R Street Institute
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R Street Letter on 2026 National Drug Control Strategy

by Chelsea Boyd
June 20, 2025
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issues: Harm Reduction, Opioid Harm Reduction

June 20, 2025

Mr. Jon E. Rice
Acting Director
Office of National Drug Control Policy
Executive Office of the President

Washington, D.C. 20503

RE: 2026 National Drug Control Strategy

Dear Mr. Rice:

The R Street Institute, a nonpartisan public policy research organization, appreciates the opportunity to provide feedback on the 2026 National Drug Control Strategy. The administration’s Drug Policy Priorities demonstrate the complexity of creating policies to address substance use.[1] The priorities include efforts to decrease the supply of illicit drugs, prevent drug use before it begins, and provide treatment opportunities for those who already use drugs. When translating these priorities into the National Drug Control Strategy, we urge you to take a comprehensive approach to drug policy that utilizes all available methods for reducing demand for illicit substances.

Addressing Supply is Not Enough

Although deaths from drug overdoses decreased in 2024 compared to 2023, more than 80,000 Americans lost their lives to overdose in 2024.[2] For comparison, the second through fifth leading causes of death among Americans under 45—suicide, cancer, homicide, and heart disease—killed 73,800 Americans, according to most recent data from 2023.[3] Even though we are making progress in decreasing overdose deaths, the magnitude of the problem warrants approaching solutions from every angle.

Supply-side interventions that attempt to limit the flow of drugs into American communities are one side of the drug control equation; however, they are not the only way to address substance use and overdose. In fact, evidence suggests that drug overdose deaths began decreasing in most states in 2022 or 2023, before Drug Enforcement Administration (DEA) actions, such as Operation Blue Lotus, Operation Apollo, and Operation Plaza Strike, commenced and Sinaloa Cartel leaders were arrested.[4] This suggests that multiple factors contributed to bending the overdose curve. Among them are local efforts that decrease demand through prevention and treatment, as well as interventions that reduce the risk of overdose death, such as naloxone distribution.[5] Focusing solely on reducing supply, especially without expanding treatment options, leaves behind the people who already use drugs. The same people are most likely to overdose.

America’s Treatment Infrastructure has Limits

One of the most obvious ways to decrease demand for illicit drugs is by increasing the number of people with substance use disorder (SUD) who are in treatment. However, estimates suggest that only 13 percent of people with SUD receive treatment each year.[6] While not every person with SUD is ready to enter treatment, there is evidence that people who are ready often experience challenges with access.[7] There are an estimated 14,700 SUD treatment facilities in the United States as of 2022, but there is still significant unmet demand for services.[8] This means that facilities are often over capacity and people in some areas, especially rural regions, often have fewer treatment options and must travel long distances to reach them.[9]

Additionally, initiating treatment quickly once a person is ready can influence outcomes. For example, studies have shown that people often face treatment wait times before receiving an initial consultation and while waiting for a space in the treatment program after the initial consultation.[10] During the waiting period between consultation and program admission, up to 50 percent of people will decide not to seek treatment.[11] The longer the waiting time, the more attrition occurs.[12] Since the window when a person is ready to enter treatment is often narrow, expanding the United States’ SUD treatment infrastructure is necessary to ensure that this window of opportunity is not missed.

SUD treatment can take many forms; however not all treatment modalities are supported by experimental evidence. If reducing demand for illicit drugs is the goal, prioritizing expanded access to evidence-based SUD treatments is necessary. For opioid use disorder (OUD), medications for opioid use disorder (MOUD) are an evidence-based treatment.[13] Buprenorphine and methadone are the only MOUD that reduce overdose risk; they are the most commonly used MOUD, and each has its advantages and drawbacks, depending on the particular needs of the individual with OUD.[14]

