessness reveals similar contradictions. The July 2025 executive order abandons Housing First, the evidence-based model that prioritizes stable housing as a foundation for recovery. In its place, the order directs agencies to prioritize jurisdictions that enforce bans on urban camping, loitering, and open-air drug use when awarding federal grants. It encourages states to expand involuntary civil commitment and conditions housing assistance on participation in behavioral health treatment. The Bipartisan Policy Center notes this approach may invite Fair Housing Act lawsuits, since conditioning housing on treatment could constitute discrimination against people with disabilities, including those with substance use disorder.

HHS’s $100 million STREETS Initiative operates within this enforcement-first framework. Kennedy described the model as finding people on the street and moving them "from crisis to detox treatment to housing to employment." Housing comes after treatment compliance, not before. The National Alliance to End Homelessness has been direct in its assessment: "Deinstitutionalization did not cause homelessness, and re-institutionalization will not solve it."

The 2024 Point-in-Time count recorded over 770,000 people experiencing homelessness, an 18% increase from the previous year and the largest annual jump ever recorded. Those most affected include people with mental illness or substance use disorder, LGBTQ youth, and veterans, as Harvard's Howard Koh has noted. A $100 million pilot serving eight cities cannot address a crisis of this scale, particularly when the broader policy framework criminalizes the people it claims to help.

Access barriers to existing treatments compound the problem. The Cato Institute reports that 80% of U.S. counties have no opioid treatment programs, and only 600,000 of the 8 million people meeting criteria for opioid use disorder received methadone in 2024. The bipartisan Modernizing Opioid Treatment Access Act would have enabled primary care prescribing of methadone; it was not reintroduced in the current Congress.

The Path Forward

The promise of emerging treatments like GLP-1 agonists cannot be realized without the infrastructure to deliver them. A breakthrough medication for stimulant use disorder means nothing to someone cycling between encampments and emergency rooms because Housing First was abandoned in favor of treatment mandates they cannot access. Flat funding for SAMHSA, restrictions on harm reduction, and criminalization of homelessness create gaps that no medication can bridge.

"If we want to create a world where there's opioid recovery, we need to also offer affordable housing and access to affordable food and improved access to health care," Dr. Sadie Elisseou of Harvard told Behavioral Health Business. This syndemic framing should guide policy. It currently does not.

The administration cannot simultaneously expand medication access, gut the agency responsible for treatment infrastructure, restrict the harm reduction programs that keep people alive and connected to care, and criminalize the circumstances of those most in need of help. These policies do not form a coherent strategy. They form a contradiction.

Congress rejected the administration's most extreme proposals through the passage of the L-HHS funding package, but holding ground is not progress. Advocates should monitor SAMHSA implementation closely, push for evidence-based harm reduction funding that aligns with the VA's proven model, defend Housing First against ideological attack, and ensure that new treatments reach marginalized communities rather than only those with private insurance and stable housing.

The tools to address substance use disorder exist. What remains absent is a policy framework that treats people who use drugs as deserving of care rather than punishment. Until that changes, the Great American Recovery will remain a slogan, not a strategy.

Underprepared: Opioid Settlement Dollars are Coming

Past public health crises have led to significant settlements. The 1998 Tobacco Master Settlement Agreement, for instance, was heralded as a landmark deal. Major tobacco companies agreed to pay billions to 46 U.S. states, funds that were ostensibly earmarked for anti-smoking campaigns and health programs. Yet, as research from RAND later revealed, a significant portion of these funds were diverted to unrelated projects. The promise of a healthier future was overshadowed by the allure of immediate fiscal relief, a misstep that has had lasting implications and begs the question. Will the opioid settlement reach the same result or have states learned their lesson?

Recent Concerns

Probably not, as the misuse of settlement funds remains a concern:

•COVID Funds Misdirection: In a move that sparked controversy, some states opted to use COVID relief funds for prisons, diverting resources from pandemic relief efforts. This decision underscores the tension between immediate fiscal needs and long-term public health goals.

•Mendocino County's Opioid Funds Dilemma: In a decision that drew sharp criticism, especially from those directly affected by the opioid crisis, Mendocino County used over $63,000 of opioid settlement funds to address a budget shortfall, despite having the highest rate of overdose deaths in California.

•New York's Opioid Funds Controversy: Raising eyebrows and questions about the state's priorities, funds intended for opioid crisis mitigation in New York were instead used for overtime expenses related to narcotics investigations.

The Current Landscape

While the anticipated $50 billion from opioid lawsuits offers hope, the lack of standardization and oversight in fund distribution is concerning. The primary objective of these funds is to bolster prevention, treatment, and recovery infrastructure, but it is feared that the absence of clear guidelines and reporting mechanisms will lead to misallocation and abuse. Only 12 states have committed to detailed reporting, emphasizing the need for transparency.

