Department of Health and Human Services 200 Independence Avenue, S.W. Washington, D.C. 20201
Re: Request for Information on Chronic Disease of Addiction Federal Register Document Number 2026-11602Submitted Electronically. This Document is Approved for Public Dissemination
Comments of the R Street Institute in Response tothe Request for Information on Chronic Disease of Addiction
I.OVERVIEW OF R STREET’S COMMENTS
Thank you for the opportunity to respond to the Request for Information on Chronic Disease of Addiction
My name is Stacey McKenna, and I am associate director and a Resident Senior Fellow in the Healthier Communities department at the R Street Institute, a nonprofit, nonpartisan public policy research organization. R Street supports pragmatic, evidence-backed policy solutions that leverage free markets and limited effective government to address complex issues, including substance use disorder (SUD) and the overdose crisis. I have been studying and writing about licit and illicit substance use, harm reduction, SUD recovery, and associated policies for nearly two decades. Drawing on this extensive experience, I submit this comment in response to the Department’s June 2026 Request for Information on Chronic Disease of Addiction.[1]
In recent years, the United States has made considerable progress in combating the overdose crisis. Approximately 70,000 Americans died of an overdose in 2025, down from roughly 110,000 in 2022 and 2023.[2] But this is still too many lives lost annually, and millions of individuals continue to struggle with a substance use disorder across the country.[3] Furthermore, the consequences of SUD extend well beyond the individual suffering. Almost half of Americans say they personally know someone who died of an overdose, and many communities are actively struggling with associated issues like public drug use and trafficking-related violence.[4]
Truly having an impact on this crisis requires a comprehensive approach that acknowledges the non-linear and deeply complicated reality of addiction. To that end, this Guidance puts forth several strong recommendations and we support these aspects of it. In particular, medications for opioid use disorder have decades of evidence supporting their efficacy in reducing overdose and improving long-term recovery outcomes while preventing criminal recidivism and increasing social and workforce engagement.[5] Supporting access to them, as suggested in the Guidance, will improve individual and family well-being. In addition, individuals struggling with addiction benefit greatly from a full continuum of care.[6] Consequently, investing in programs like recovery housing and comprehensive rural prevention and treatment programs will help meet these needs.
These efforts will be bolstered by the Guidance’s streamlining of access and push for a more integrated and collaborative system. However, they will be undermined and actively harmed by this Guidance’s withdrawal of support for harm reduction. That is because harm reduction does not undermine recovery or encourage drug use; rather, it can work on a continuum with and alongside treatment to support people trying to overcome their SUD. In addition to saving lives and improving general well-being, harm reduction serves as an important pathway to treatment for many individuals and keeps those in recovery safer should they temporarily return to use.
II. HARM REDUCTION CONNECTS PEOPLE TO TREATMENT
Harm reduction is a pragmatic public health tool that saves lives and encourages positive changes by providing skills, knowledge, and resources without judgment. This stigma-free approach helps vulnerable individuals who may be wary of traditional health systems remain engaged. For many, that engagement translates to recovery. Syringe services programs (SSPs) are one of the most important points on this continuum of care. Every time they distribute needles—an act which cuts HIV and hepatitis C risk by 50 percent—or pass out naloxone or drug checking equipment, they build trust and a relationship that often leads people to treatment.[7] In fact, new SSP users are five times more likely to enter treatment than nonparticipants and roughly three times more likely to stop using drugs altogether.[8] Furthermore, recent research shows that SSP engagement is a much more reliable pathway to treatment engagement than contact with the criminal justice system.[9] Many SSPs and other harm reduction organizations and overdose response units actively offer treatment initiation to their participants.[10]
III. HARM REDUCTION HELPS PEOPLE STAY IN RECOVERY
As recognized by this Guidance, SUDs are chronic conditions that individuals may struggle with for years, decades, or their entire life.[11] Most people, therefore, do not experience recovery as a linear process. A return to use can be triggered by a number of life factors, but it is most likely during “periods of stress, transition, or insufficient support.”[12] This means that people in recovery, like those experiencing active addiction, are at risk for overdose, injection wounds, and blood-borne infections.[13] Harm reduction helps these individuals stay alive and as healthy as possible during these difficult periods. For example, drug checking equipment gives individuals the information and agency to stay as safe as they can even when actively struggling with an SUD. Legalizing fentanyl test strips has been shown to reduce overdose deaths.[14] Distribution of sterile injection equipment reduces infectious disease transmission and lowers the odds that a person will develop injection-site infections or associated complications.[15] In addition, when recommended by or offered through treatment programs, harm reduction strengthens connection to the program, increasing the likelihood the individual will return to treatment and remain engaged with recovery.[16]
IV. HARM REDUCTION CAN BENEFIT COMMUNITIES
Although harm reduction has been blamed for many of the United States’ current struggles with public disorder, the approach and programs can actually help reduce some of these issues. Harm reduction organizations are often responsible for community cleanups that reduce syringe litter: Opening an SSP in a community is consistently followed by reductions in improper disposal of used equipment.[17] These types of organizations also save taxpayers and community health systems money by averting costly infections and preventing or reversing overdoses before an individual needs emergency services or hospitalization.[18] These cost savings are especially powerful in rural communities, where health-related expenses tend to be disproportionately high.[19]
We support the Guidance’s recognition of SUD as a chronic condition and the associated call for a comprehensive, evidence-based approach that improves access to a full continuum of care. The withdrawal of support for harm reduction, however, will actively undermine these efforts. Harm reduction cannot solve societal issues like homelessness and public drug use alone. But it is an essential piece of the puzzle. If lawmakers and regulators want to save American lives, encourage recovery, reduce illicit drug use, and make communities safer and cleaner, then they must utilize harm reduction.