In recent years, federal policymakers have relaxed restrictions on buprenorphine prescribing—expanding telemedicine and the pool of potential prescribers—in an effort to increase accessibility.[15] Due to how recently the DEA’s changes to telemedicine occurred, evidence of its effect is yet to be evaluated. However, some studies have assessed the effects of eliminating the “X-waiver” training that was previously required to prescribe buprenorphine.[16] Unfortunately, the studies suggest that this policy change has not meaningfully increased access to buprenorphine treatment.[17] Even when people with OUD receive a prescription, they may not be able to fill it because DEA oversight and prescription-monitoring programs can deter pharmacies from stocking and dispensing buprenorphine.[18] Declining to fill a prescription is especially common when a patient’s prescriber is located far away from the pharmacy, which is highly relevant in rural areas.[19] This suggests that a more comprehensive approach to expanding treatment options and access is necessary.

Compared to buprenorphine, methadone remains even more highly regulated. Exploring opportunities to modify regulations can safely expand access to methadone.[20] Considering policies that allow methadone prescribing and dispensing outside of opioid treatment programs (OTPs) and encouraging states to update policies that do not reflect federal guidance that allows more expansive take-home dosing could decrease the burden on people with OUD.[21]

Although there are evidence-based MOUDs, there are no medications that treat addiction to other illicit drugs, such as stimulants.[22] This is especially challenging because stimulant and polysubstance use rates are rising.[23] Despite the lack of medications for stimulant use disorder, there are still evidence-based treatment options that are underutilized.[24] The Department of Veterans Affairs has successfully implemented contingency management, an evidence-based psychosocial intervention for stimulant use disorder, but further uptake has been limited.[25] As polysubstance use, especially combined opioid and stimulant use, becomes more common, evolving the treatment landscape by including underutilized evidence-based treatments becomes even more important.[26]

Addressing the Gap Between Prevention and Treatment

Ensuring that people who are ready to enter treatment can access it and preventing people who do not use illicit drugs from starting are vital to reducing demand. However, focusing only on prevention and treatment leaves behind the many people who currently use drugs recreationally or have a SUD but are not ready to enter treatment. Harm reduction interventions are evidence-based and help people who already use drugs stay alive and healthy and can increase the likelihood of them entering treatment.[27]

As the Trump administration’s drug policy priorities state, “The statistics surrounding drug use and overdose deaths mandate a comprehensive approach that emphasizes drug use prevention and increases access to recovery and overdose prevention and reversal services.”[28] “Overdose prevention and reversal services” fall squarely under the umbrella of harm reduction services. Yet overdose prevention and reversal services are only part of harm reduction’s person-centered approach. Harm reduction services help build agency among people who use drugs by empowering them to make healthier and safer decisions.[29] In fact, people who engage with harm reduction organizations are up to five times more likely to enter treatment and three times more likely to stop using drugs altogether.[30]

A comprehensive approach to drug control requires considering prevention, treatment, and the space between them. Continuing to promote harm reduction programs, such as naloxone distribution to people likely to witness an overdose, and supporting syringe services programs to counter infectious disease spread, should be central to the drug control strategy.

Systemic Solutions are Necessary

Committing “to educate the American public on the dangers of drug use, prevent drug use before it starts, and provide treatment and recovery support for Americans in need,” is noble, yet it will not address the root causes of drug use.[31] People use drugs for many different reasons, but those reasons do not evaporate with the drug supply.[32]

Although individual circumstances leading to drug use are unique, research has identified some protective and risk factors for drug use initiation and progression to SUD.[33] Among these factors are measures of social and economic advantage, which interact to create a complex and bidirectional relationship.[34] Nevertheless, studies indicate that people experiencing poverty have higher opioid overdose rates and greater socioeconomic stability is associated with less frequent injection drug use among people who inject drugs.[35] These findings suggest that addressing socioeconomic instability might reduce the incidence and prevalence of SUD and cut demand for substances, including illicit drugs.

