The nation’s drug overdose crisis is finally beginning to slow down. After it reached a peak during the years of the Covid-19 pandemic, there have been substantial declines in overdose deaths over the past two years. The Centers for Disease Control and Prevention reports that from 2023 to 2024, there was a 24 percent drop in overdose deaths. This is good news, and while we don’t know exactly what caused the decline, investments in overdose prevention, treatment, and health care supports certainly played a role.
Still, there is more to be done, and the crisis is far from over: Many states continue to report overdose death rates above their pre-pandemic levels. Recognizing this fact, Secretary of Health and Human Services Robert F. Kennedy Jr. recently signed a declaration extending the public health emergency for the overdose crisis.
But not everyone is on the same page. Despite the secretary’s acknowledgment of the ongoing crisis, this progress is now imperiled by recent cuts that have been made to the workforce of the Substance Abuse and Mental Health Services Administration, or SAMHSA, by DOGE. It may be one of the smallest agencies in the federal government, but on the public health front, it’s been delivering bang for the buck, at least until now. In the recent round of cuts, SAMHSA reportedly lost more than 10 percent of its staff—100 probationary staffers out of a workforce of more than 600.
These cuts may seem insignificant, but SAMHSA plays an outsize role in the federal government’s response to the overdose crisis. The agency awards millions of dollars in grants to behavioral health care clinics, overdose prevention and outreach programs, substance use disorder treatment and recovery services, and tribal health care services, to name a few. These programs go beyond just monetary support, as SAMHSA provides training and technical assistance to these organizations as well.
For instance, its Center for Addiction and Recovery Support helps to train peer recovery support specialists (people who are in recovery who can assist others with substance use disorder). According to agency estimates, this agency trained around 2,500 people in 2024. Perhaps most importantly, SAMHSA ensures that opioid treatment providers, or OTPs, stay in compliance with federal regulations; a disruption to that workforce could have detrimental impacts on the ability of OTPs to operate. Finally, SAMHSA also provides services directly to individuals—namely, the 988 National Suicide and Crisis Line; employees who helped operate this line were reportedly laid off.
According to Representative Paul Tonko, these layoffs cut deep, cutting all staff in SAMHSA’s regions Four and Five (which encompass much of the Midwest, Appalachia, and the South). Representative Tonko cited an absence of staff on the website; since his letter, some of the staff profiles have returned to the site. Nonetheless, Tonko and others have also alarmingly heard word of further cuts (50 to 70 percent) to the agency.
Cuts to the SAMHSA workforce are the most critical for people directly impacted by the overdose crisis, but as jobs are rapidly and indiscriminately eliminated across the government in health care—from the CDC to the Department of Veterans Affairs—we can expect similar impacts across many other groups. Cuts to SAMHSA also go beyond its workforce—on Monday, the Department of Health and Human Services announced it was cutting $1 billion in grants from SAMHSA to states, affecting state health departments that heavily rely on federal funding.
But beyond federal agencies, particularly worrying are the impending cuts to Medicaid—after passing a continuing resolution, Congress is now looking to make $880 billion in cuts to spending, the vast majority expected to come from Medicaid. This would be extraordinarily detrimental to people who have substance use disorders, in a wide variety of ways. People who are enrolled in Medicaid have a higher overdose risk: One study documented a rate twice as high as the rest of the U.S. population in 2020. Another study found a risk about four times higher than for those on private insurance. This is likely because Medicaid is a proxy indicator for poverty, which is also a risk factor for overdose death.
Medicaid is also a primary payer for lifesaving treatment. A recent study in JAMA Network Open, which analyzed claims data, found that Medicaid made up 93 percent of claims for substance use disorder treatment and 75 percent of claims for telehealth treatment. Private insurance by contrast made up 6 percent and 24 percent, respectively. Still, people on Medicaid face barriers in accessing treatment: Another study found that only 55 percent of Medicaid enrollees diagnosed with opioid use disorder received treatment. These disparities are worse in the South—with Oklahoma, Arkansas, Mississippi, and Alabama having rates ranging from 19 percent to 25 percent. Cuts to Medicaid would only increase these barriers to evidence-based treatment and health care and potentially lead to higher rates of overdose and overdose deaths.
All of these factors—job loss, losing health care, losing access to treatment and services—can cause a disruptive impact to people who use drugs or have a substance use disorder. If you take methadone daily and all of a sudden, you’re no longer covered by Medicaid, you’re at risk of using street drugs and courting an overdose. If the overdose prevention team that gives you naloxone, supplies, and other resources has to cut back its hours or close completely, an overdose could turn into an unnecessary and preventable death.
We saw all of this during the first few years of the pandemic, when overdose deaths skyrocketed to over 100,000. A study conducted in Rhode Island during 2020 found that job loss in the previous year was associated with increased overdose risk, while another study from New Jersey found that losing medical insurance tripled the risk of overdose. Back in Rhode Island, researchers interviewed people who use drugs during the Covid-19 pandemic and found that many of them could not access housing, social services, and health care. If such indiscriminate cuts to federal health care funding and the workforce committed to addressing the nation’s overdose crisis are to go through, we risk returning to this dire situation.
Overdose rates are finally declining, but far more progress needs to be made. For one thing, overdoses among Black and Indigenous people continue to rise. Overdose death rates are also now higher in rural areas than they are in urban areas. These are the challenges that the dedicated workforce at SAMHSA is best suited to face head-on, using time-tested solutions and knowledge about how best to prevent public health crises. From West Virginia to the Bronx, the United States is at a crossroads; public officials can either choose to invest in communities and expand on all the progress that’s being made or they can proceed with disastrous cuts that threaten to reverse long-fought and hard-earned progress. We hope it’s the former, but if these haphazard cuts continue we fear the worst.