The Profit-Driven Rehab Industry's Ethical Crisis

Challenges posed by the profit-driven rehab industry in the U.S. include aggressive sales techniques, overcharging, and substandard care. The system often pushes vulnerable individuals into treatments that may not be in their best interest. The Affordable Care Act, while praised for mandating private insurance programs to cover addiction treatments, inadvertently led to a surge in for-profit rehab clinics, some of which prioritize profit over patient care, further emphasizing the need for rigorous oversight and quality standards. Few state officials are familiar with these market and health landscape dynamics, meaning few officials are ready to offer the necessary oversight of these dollars and the programs they’ll be going to support. That includes drug court programs.

A recent investigation by Spotlight PA highlighted the lax oversight of addiction treatment facilities in Pennsylvania. The Department of Drug and Alcohol Programs (DDAP) in Pennsylvania has been criticized for allowing providers to continue operating despite repeated violations and harm to clients. The tragic story of Adam Kalinowski, who died less than 24 hours after entering a treatment center known as Addiction Specialists, Inc. (ASI), serves as a poignant example. ASI had a history of violating state rules, and a wrongful death suit against them resulted in a judgment of over $1.6 million in damages.

Drug Courts

In response to surging drug-related criminal cases, drug courts have emerged as a solution, offering offenders a chance at rehabilitation instead of incarceration. However, there are serious vulnerabilities. Recent revelations in Louisiana provide an example of how lax federal oversight of the Department of Health and Human Services (HHS) grants funding of drug courts have lead to corruption, kickbacks, and questionable practices within these drug court systems and the treatment centers they refer defendants to.

In Lafayette, Louisiana, a mysterious $3 million appropriation for a substance abuse rehab facility became the epicenter of controversy. In the previous year, while the state Senate was formulating the state budget, an unusual amendment was introduced, directing $3 million to a governmental health organization in Lafayette for a 70-bed addiction treatment center. It was later revealed that three businessmen, Mark Fontenot, Jeff Richardson, and Leonard Franques, were advocating for this funding to establish a substance abuse rehabilitation facility in Lafayette. Franques is currently at the heart of an expanding bribery investigation that has implicated officials from the 15th Judicial District Attorney’s office in Lafayette, among others. The scheme involved DA Office kickbacks for steering pretrial diversion defendants to four businesses, including Lake Wellness Center, Franques' outpatient rehab facility.

The scandal in Lafayette highlights the intricate web of connections and potential conflicts of interest surrounding substance abuse rehab facilities, the justice system, and state legislatures who will be in charge of setting appropriations for these historic opioid settlement funds. Harm reduction and Justice advocates will need to work closely together in order to push for necessary “watch dog” activities and opportunities in these referral systems.

The Crisis of Medication Assisted Treatment Access for Minors

The rise of fentanyl has dramatically altered the landscape of opioid addiction. Teenagers are developing severe dependencies at an alarming rate, transitioning rapidly from experimentation to intense dependence. This swift onset of addiction underscores the urgent need for effective treatments tailored to this age group.

Despite the proven efficacy of buprenorphine, considered the gold standard for treating opioid use disorder, less than a quarter of residential treatment centers for adolescents offer it. This lack of access is deeply concerning, especially given the sharp rise in overdose deaths among teenagers, exacerbated by the proliferation of fentanyl.

Several barriers hinder the provision of MAT to minors:

•     Philosophical Objections: Some facilities object to medications like buprenorphine on philosophical grounds, despite its proven efficacy.

•     Lack of Expertise: Many treatment centers lack the necessary expertise to treat adolescents with MATs.

•     Stigma: The stigma associated with MATs, especially among teenagers, poses a significant barrier. If teenagers feel marginalized for taking medication, they might avoid it.

•     Systemic Barriers: A shortage of certified providers and underfunded facilities highlight the systemic challenges that need to be addressed to tackle the opioid crisis effectively.

The lack of MAT access for minors raises concerns about the allocation of opioid settlement funds. The funds are intended to address the opioid crisis head-on. If they aren't used to ensure access to MAT for all, including minors, public trust in the system could erode. Furthermore, without access to effective treatments and education, teenagers are at a higher risk of overdose and death. Addressing the barriers to MAT access for teenagers is crucial to ensure that the funds are used effectively and that this vulnerable population receives the care they desperately need.

The Role of the Department of Health and Human Services

The HHS plays a pivotal role in shaping the nation's response to the opioid epidemic. It oversees fund allocation, issues grants to incentivize particular programming, and sets care standards. Ensuring these standards are stringent and patient-centric is vital. State health departments face challenges, including staffing shortages, which can impact fund management.

