Alarm is growing among harm reduction proponents that the Trump administration’s health and human services secretary, Robert F. Kennedy Jr., is shifting the nation’s strategy to tackle the drug crisis away from what the Biden administration called “evidence-based care” — mainly, harm reduction — toward a 12-step, abstinence-based recovery model.

To those who think America’s drug policy has become too permissive, this is welcome news. The debate about whether harm reduction is helpful or harmful morphed from a niche policy concern to mainstream public discourse in the last five years, as cities across the country faced growing numbers of homeless and addicted persons on their streets.

Harm reduction is a philosophy and a set of public health interventions that seeks to reduce the harms associated with drug use by moving away from punitive practices and toward an approach that meets drug users “where they’re at.” The Biden administration embraced harm reduction like no previous administration, allocating more than $1 billion in grants to fund distribution of the overdose reversal drug naloxone, syringe exchange services, medication-assisted treatment, and drug testing strips.

Mr. Kennedy, who is open about his 14-year heroin addiction and four decades in 12-step recovery, proposed a New Deal-scale program for recovery “healing farms” — in addition to supporting some harm reduction — when he was running for president as an independent. Since joining the Trump administration as the overseer of health policy, though, Mr. Kennedy’s policy prescriptions have been somewhat opaque.

“To end the overdose crisis, HHS must return to common-sense public health approaches focused on prevention, treatment, and long-term recovery,” a representative of the Department of Health and Human Services tells The New York Sun. “HHS is supporting the use of naloxone and raising awareness about the toxic drug supply to save lives.”

The number of overdose deaths declined by about 23 percent last year, after reaching a peak of 114,000 in 2023, according to provisional Centers for Disease Control data. This is good news, but deaths from overdose still exceed pre-Covid numbers.

Mr. Kennedy has repeatedly said that America’s addiction and overdoses crisis deserves the kind of attention we give to wars. “America lost about 3,000 people on 9/11, and we launched an $8 trillion War on Terror. We’re losing 30 times that number every year to drug overdoses and we hardly do anything about it,” he told the Sun in June.

A document released last month by the White House’s Office of National Drug Policy says the administration will focus on prevention, incarceration diversion programs, implementing “the harshest available penalties” for fentanyl dealers, and “will encourage state and local jurisdictions to increase the availability of drug test strips and naloxone to mitigate the impact of deadly drugs on communities across the country.”

The promotion of the overdose-reversing drug naloxone and drug testing strips — two harm reduction tools — should appease the harm reduction backers, but a 2026 discretionary budget request from the White House that was sent to Congress on Friday shows more than $1 billion in spending cuts to the Substance Abuse and Mental Health Services Administration, the HHS department that funds and oversees the nation’s addiction and mental health response, including harm reduction.

The administration has already cut thousands of jobs from Samsha and plans to consolidate the department under a new Administration for a Healthy America. A former fentanyl addict who now travels the country consulting on drug policy and recovery, Tom Wolf, says he doesn’t think these cuts and reorganization are necessarily a bad thing.

“While Samsha has done some good work in the past, over the last several years, they really pivoted hard towards a more permissive harm reduction approach to drugs,” Mr. Wolf tells the Sun. He says he attended a Samsha meeting and it was filled with “the most radicalized harm reduction folks that you can imagine, basically of the mentality that we should legalize drugs, they should normalize drug use or decriminalize drug use, and that recovery itself, especially abstinence-based recovery, can actually be potentially dangerous.”

“I think Kennedy, in my interactions with him, is his goal was recovery and to promote recovery, to bring healing to America,” Mr. Wolf says. “How can you tell me that the harm reduction policies that we’ve been implementing around drugs and drug policy in general has been working? You can’t.”

Critics of Mr. Kennedy say the language in the White House’s budget request shows harm reduction is on the chopping block. “Unfortunately, under the previous administration, SAMSHA grants were used to fund dangerous activities that billed as ‘harm reduction,’ which included funding ‘safe smoking kits and supplies’ and ‘syringes’ for drug users,” the budget document says.

“If we want to Make HIV Great Again, we should cut funding for syringe exchange,” a former heroin user and journalist who’s written books about the science of addiction and harm reduction, Maia Szalavitz, tells the Sun sarcastically. “The evidence is enormously clear about syringe exchange. For example, New York City went from having 50 percent of its drug users HIV positive to under 3 percent.”

Even President Trump’s first-term vice president, Mike Pence, reluctantly supported authorizing syringe exchanges as governor of Indiana in 2015, after an outbreak of HIV from intravenous drug use in the small town of Austen resulted in higher incidence of HIV in that rural county than “any country in sub-Saharan Africa,” according to the CDC’s director at the time, Tom Friedan.

Handing out “safe smoking kits” — in other words, free crack pipes to drug users — is a more controversial policy that the Biden administration tried to deny was happening. The Trump administration seems poised to cut it.

The backlash to harm reduction is not just coming from the right. San Francisco’s moderate Democratic mayor, Daniel Lurie, recently changed city policy to prohibit street distribution of “safe use” kits and to require treatment counseling before people receive these supplies. Democrats across the country are debating or supporting policies to force treatment for those suffering with mental illness or addiction.

For those not following national drug policy debates, the conflict between harm reductionists and abstinence recovery proponents has intensified in recent years, even though many of the pioneers of harm reduction got clean through AA or Narcotics Anonymous. Ms. Szalavitz says part of this has to do with AA and NA dogma that a person on methadone or buprenorphine is not clean.

Those critical of harm reduction say some of the tools are effective but that many people in the field have taken the philosophy to a radical extreme, proposing that the solution to the shoplifting problem, for example, is not incarceration but “safe supply” — in other words, distributing drugs to users. These critics point to city-funded billboards that went up around San Francisco in 2020 encouraging drug users, “Do it with friends,” as opposed to alone.

“Actual people on the ground in harm reduction sometimes will present a much more radical stance to the public than they actually have simply because they want to stand up for oppressed people,” Ms. Szalavitz says.

Mr. Wolf disagrees. “If you ask them deep down, they’ll tell you their goal is to legalize drugs,” he says of harm reductionists.

In an interview with the Sun in June, Mr. Kennedy said he was in favor of an all-of-the-above approach to solve the drug crisis. At the Rx and Illicit Drug Summit in Nashville a week ago, Mr. Kennedy spoke for 35 minutes about his heroin addiction and the spiritual and service-based path to recovery he found in Alcoholics Anonymous. 

Most of Mr. Kennedy’s speech, peppered with AA aphorisms, was about the larger societal ills that he says cause or exacerbate addiction and how he thinks reconnecting with community, family, service, and developing a sense of purpose in life are the long-term solutions to addiction. He said HHS will have $4 billion to tackle the drug crisis. 

Mr. Wolf hopes Mr. Kennedy will fund long-term abstinence-based recovery housing and rehabs. If Mr. Kennedy uses his own personal experience to guide policy — as his remarks suggest he will — then a shift to funding abstinence-based recovery programs is likely. 

“What does that mean for national policy? What it means is we have to do all the nuts and bolts things that you are all involved with — the practical, pragmatic things,” Mr. Kennedy said in Nashville. He then listed harm reduction tools such as medication-assisted treatment options like methadone and buprenorphine, naloxone, and drug testing strips to help detect fentanyl in pills.

“But that alone — throwing money at it — is not alone going to work. We need to really focus on reestablishing these historic ties to community. We have this whole generation of kids who’ve lost hope in their future,” Mr. Kennedy said.