The Pittsburgh region saw a 39% drop in the number of people dying from an overdose in 2024, according to preliminary data from Allegheny County. That's a significant decrease and one that county officials say points to the success of harm reduction intervention such as free access to overdose reversal drugs and clean supplies.
"Harm reduction … is evidence based," said Stuart Fisk, who manages the funds Allegheny County receives from settlements with opioid manufacturers. "And we're pretty certain [it's] contributing to significant declines in overdose deaths."
But the federal funding to support harm reduction initiatives could disappear under President Trump's budget proposal, which calls for major cuts to agencies tasked with fighting the opioid epidemic. And at the same time, local recovery groups say they have no clear indications about government support beyond 2025.
Harm reduction interventions include free distribution of overdose reversal drugs like naloxone, clean injection supplies and other things that make using illicit drugs safer. They have been heralded as one of several key components of a nationwide reduction in overdose deaths. According to federal data, those who receive clean injection supplies are five times more likely to enter treatment.
The proposal would shrink the Centers for Disease Control and Prevention (CDC), the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Health Resources and Services Administration (HRSA).
Trump's budget plan calls for a more than $1 billion reduction at SAMHSA, an agency charged with improving substance abuse and mental health treatment services.
"Unfortunately, under the previous administration, SAMHSA grants were used to fund dangerous activities billed as 'harm reduction,' which included funding 'safe smoking kits and supplies' and 'syringes' for drug users," the proposal reads.
SAMHSA has endorsed harm reduction, arguing it "plays a significant role in preventing drug-related deaths and increasing access to healthcare, social services, and treatment."
In addition to the budget cut, Trump has also proposed restructuring the agency. The White House said the proposal eliminates "inefficient funding" for mental health and substance use disorder programs at the national and local level, describing them as duplicative of other federal efforts.
Trump's budget proposal also calls to reduce the CDC budget by $3.6 billion, which amounts to nearly half of the agency's current budget. Another $1.7 billion is proposed to be cut to HRSA.
The specifics of the federal budget are likely to change as Congress hammers out the details. But with several federal funding streams up in the air, recovery groups and local government officials have no way of planning long term.
"Nobody's there yet in understanding what this budget looks like and how it will impact our funding and thus the choices we have to make," said Erin Dalton, director of Allegheny County's Department of Human Services. "But I think we do have to start with squaring around what we're ultimately responsible for and making sure we can cover that."
That could mean downsizing or eliminating programs that have been effective, but come at a price.
Allegheny County spends roughly $110 million annually on substance use treatment and prevention programs and according to a 2023 report, roughly 93% of the funding comes from the state and federal government.
And as federal priorities evolve, local officials have begun to consider how to maintain the success of programs reliant upon federal funding.
Syringe services programs are in a legal quagmire in Pennsylvania. While the distribution of drug paraphernalia is a misdemeanor under state law, Allegheny County and Philadelphia have local ordinances authorizing controlled programs. The state does not provide support to operate these programs, making federal funding more critical.
"There's no other source of funding for syringe services in Pennsylvania really," Fisk said. "The possibility of us moving backwards 20 years to where harm reduction was not funded could be very well possible."
SAMHSA has distributed roughly $9.7 million per year to harm reduction programs across the country beginning in 2022. In 2024, Allegheny County received around $2 million from SAMHSA toward harm reduction efforts. But those grants could be dissolved under larger budget cuts as the Trump administration shifts away from harm reduction strategies.
"I would really hate to see that ripped out of the existing system because of philosophical differences about what harm reduction is and what it should be," Fisk said. "It's not a belief system, it's an evidence-based approach to saving people's lives and saving money."
Downsized federal support could require the county to reconfigure how it spends other funds earmarked to fight the drug epidemic, including millions of settlement dollars from companies that manufacture or distribute opioids.
"If those monies need to shift back to cover funding gaps created by the new budgets, then our ability to sustain the programs that we've started may be impacted," Fisk said.
That includes an innovative medication assisted treatment program at the Allegheny County Jail. The county expanded the jail's substance use treatment capacity in March by launching a licensed medication unit. The in-house treatment program can start an incarcerated individual on methadone treatment as well as continue treatment for someone who enters the facility with a prescription. The jail also administers other medications used to treat substance use disorder.
"That single program I think is really a linchpin in our fight against the opioid crisis," Fisk said.
The county allocated nearly $9 million this year from the lawsuit settlement payouts to operate the treatment program. But that money could be shifted toward sustaining other programs in Allegheny County if federal dollars disappear.
"We will have to make hard choices," Dalton said. "And look for the people, the providers, the treatments and resources that we think will be most effective."
Dalton said the county is committed to supporting the distribution of overdose reversal drugs and syringe services as well as medication assisted treatment.
Another federal program that could be scaled back is the annual nationwide survey of drug use in the U.S. used to inform doctors, researchers and policymakers. The data reveals trends in specific substance use and mental illness measures and identifies groups at higher risk of substance use disorder. The entire team that managed the survey was laid off amid federal staffing cuts last month.
Fisk said without that survey, it would be harder to know what substances are present in the illicit drug supply. And as fentanyl is increasingly replaced by substances like xylazine and medetomidine, health care providers need the latest data to effectively treat their patients.
"As [drugs] get scheduled as controlled substances by the state or the federal government, they begin to disappear from the drug supply, but they're rapidly being replaced by new substances," Fisk said. "So our ability to surveil the illicit drug supply becomes really critical."
Otherwise, "we're kind of flying blind in a very big storm," he said.
For recovery providers, who are often contracted by Allegheny County, the future is even less clear.
Zach Benkovitz, executive director of Onala Recovery Center, said the uncertainty and back and forth he's observed within the federal government "makes making any decision harder and slower."
Onala offers recovery meetings, rehab referrals, naloxone training, free meals and referrals to recovery specialists at its West End facility. Benkovitz said the "majority" of the nonprofit's operating budget is supported by Allegheny County but declined to provide a specific percentage.
"Our survival in many ways is dependent on the county continuing that funding," he stressed.
Benkovitz said he's been worried about the center's finances since he took over at the beginning of the year. He said that concern goes beyond the evolving circumstances in D.C.
"I think a person in my position should just always be worried about and thinking about funding," Benkovitz said.
Allegheny County officials said they've been routinely meeting with providers like Onala as the federal budget process plays out. But in a departure from standard practices, the county has not promised financial support to recovery providers beyond 2025.
Dalton said that's because the state has not begun its funding cycle for these programs on schedule. Federal money passes through Harrisburg before it arrives in Allegheny County. Typically, funding is guaranteed over a five-year period.
The Pennsylvania Department of Drug and Alcohol Programs, which is responsible for distributing federal funds, did not respond to WESA's questions about why it has held up negotiations with the county.
Dalton said the county is working with the state to set a new timeline for providers who are reliant upon government support.
But the uncertainty has providers like Onala reconsidering how to maintain outreach programs that bring in people who otherwise may never explore their supportive services.
"We want to make sure we're reaching communities who are having a harder time being targeted for assistance by traditional models of care," Benkovitz said. But "we might not be able to do that if all these dominoes start to fall."
Onala has begun to solicit private funding from individuals and corporations as it plans to supplement a potential drop off in government support.
Benkovitz pledged that the organization will continue to support the community regardless of whether government funding dies down. But he wondered whether Onala will be able to continue to send people to county recovery housing programs or medical providers.
"Where we can send them to is potentially going to be limited," Benkovitz said. "[But] we will find a way to adapt and continue to open our doors and provide services to people."
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