State Health Department Challenges

State health departments, such as the North Carolina Department of Health and Human Services (NCDHHS), play a crucial role in addressing the opioid crisis at the local level. However, these departments face significant challenges, including staffing shortages and budget constraints. For instance, the NCDHHS has grappled with a 28% vacancy rate, which has doubled since the onset of COVID. Such staffing shortages can severely hamper the department's ability to manage and allocate funds effectively. These challenges have direct implications for local initiatives, such as the Queen City Harm Reduction's housing pilot program, which faced delays due to funding issues.

Lack of Guidance on Contract Quality with Local Drug Courts

While the HHS provides oversight and sets standards for care, there has been a notable lack of guidance on increasing contract quality between local drug courts, private and publicly funded managed care programs, and providers. Given the potential for conflicts of interest and corruption within the drug court system, as evidenced by the Lafayette bribery scandal, this lack of guidance is concerning. Ensuring transparency, accountability, and quality in contracts is a key factor that will ensure opioid settlement funds are effectively used at every level.

Conclusion and Call to Action

The opioid epidemic presents a monumental public health challenge. The opioid settlement funds offer a unique opportunity to address these interlinked crises. However, without stringent oversight and a clear roadmap, there's a risk that these funds might not be used to their maximum potential.

The rapid allocation of funds without proper oversight is a recipe for disaster. It's crucial to ensure that these funds are channeled into comprehensive programs that not only address OUD but also the associated risks of HIV and HCV infections.

The opioid epidemic and the associated settlement funds present both an opportunity and a challenge. Proper oversight is essential to ensure these funds are used effectively. Advocacy groups, community leaders, and stakeholders must rally together to push for rigorous HHS contract quality standards, ensuring transparency and accountability.

Congress Eyes Equipping Providers to Combat the Opioid Crisis; The MAT Act

A year ago this month, Representative Paul Tonko introduced H.R. 1348 to the House of Representatives and Senator Maggie Hassan (NH) introduced its companion bill, S. 445, to the Senate. Both of these bills hold the short title “Mainstreaming Addiction Treatment Act of 2021”. The House version boasts 239 cosponsors with the Senate version enjoying 3 cosponsors. Both are supported on a bipartisan basis. The most recent action on the MAT Act is Senate “HELP” (Health, education, Labor, and Pensions) Committee hearing on February 1st, 2022, wherein the committee discussed and heard testimony on issues of mental health amid the COVID-19 pandemic.

End Substance Use Disorder, an issue education campaign endorsing the MAT Act, describes the more than a century old policy of outlawing medication assisted treatment as “outdated” and a moralization of a medical condition. Founded by Erin Shanning after her younger brother, Ethan, experienced a fatal overdose, the organization seeks to educate legislative stakeholders and urge action to adopt a more modern and medicalized approach to substance use disorder. The MAT Act removes the prohibition on providers on prescribing certain medications for the treatment of opioid use disorder maintained in the Controlled Substances Act and entirely removes the necessity for the DEA waiver of this prohibition, known as the “X” waiver. According to ESUD is joined by 418 organizations have either directly supported the MAT Act or have voiced support for eliminating the X waiver, including criminal justice and law enforcement entities. For immediate transparency, Community Access National Network is one of those 418 organizations.

This relatively straight-forward bill would help to expand access to care – especially in rural communities, move public policy into better alignment with research-proven best practices, combat racialized public health disparities, better support families, reduce overdose deaths, and more. Directly, the most immediate and significant impact of the MAT Act is an expansion of providers eligible to prescribe medication assisted treatment, specifically including certain community health practitioners. The only apparent opposition to the MAT Act is a group representing the interests of commercial addiction treatment centers.

With overdose deaths having skyrocketed by at least 20% in 2020, relative to 2019, emphasizing the need to press forward with the MAT Act is the least the Biden administration can do to begin to meet its promises around drug reform and health care access. Mental health and substance use service providers still need more support from the federal government in order to meet the need of the moment. Equipping providers with tools like medication assisted treatment, improving (read: increasing) Medicaid reimbursement rates for the treatment of substance use disorder, working to destigmatize the issue of substance use disorder, and more explicitly issuing Department of Justice guidance to family courts, social service organizations, and employers on protections afforded under the Americans with Disabilities Act for people recovering from substance use disorder are the least in a long list of actions this administration can take today.

If you would like to urge your elected representatives to remove barriers to care for clinically-proven, best practices in harm reduction, follow this link and to add your organization’s name to ESUD’s letter of support for the MAT Act, click here.