Navigating Changes to SAMHSA’s Approach to MOUD and Harm Reduction
What It Means for You
October 29, 2026
On April 24, 2026, the Substance Abuse and Mental Health Services Administration (SAMHSA) published two “Dear Colleague” letters setting new directives for how federal grant dollars can support opioid use disorder (OUD) care. The first shifts funding priority away from medication-only models toward comprehensive care that pairs medications for opioid use disorder (MOUD) with psychosocial treatment and recovery support. The second narrows the harm reduction supplies and services that SAMHSA funds can cover.
SAMHSA said the MOUD guidance will be built into updated grant terms and FY2026 funding announcements, and the harm reduction limits apply to SAMHSA grant funds. Coverage of the guidance has varied widely, leaving many treatment programs unsure what has actually changed. This article breaks down what each letter requires, what it does not say, where experts have raised concerns, and what it means for MOUD and harm reduction programs.
What the MOUD letter requires
SAMHSA will prioritize funding for comprehensive care models over medication-only models. The MOUD letter says this language will appear in updated terms and conditions for current grantees and in new FY2026 funding announcements. In practice, that means:
- Comprehensive services. Medication, where clinically indicated, delivered alongside psychosocial treatment and recovery support services.
- A regular treatment review. Once a patient is stable and has recovery supports in place, and at least once a year, clinicians should talk with the patient about treatment and recovery goals and the continued role of medication.
- Individualized decisions. Whether to continue medication is evaluated person by person, weighing progress toward goals, stability, recovery capital, and patient preference.
- Gradual, supported changes. If a patient and clinician decide together to stop medication, the taper should be gradual, with added support and monitoring, within ongoing comprehensive care.
- Clinician training. Funds should support training on appropriate medication use, shared decision-making, and connecting patients to comprehensive treatment and recovery services.
Learn how digital tools can improve recovery, retention, and linkage to care!
What the MOUD letter does not say
The letter does not cap treatment length, require tapering, or direct providers to stop medication for patients who are doing well. Several points in the letter itself are worth knowing:
- MOUD remains core, evidence-based care. SAMHSA credits these medications with reducing opioid use, overdose deaths, and recidivism, and restates its commitment to expanding access.
- Arbitrary limits are cautioned against. The letter notes that maximum time limits or abrupt discontinuation can lead to poor outcomes for patients.
- Long-term treatment stays an option. Lifelong medication remains available when clinically indicated; SAMHSA’s position is that it should not be the automatic default for everyone.
- Stopping is a shared decision. Any change is made by the patient and clinician together, based on the individual’s circumstances and preferences.
The letter also does not direct programs to withhold medication from patients who decline counseling or other services, and current standards of care do not support doing so. For most programs, the practical change is documenting a regular treatment review and showing that patients have access to recovery supports alongside their medication.
Where the field has raised concerns
Many addiction medicine and policy experts have pushed back on the MOUD letter, and their concerns deserve a fair hearing.
- The problem is underuse, not overuse. Only 16 percent of people with OUD reported using MOUD in 2025. Of those who start, about 20 percent stop in the first month and 64 percent by six months (Health Affairs). Critics argue new review requirements add administrative burden without addressing that gap.
- Risk of early discontinuation. Some experts worry the letter could lead providers to taper buprenorphine too quickly or discourage patients from seeking methadone (Partnership to End Addiction).
- Stigma in the framing. Some readers see the letter’s language about lifelong medication as echoing the idea that recovery on medication is not “real” recovery (Partnership to End Addiction).
Both sides share the same goal: keeping people in care long enough to recover. Given how many patients leave treatment in the first months, the most useful step for providers is strengthening the support around medication so patients stay engaged.
Who benefits from MOUD
Anyone diagnosed with OUD should be assessed and offered individualized medication. The ASAM National Practice Guideline sets no recommended time limit on medication, and says that declining counseling, or a lack of available counseling, should not delay or prevent it. The three FDA-approved options serve different needs:
- Methadone is a long-acting opioid agonist dispensed through certified opioid treatment programs. It reduces cravings and eases withdrawal.