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[1] U.S. Health and Human Services. (June 10, 2026). HHS Request for Comment on Addiction as a Chronic Disease. https://www.federalregister.gov/documents/2026/06/10/2026-11602/hhs-request-for-comment-on-chronic-disease-of-addiction
[2] “Provisional Drug Overdose Death Counts,” National Center for Health Statistics, Centers for Disease Control and Prevention. Last accessed July 1, 2026. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm
[3] “Alcohol and Drug Abuse Statistics (Facts About Addiction),” AmericanAddictionCenters, Last updated Dec. 16, 2025. https://americanaddictioncenters.org/rehab-guide/addiction-statistics-demographics
[4] Emily Harris, “More Than 40% of US Adults Know Someone Who Died of Drug Overdose,” JAMA: Medical News in Brief, 331:12, (March 6, 2024). https://jamanetwork.com/journals/jama/article-abstract/2816186; Charles Fain Lehman, “Inside the East Coast’s Largest Open-Air Drug Market,” City Journal, Winter 2025. https://www.city-journal.org/article/inside-the-east-coasts-largest-open-air-drug-market; Ryan Krull, “Open-air drug market thrives near Downtown West tourist attractions,” St. Louis Magazine, Aug. 29, 2025. https://www.stlmag.com/news/open-air-drug-market-downtown-west; “The Real Causes and Solutions to Public Suffering, Including Public Drug Use,” Drug Policy Alliance, January 2024. https://drugpolicy.org/wp-content/uploads/2024/02/2023.01.31_MEDIA_PublicSufferingRealCausesandSolutions_factsheet.pdf.
[5] Shari Doyle, “Medications for Opioid Use Disorder Improve Patient Outcomes,” Fact Sheet, Pew Charitable Trusts, Dec. 17, 2020. https://www.pew.org/en/research-and-analysis/fact-sheets/2020/12/medications-for-opioid-use-disorder-improve-patient-outcomes; Alex L. Fixler et al., “There goes the neighborhood? The public safety enhancing effects of a mobile harm reduction intervention,” International Journal of Drug Policy, 124, February 2024. https://www.sciencedirect.com/science/article/abs/pii/S0955395924000148; Mary A. Burke and Riley Sullivan, “Can Treatment with Medications for Opioid Use Disorder Improve Employment Prospects? Evidence from Rhode Island Medicaid Enrollees,” New England Public Policy Center Research Reports, 22-3, 2022. https://www.bostonfed.org/publications/new-england-public-policy-center-research-report/2022/can-treatment-with-medications-for-opioid-use-disorder-improve-employment-prospects.aspx.
[6] “What is the Continuum of Care in Addiction Treatment?” encore Outpatient Services. 2025. https://encorerecovery.com/what-is-the-continuum-of-care-in-addiction-treatment
[7] Leslie W. Suen et al., “Linkage to Substance Use Disorder Treatment Through Syringe Services Programs and the Criminal Legal System: A Cross-Sectional Study,” 70:2, February 2026. https://www.ajpmonline.org/article/S0749-3797(25)00618-X/fulltext; “Syringe Services Programs,” HIV.gov, last accessed July 2, 2026. https://www.hiv.gov/federal-response/other-topics/syringe-services-programs
[8] Holly Hagan et al., “Reduced injection frequency and increased entry and retention in drug treatment associated with needle-exchange participation in Seattle drug injectors,” Journal of Substance Abuse Treatment, 19 (2000), pp. 247-252. https://www.jsatjournal.com/article/S0740-5472(00)00104-5/pdf; Jerome M. Adams, “Making the Case for Syringe Services Programs,” Public Health Reports, 135:1 Suppl (July 31, 2020), pp. 10S-12S. https://journals.sagepub.com/doi/pdf/10.1177/0033354920936233.
