By Taylor Knopf
For the third year in a row, drug overdose deaths in the U.S. have trended downward. North Carolina had one of the largest year-over-year decreases — a nearly 29 percent drop in overdose deaths from the end of 2024 to 2025.
Substance use experts worry these hard-fought gains could now be in jeopardy as President Donald Trump’s administration chips away at funding for addiction programs and some key evidence-based overdose prevention tools.
Most recently, the federal Substance Abuse and Mental Health Services Administration banned the use of the agency’s grant funding to support some harm reduction interventions. Among the items federal officials have said agencies can’t spend money on: sterile syringes that prevent the spread of diseases and rapid test strips that detect harmful additives in street drugs.
Harm reduction is a public health approach that aims to minimize the ill effects associated with drug use — to prevent the spread of disease and help people stay alive and connect with support services. These interventions acknowledge the realities of drug use, prevent overdose deaths and drive down rates of infection.
Recently, the Trump administration has discouraged such harm reduction interventions, saying that they only facilitate illegal drug use. The updated guidance from SAMHSA released in a “Dear Colleague” letter in April is a continuation of a similar letter released last summer in which the agency described its shift away from harm reduction.
Those who work directly with people who use drugs say the federal agency’s new guidance conflicts with other national policies and could have far-reaching consequences on different streams of funding. They also say the crackdown on drug testing strips could not have come at a worse time due to the heavily adulterated street drug supply.
Ever-changing street drug supply
The street drug supply has become increasingly contaminated by different substances — from benign additives like caffeine to veterinary tranquilizer xylazine, which can cause severe skin wounds. Meanwhile, the extremely potent and deadly opioid fentanyl has been pressed into counterfeit prescription pills and sold as Xanax or Percocet to the unwitting.
“I know people personally who have taken something — thinking it was one thing and it was something else — and lost their life,” said Greg Berry, director of the Law Enforcement Assisted Diversion and Deflection programs at the North Carolina Harm Reduction Coalition. “They’re unprepared. They don’t have naloxone. They’re not thinking that they’re taking the opioid.”
Drug testing strips give people real-time information about what’s in the substance they’re using and allows them an opportunity to make safer choices. The knowledge could lead someone to perhaps acquire naloxone, to use less of a substance, or to use in the presence of someone who can get medical help if it’s needed.
Berry said he has even seen the results of a rapid drug checking test — or more detailed results from the Street Drug Analysis Lab at UNC — be the catalyst for someone to seek addiction treatment.
The stakes are especially high with contaminants such as xylazine, which has become prevalent in the circulating supply. The substance often causes chronic soft tissue injuries that can worsen over time. Berry, who has been conducting community health education campaigns about what’s in the drug supply, calls it a silent killer. He said he knows three people who died from complications from their wounds.
Harm reduction pioneer Louise Vincent had an adverse reaction to xylazine a few years ago; it contributed to her subsequent death in 2025.
Unpublished survey research Berry conducted with a researcher at Fayetteville State University found that among people in Cumberland County who self-reported exposure to xylazine, more than four in 10 said they developed wounds. Of those, 32 percent reported mild wounds, 51 percent reported moderate wounds requiring medical treatment, and 17 percent reported severe wounds requiring extensive care or resulting in long-term complications.
Meanwhile, new adulterants crop up in the street drug supply all the time. In the past year, the Street Drug Analysis Lab at UNC has documented a rise in medetomidine — a sedative used in hospitals to keep surgery patients and infants on ventilators comfortable. The lab, which tests drugs mailed in anonymously from harm reduction programs across the country, has analyzed more than 21,500 samples from 202 programs in 44 states and detected 514 unique substances.
According to the lab’s latest newsletter, medetomidine has been identified in at least 14 states and appears to be replacing xylazine in prevalence. In an analysis of more than 11,000 specimens, researchers found that samples containing medetomidine were 12 times more likely to be associated with hallucinations — an effect not typically seen with opioid use.
Unlike xylazine, which causes visible wounds, medetomidine is most dangerous when people try to stop using it, according to the UNC lab researchers. Withdrawal symptoms start within a day of last use and can trigger cardiac problems severe enough to require hospitalization, the researchers wrote. Harm reduction workers in Pittsburgh are now directing people whose drugs may contain medetomidine to bypass methadone clinics and go straight to an emergency room if they plan to stop using.
Given how quickly the drug supply changes, Berry and the UNC lab researchers argue that drug checking is one of the most crucial tools to protect those who use drugs.