With states receiving an influx of opioid settlement funds, the Office of National Drug Control Policy can help steer the use of these funds by providing guidance on interventions that directly save lives, improve the health of people who use drugs, and/or help reduce the demand for illicit drugs. A comprehensive drug control strategy combines targeted prevention and treatment interventions with systemic solutions to housing instability and affordability, healthcare access, career readiness, and other factors that support a prosperous life.[36]

Summary of Policy Recommendations

Addressing drug use in the United States will require action at all levels of government, and the Office of National Drug Control Policy plays a key role in setting the national policy agenda. Incorporating the following suggestions into the 2026 National Drug Control Strategy will provide a comprehensive blue-print that applies to all stages of drug use.

This administration has committed to taking “bold and necessary actions to address the drug crisis, and protect the health and safety of all Americans.”[37] In building the 2026 National Drug Control Strategy, we urge you to expand traditional supply-side interventions to include comprehensive demand-side approaches to curtailing drug use and overdose. To “protect the health and safety of all Americans,” it is essential that people who use drugs can access evidence-based treatment and harm reduction services as we strive to address the systemic causes of substance use.[38]

We look forward to continued collaboration in advancing effective and comprehensive drug policy. Thank you for taking the time to consider our position on the National Drug Control Strategy. Please let us know if you have any questions or wish to discuss our views further.

Sincerely,

Chelsea Boyd
/s/
Research Fellow, Integrated Harm Reduction
R Street Institute
cboyd@rstreet.org

[1] Office of National Drug Control Policy, “Statement of Drug Policy Priorities,” The White House, April 1, 2025. https://www.whitehouse.gov/wp-content/uploads/2025/04/2025-Trump-Administration-Drug-Policy-Priorities.pdf.

[2] National Center for Health Statistics, “Provisional Drug Overdose Death Counts,” U.S. Centers for Disease Control and Prevention, June 11, 2025. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm.

[3] Web-based Injury Statistics Query and Reporting System, “Injury and Violence Are Leading Causes of Death,” U.S. Centers for Disease Control and Prevention, last accessed June 2, 2025. https://wisqars.cdc.gov/animated-leading-causes.

[4] Nabarun Dasgupta et al., “Peak OD Phenotypes,” University of North Carolina at Chapel Hill, Feb. 12, 2025. https://opioiddatalab.ghost.io/peak-od-phenotypes.

[5] Ibid.

[6] Ethan Sahker et al., “Evaluating the substance use disorder treatment gap in the United States, 2016-2019: A population health observational study,” The American Journal on Addictions 33:1 (Aug. 15, 2023), pp. 36-47. https://onlinelibrary.wiley.com/doi/abs/10.1111/ajad.13465.

[7] Ali Farhoudian et al., “Barriers and Facilitators to Substance Use Disorder Treatment: An Overview of Systematic Reviews,” Substance Use: Research and Treatment 16 (Aug. 29, 2022). https://journals.sagepub.com/doi/full/10.1177/11782218221118462.

[8] Heather Saunders and Rhiannon Euhus, “A Look at Substance Use and Mental Health Treatment Facilities Across the U.S.,” KFF, Feb. 2, 2024. https://www.kff.org/mental-health/issue-brief/a-look-at-substance-use-and-mental-health-treatment-facilities-across-the-u-s; Jonathan H. Cantor et al., “Patterns in Geographic Distribution of Substance Use Disorder Treatment Facilities in the US and Accepted Forms of Payment From 2010 to 2021,” Substance Use and Addiction 5:11(e2241128) (Nov. 11, 2022). https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2798325; Victoria Lynch et al., “State Variation in Substance Use Disorder and Mental Health Treatment Facility Characteristics in 2022,” Urban Institute, August 2024. https://www.urban.org/sites/default/files/2024-08/State%20Variation%20in%20Substance%20Use%20Disorder%20and%20Mental%20Health%20Treatment%20Facility%20Characteristics%20in%202022.pdf. 

