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.