Sowing fear and uncertainty
Beyond the immediate ban on drug checking supplies, experts say the federal guidance creates uncertainty that could ripple beyond SAMHSA-funded programs.
Berry worries that the agency’s position will influence other funders and organizations in the public health system.
“Even if they’re not receiving those funds, they still take direction from them,” Berry said. “[SAMHSA] saying ‘We’re no longer supporting that’ sends downstream messaging to other folks and other agencies who are looking to them as leaders to guide them.”
The uncertainty is already hitting North Carolina harm reduction programs. Lauren Kestner, director of Queen City Harm Reduction in Charlotte, said she got an email from the N.C. Department of Health and Human Services encouraging organizations to expedite their purchases of drug checking supplies just in case more restrictions materialize from other funders. Another recent email from a state health department employee included a form for organizations to order naloxone, and it noted in highlighted text: “At this time, test strips are not available for request.”
A DHHS spokesperson told NC Health News that the department has temporarily paused the purchasing of fentanyl and xylazine test strips while awaiting clarification from SAMHSA about the recent “Dear Colleague” letter and any potential changes related to allowable costs under federal funding.
“It is important to note that other non-federally funded resources remain available and may be used for overdose prevention programs to access test strips, such as state and local opioid settlement funds,” the department wrote in an email.
For Kestner, the pause shows how quickly federal policy changes filter down to organizations such as hers. She called the new SAMHSA guidance a fear-mongering tactic that she believes will continue spreading.
“This is having a really nasty ripple effect all the way from top to bottom,” she said, adding that it will lead to more overdose deaths and infectious disease outbreaks.
“It’s very ominous, and it’s setting us back decades,” she said.
In addition to SAMHSA’s ban on certain harm reduction supplies, the agency released a second “Dear Colleague” letter in April that gave recommendations for how health providers should engage people on medications for opioid use disorder. The letter encouraged providers to taper people off of medications at a certain point.
“[W]e are equally committed to ensuring that medications are part of the pathway to long-term recovery and sobriety, self-sufficiency, and thriving, not as a default sentence to life-long medication use,” the second letter stated.
There are already a limited number of providers willing to prescribe medications for opioid use disorder. Kestner said such guidance only sows additional uncertainty for these providers and will ultimately harm some of society’s most vulnerable. She said her organization partners with a lot of groups that receive SAMHSA money, and it’s led to questions of where they can link people to medication treatment for opioid use disorder.
Mixed messages
The latest SAMHSA guidance has also drawn criticism because it appears to contradict other federal policies that support drug checking.
“It was quite the about-face on test strips,” said Roxanne Saucier, a North Carolina-based harm reduction and drug policy consultant. “Especially after the letter last year that specified federal funds could be used for these.”
She noted that just weeks after SAMHSA’s ban on funding of test strips, the White House Office of National Drug Control Policy published its 2026 National Drug Control Strategy, which identified drug checking and testing as important tools for responding to emerging drug threats.
That plan calls for assessing and using public drug-checking programs to provide near real-time information about changes in the drug supply. The plan also states that rapid test strips used to detect fentanyl and other substances are important overdose prevention tools and should not be treated as drug paraphernalia.
Federal law also supports drug checking. The SUPPORT for Patients and Communities Reauthorization Act, signed into law by President Trump in December 2025, authorizes State Opioid Response grant funding for the purchase of drug checking supplies that detect substances such as fentanyl and xylazine.
The apparent contradiction prompted Sen. Edward Markey (D-Mass) and 20 other Democratic members of Congress to send a letter to SAMHSA leaders urging them to reverse their latest guidance.
The lawmakers argued that restricting access to test strips and sterile syringes “threatens to reverse years of progress in combating the overdose epidemic” and conflicts with evidence showing that harm reduction interventions reduce overdose deaths and infectious disease transmission.
They also noted that SAMHSA’s position appears at odds with guidance from the Centers for Disease Control and Prevention, which promotes fentanyl test strips as a low-cost tool that can help prevent overdose deaths.
In their letter, the members of Congress challenged the assertion by SAMHSA that harm reduction practices are incompatible with federal law. They wrote that drug test strips are not illegal under federal law and are legal in most states. Additionally, Congress recently affirmed its support of drug testing strips by authorizing federal grant funding for them.
“This law, which passed unanimously in the Senate and with broad bipartisan support in the House, encourages use of the precise tools SAMHSA is now working to ban,” the lawmakers wrote.
The mixed messages have left public health workers trying to reconcile federal support for drug checking in some policies with restrictions on funding for the same tools in others. In North Carolina, organizations are closely watching to see what additional guidance and funding limitations may follow.
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