[9] “Substance Use and Misuse in Rural Areas,” Rural Health Information Hub, March 13, 2025. https://www.ruralhealthinfo.org/topics/substance-use; Lynch et al. https://www.urban.org/sites/default/files/2024-08/State%20Variation%20in%20Substance%20Use%20Disorder%20and%20Mental%20Health%20Treatment%20Facility%20Characteristics%20in%202022.pdf.

[10] Cristina Redko et al., “Waiting Time as a Barrier to Treatment Entry: Perceptions of Substance Users,” Journal of Drug Issues 36:4 (September 2006), pp. 831-852. https://pmc.ncbi.nlm.nih.gov/articles/PMC2396562.

[11] Ibid.

[12] Ibid.

[13] U.S. Food and Drug Administration, “Information about Medications for Opioid Use Disorder (MOUD),” U.S. Department of Health and Human Services, last accessed June 2, 2025. https://www.fda.gov/drugs/information-drug-class/information-about-medications-opioid-use-disorder-moud.

[14] Bohdan Nosyk et al., “Buprenorphine/Naloxone vs Methadone for the Treatment of Opioid Use Disorder,” JAMA 332:21 (Oct. 17, 2024), pp. 1822-1831. https://jamanetwork.com/journals/jama/fullarticle/2825088.

[15] Anita Silwal et al., “State alignment with federal regulations in 2022 to relax buprenorphine 30-patient waiver requirements,” Drug and Alcohol Dependence Reports 7:100164 (May 2, 2023).  https://pmc.ncbi.nlm.nih.gov/articles/PMC10206439; “Select Federal Policies Governing Methadone and Buprenorphine for Opioid Use Disorder,” American Society of Addiction Medicine, last accessed June 2 2025. https://www.asam.org/advocacy/practice-resources/regulatory-resources/select-federal-policies-addiction-medications.

[16] American Society of Addiction Medicine. https://www.asam.org/advocacy/practice-resources/regulatory-resources/select-federal-policies-addiction-medications.

[17] Paul J. Christine et al., “Buprenorphine Prescribing Characteristics Following Relaxation of X-Waiver Training Requirements,” Substance Use and Addiction 7:8(e2425999) (Aug. 5, 2024). https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2821949; Rebecca C. Bilden et al., “Examining the Impact of Eliminating the X Waiver on Buprenorphine Dispensation in 63 Counties in Pennsylvania,” Substance Use & Addiction Journal 29767342241303583 (Dec. 15, 2024). https://pubmed.ncbi.nlm.nih.gov/39676259; Payel Jhoom Roy et al., “Buprenorphine dispensing before and after the April 2021 X-Waiver exemptions: An interrupted time series analysis,” International Journal of Drug Policy 126:104381 (April 2024). https://www.sciencedirect.com/science/article/abs/pii/S0955395924000665?via%3Dihub.

[18] Dima M. Qato et al., “Federal and State Pharmacy Regulations and Dispensing Barriers to Buprenorphine Access at Retail Pharmacies in the US,” JAMA Health Forum 3:8(e222839) (Aug. 26, 2022). https://jamanetwork.com/journals/jama-health-forum/fullarticle/2795746.

[19] Ibid.

[20] Stacey McKenna, “Unshackled from OTPs, Methadone Can Still Be Safe and Effective,” R Street Institute, April 11, 2024. https://www.rstreet.org/research/unshackled-from-otps-methadone-can-still-be-safe-and-effective; Stacey McKenna, “We can supervise methadone dosing outside of OTPs,” R Street Institute, May 9, 2024. https://www.rstreet.org/commentary/we-can-supervise-methadone-dosing-outside-of-otps.