- Buprenorphine is a partial agonist that clinicians can prescribe for use outside a clinic, with a lower overdose risk than full agonists.
- Naltrexone is not an opioid. It blocks opioid receptors and is typically started after withdrawal is complete.
Comprehensive care alongside medication can be especially valuable for people with co-occurring mental health conditions or other substance use, chronic pain, or pregnancy, and for those facing challenges with housing, employment, legal issues, or family. How long a person stays on medication is a decision made with their clinician, guided by their goals, stability, and preferences.
What the harm reduction letter changes
The second letter narrows the harm reduction supplies and services that SAMHSA grant dollars can cover, building on SAMHSA’s July 2025 guidance. The most notable change is that grantees can no longer use SAMHSA funds to buy fentanyl test strips for distribution.
Still fundable with SAMHSA dollars
- Overdose reversal medications such as naloxone and nalmefene, plus distribution and training
- Medication lock boxes and disposal kits
- Wound care supplies
- HIV and hepatitis home testing kits, education, navigation, and referrals to care
- Sharps disposal kits
- Nicotine cessation therapies
No longer fundable with SAMHSA dollars
- Syringes
- Pipes and other safer smoking supplies
- Fentanyl, xylazine, and medetomidine test strips or other drug checking kits for people who use drugs (law enforcement, EMS, public health officials, and health care professionals may still use them in their work)
- Overdose hotlines that stay on the line while someone uses
- Sterile water, saline, and ascorbic acid
- Other supplies not on the approved list
Programs that relied on SAMHSA funds for items now excluded may need other funding sources. Navigation, referrals, and connection to care remain fundable, which keeps engagement at the center of harm reduction work.
Comprehensive care that keeps patients on medication
Regardless of federal funding policy, the clinical goal for MOUD programs stays the same: keeping patients engaged in treatment. The ASAM National Practice Guideline has long described ongoing medication, combined with psychosocial support matched to each patient’s needs, as the standard of care for OUD.
Porch Light Health, a substance use disorder provider with 60 locations across Colorado and New Mexico, launched a contingency management program in 2025 using CHESS Health’s Rewards Engine. Patients earned immediate reinforcement for attending appointments, adhering to medication, and staying engaged in care. The program saw:
- MAT compliance increase by 30%
- Behavioral health visits increase by 294%
- Psychiatric visits increase by 69%
Digital tools can help programs deliver that support without adding staff burden:
- Recovery support: around-the-clock access to peer support through the Connections app, plus a companion app for family members and loved ones.
- Care coordination: shared communication between prescribers, counselors, peers, and community services.
- Ongoing monitoring: engagement between appointments that gives clinicians a fuller picture for regular treatment reviews.
- Navigation and connection to care: closed-loop referral that connects people from a clinic, outreach, or harm reduction setting to treatment, mental health, and social services, and tracks each referral until it is complete.
Linkage is often where people are lost. CHESS Health’s eIntervention, a closed-loop referral solution built for behavioral health, makes that handoff trackable. At FLACRA in New York, it has supported nearly 12,000 referrals for more than 9,450 clients, with 99.3% of intended case outcomes met. JusticeLink in Tulsa County, which serves people reentering the community after incarceration, saw a 71% increase in documented closed referrals.
Maintaining approaches that work
Despite changes in what federal grants will fund, what hasn’t changed is what helps people recover and what keeps treatment programs strong. For MOUD programs, that means meeting new expectations for treatment reviews and comprehensive services while medication remains a core, evidence-based option. For harm reduction programs, it means an opportunity to focus funding on stronger navigation and better linkage to care, so more people move from a first contact into treatment and support.
Across both, the priority is the same: connect people to care, keep them engaged, and support them in staying on treatment. Those same steps drive business outcomes. Every patient connected through a closed-loop referral is a new admission, and every patient retained in care means more completed visits, steadier census, and sustained revenue. Programs that strengthen linkage, engagement, and retention will be better positioned for patients and for their bottom line, in any funding environment.