[9] Suen et al. https://www.ajpmonline.org/article/S0749-3797(25)00618-X/fulltext
[10] “Post-Overdose Response Teams,” National Association of Counties, July 17, 2023. https://www.naco.org/re inductions at harm reduction agencies to increase treatment engagement and reduce HIV risk: Design and rationale,” Contemporary Clinical Trials, 114 (March 2022). https://www.sciencedirect.com/science/article/abs/pii/S1551714421004109
[11] “Treatment of Substance Use Disorders,” Centers for Disease Control and Prevention, April 25, 2024. https://www.cdc.gov/overdose-prevention/treatment/index.html
[12] Stacey McKenna and Chelsea Boyd, “Why Quitting Cold Turkey May Not Be the Best Answer to Addiction,” Discourse Magazine, May 31, 2023. https://www.discoursemagazine.com/p/why-quitting-cold-turkey-may-not-be-the-best-answer-to-addiction; “Addiction Recovery is Not Linear. It’s Important Not to Give Up,” CleanSlate Outpatient Recovery Centers, Feb. 8, 2021. https://www.cleanslatecenters.com/blog/addiction-recovery-is-not-linear-its-important-not-to-give-up; “Recovery Is Not Linear: Why Setbacks Are Part of Healing,” Riverbend, Jan. 29, 2026. https://riverbendmv.org/recovery-is-not-linear-why-setbacks-are-part-of-healing.
[13] Daniela P. Sanchez et al., “Wounds and Skin and Soft Tissue Infections in People Who Inject Drugs and the Utility of Syringe Service Programs in Their Management,” Advanced Wound Care, 10:10 (July 23, 2021). https://pmc.ncbi.nlm.nih.gov/articles/PMC8312019; Kinna Thakarar et al., “Harm Reduction Services to Prevent and Treat Infectious Diseases in People Who Use Drugs,” Infectious Disease Clinics of North America, 34:3 (Sept. 1, 2021), pp. 605-620. https://pmc.ncbi.nlm.nih.gov/articles/PMC7596878; Orrin D. Ware et al., “Risk of Relapse Following Discharge from Non-Hospital Residential Opioid Use Disorder Treatment: A Systematic Review of Studies Published from 2018 to 2022,” Substance Abuse and Rehabilitation, 16 (April 22, 2025), pp.105-118. https://www.tandfonline.com/doi/full/10.2147/SAR.S440214#abstract.
[14] Moiz Bhai et al., “Impact of Fentanyl Test Strips as Harm Reduction for Drug-Related Mortality,” Medical Care Research and Review, 82:3 (Feb. 12, 2025). https://journals.sagepub.com/doi/abs/10.1177/10775587251316919? cf_chl_f_tk=UhFUhDLtVb2x_mlz5k4nR 1O86lTwoU.oA6eYddMaASg-1782993535-1.0.1.1-DfQQyTdfvr2VIDU6a2pmLEriZGUu7Yz8bPqbvjRpicE
[15] “Strengthening Syringe Services Programs (SSPs),” Centers for Disease Control and Prevention, March 20, 2024. https://www.cdc.gov/hepatitis-syringe-services/php/about/index.html
[16] Stacey McKenna and Chelsea Boyd, “Treatment and Harm Reduction Can Work Together to Save Lives and Reduce Demand for Drugs,” Poster presented at the Rx and Illicit Drugs Summit, April 2026. https://www.rstreet.org/wp-content/uploads/2026/04/WEB-2026-RX-summit-poster.pdf
[17] Stacey McKenna, “How Harm Reduction Prevents Syringe Litter,” R Street Institute Explainer, April 8, 2025. https://www.rstreet.org/research/how-harm-reduction-prevents-syringe-litter
[18] “Saving Lives and Saving Money: Harm Reduction in Action,” Colorado Health Network, May 7, 2026. https://coloradohealthnetwork.org/blog/harm-reduction-programs-colorado-impact
[19] Stacey McKenna and Jay Bell, “Five Levels of Cost-Effective Harm Reduction for Rural Communities,” R Street Institute Analysis, April 15, 2026. https://www.rstreet.org/commentary/five-levels-of-cost-effective-harm-reduction-for-rural-communities