[21] McKenna. https://www.rstreet.org/commentary/we-can-supervise-methadone-dosing-outside-of-otps; Jane Koppelman, “Federal and State Governments Can Reduce Roadblocks to Methadone Access,” The Pew Charitable Trusts, Dec. 5, 2024. https://www.pew.org/en/research-and-analysis/articles/2024/12/05/federal-and-state-governments-can-reduce-roadblocks-to-methadone-access; Nora Volkow, “To address the fentanyl crisis, greater access to methadone is needed,” National Institute on Drug Abuse, July 29, 2024. https://nida.nih.gov/about-nida/noras-blog/2024/07/to-address-the-fentanyl-crisis-greater-access-to-methadone-is-needed; Substance Abuse and Mental Health Services Administration, “Methadone Take-Home Flexibilities Extension Guidance,” U.S. Department of Health and Human Services, Nov. 6, 2024. https://www.samhsa.gov/substance-use/treatment/opioid-treatment-program/methadone-guidance; Arthur Robin Williams et al., “Retention and critical outcomes among new methadone maintenance patients following extended take-home reforms: a retrospective observational cohort study,” The Lancet Regional Health – Americas 28:100636 (December 2023). https://www.sciencedirect.com/science/article/pii/S2667193X23002107.

[22] U.S. Food and Drug Administration, “FDA Takes Steps to Advance the Development of Novel Therapies for Stimulant Use Disorders,” U.S. Department of Health and Human Services, Oct. 4, 2023. https://www.fda.gov/news-events/press-announcements/fda-takes-steps-advance-development-novel-therapies-stimulant-use-disorders.

[23] U.S. Centers for Disease Control and Prevention, “Polysubstance Overdose,” U.S. Department of Health and Human Services, May 8, 2024. https://www.cdc.gov/overdose-prevention/about/polysubstance-overdose.html.

[24] Frances McGaffey, “A Decades-Old Treatment Can Reduce Stimulant Use—and Overdose Deaths,” The Pew Charitable Trusts, June 18, 2024. https://www.pew.org/en/research-and-analysis/articles/2024/06/18/a-decades-old-treatment-can-reduce-stimulant-use-and-overdose-deaths; Richard A. Rawson et al., “Contingency Management for Stimulant Use Disorder: Progress, Challenges, and Recommendations,” The Journal of Ambulatory Care Management 46:2 (April/June 2023), pp. 152-159. https://journals.lww.com/ambulatorycaremanagement/abstract/2023/04000/contingency_management_for_stimulant_use_disorder_.14.aspx; Office of the Assistant Secretary for Planning and Evaluation, “Contingency Management for the Treatment of Substance Use Disorders: Enhancing Access, Quality, and Program Integrity for an Evidence-Based Intervention,” U.S. Department of Health and Human Services,” Nov. 14, 2023. https://aspe.hhs.gov/reports/contingency-management-treatment-suds; Sara C. Parent et al., “Lessons learned from statewide contingency management rollouts addressing stimulant use in the Northwestern United States,” Preventative Medicine 176:107614 (November 2023). https://www.sciencedirect.com/science/article/abs/pii/S0091743523001949.

[25] Parent et al. https://www.sciencedirect.com/science/article/abs/pii/S0091743523001949.

[26] U.S. Centers for Disease Control and Prevention. https://www.cdc.gov/overdose-prevention/about/polysubstance-overdose.html.

[27] Substance and Mental Health Services Administration, “Harm Reduction,” U.S. Department of Health and Human Services, Oct. 29, 2024. https://www.samhsa.gov/substance-use/harm-reduction; Elizabeth Salisbury-Afshar et al., “Harm Reduction Strategies to Improve Safety for People Who Use Substances,” Agency for Healthcare Research and Quality, Oct. 30, 2024. https://psnet.ahrq.gov/perspective/harm-reduction-strategies-improve-safety-people-who-use-substances.

[28] Office of National Drug Control Policy. https://www.whitehouse.gov/wp-content/uploads/2025/04/2025-Trump-Administration-Drug-Policy-Priorities.pdf.

[29] Heather Sophia Lee and Scott R. Petersen, “Demarginalizing the marginalized in substance abuse treatment: Stories of homeless, active substance users in an urban harm reduction based drop-in center,” Addiction Research & Theory 17:6 (Nov. 16, 2009), pp. 622-636. https://www.tandfonline.com/doi/abs/10.3109/16066350802168613; Substance Abuse and Mental Health Services Administration, “Harm Reduction Framework,” U.S. Department of Health and Human Services, 2023. https://www.samhsa.gov/sites/default/files/harm-reduction-framework.pdf.

[30] Andrea Jakubowski et al., “Three decades of research in substance use disorder treatment for syringe services program participants: a scoping review of the literature,” Addiction Science & Clinical Practice 18:40 (June 10, 2023). https://pmc.ncbi.nlm.nih.gov/articles/PMC10256972; U.S. Centers for Disease Control and Prevention, “Safety and Effectiveness of Syringe Services Programs,” U.S. Department of Health and Human Services, Feb. 8, 2024. https://www.cdc.gov/syringe-services-programs/php/safety-effectiveness.html; Nora Volkow, “Syringe services for people who inject drugs are enormously effective, but remain underused,” National Institute on Drug Abuse, Nov. 25, 2024. https://nida.nih.gov/about-nida/noras-blog/2024/11/syringe-services-for-people-who-inject-drugs-are-enormously-effective-but-remain-underused.

[31] Office of National Drug Control Policy. https://www.whitehouse.gov/wp-content/uploads/2025/04/2025-Trump-Administration-Drug-Policy-Priorities.pdf.

[32] Chelsea Boyd and Stacey McKenna, “Beyond Addiction: The Myriad Reasons People Use Drugs,” R Street Institute, Jun. 23, 2023. https://www.rstreet.org/research/beyond-addiction-the-myriad-reasons-people-use-drugs.

[33] Chunqing Lin et al., “A scoping review of social determinants of health’s impact on substance use disorders over the life course,” Journal of Substance Use and Addiction Treatment 166:209484 (November 2024). https://www.sciencedirect.com/science/article/pii/S2949875924001966.

[34] Chunqing Lin et al. https://www.sciencedirect.com/science/article/pii/S2949875924001966.

[35] Veronica A. Pear et al., “Urban-rural variation in the socioeconomic determinants of opioid overdose,” Drug and Alcohol Dependence 195 (Feb. 1, 2019), pp. 66-73. https://pubmed.ncbi.nlm.nih.gov/30592998; Andreea Adelina Artenie et al., “Socioeconomic stability is associated with lower injection frequency among people with distinct trajectories of injection drug use,” International Journal of Drug Policy 94:103205 (August 2021). https://www.sciencedirect.com/science/article/abs/pii/S0955395921001031.

[36] TK Logan and Jennifer Cole, “Subjective quality-of-life rating at substance use disorder treatment entry: associated client recovery needs and outcomes,” Journal of Social Work Practice in the Addictions 24:2 (Jan. 17, 2023), pp. 193-211. https://www.tandfonline.com/doi/abs/10.1080/1533256X.2023.2164967; Wenyu Zhang and Hui Wu, “The Relationship of Socioeconomic Factors and Substance Abuse Treatment Dropout,” Healthcare 13:4(369) (Feb. 10, 2025). https://www.mdpi.com/2227-9032/13/4/369; Janice L. Pringle et al., “The Role of Wrap Around Services in Retention and Outcome in Substance Abuse Treatment: Findings From the Wrap Around Services Impact Study,” Addictive Disorders & Their Treatment 1:4 (December 2002), pp. 109-118.  https://journals.lww.com/addictiondisorders/abstract/2002/11000/the_role_of_wrap_around_services_in_retention_and.1.aspx.

[37] Office of National Drug Control Policy. https://www.whitehouse.gov/wp-content/uploads/2025/04/2025-Trump-Administration-Drug-Policy-Priorities.pdf.

[38] Ibid.