While this specialization can increase efficiency, it also leads to significant institutional blind spots. In reality, people do not live within administrative divisions. The conditions that shape a person’s life—where they live, learn, work, and seek care—are deeply intertwined. As a result, a policy that may achieve desired outcomes in one department can unintentionally create harmful consequences in another, ultimately undermining broader goals of improving health and well-being.

For example, a city might fund a highly structured addiction treatment program that integrates counseling, medication, and case management. Yet without stable housing or employment opportunities, even the most effective interventions can falter once patients leave care. A state might pass legislation to improve public safety by increasing penalties for public drug use or expanding police authority to clear encampments. But without concurrent mental health and housing coordination, enforcement can produce the opposite of its intended outcome. Cities that increase enforcement without increasing services often see more frequent crisis calls, higher incarceration rates, and repeated emergency department visits, because individuals are cycled through short-term punitive responses instead of being stabilized through treatment, housing, or crisis-care coordination. These policy mismatches are a direct result of siloed policymaking, which is built to solve isolated problems rather than address the overlapping complexities of human behavior and institutional systems.

An interdisciplinary harm reduction approach identifies where policies intersect, overlap, or conflict, showing how siloed decisions can generate unintended harms elsewhere. It asks policymakers to view every issue as part of a larger ecosystem—what public health professionals call a “continuum of care.” The goal is to identify where policies may be incongruent, such as through gaps in care, conflicting mandates, or fragmented accountability, and to design coordinated responses that reduce those harms without creating new ones elsewhere. Though harm reduction is often associated with drug policy, its logic is conceptually applicable across disciplines. It is a pragmatic framework for thinking about risk mitigation that recognizes that human beings are not automatons and that each makes discreet decisions based on their own circumstances, background, and perceptions. A harm reduction approach doesn’t attempt to craft policy for a conceptualized version of humanity, but caters to the needs of real human beings by prioritizing practicality, coordination, and evidence over ideology. 

The value of an interdisciplinary approach can be better understood through economist Friedrich Hayek’s work on imperfect knowledge. Hayek argued that no single entity—whether a government agency, a business owner, or an expert committee—possesses all the information needed to make perfect decisions. Knowledge is distributed across countless individuals and institutions and is constantly in flux. This means that sound policymaking cannot rely on centralized control but must instead employ mechanisms that facilitate information sharing, test ideas in real-world conditions, and adapt based on feedback. While harm reduction does not originate from Hayek’s theories, an interdisciplinary harm reduction framework reflects this same insight. It brings together actors from different systems to identify shared goals, map where policies overlap, conflict, or create gaps, and build solutions that are both pragmatic and self-correcting.

In some arenas, these ideas are already being put into practice. For example, when police officers are trained in harm reduction principles, such as recognizing overdose symptoms, using naloxone, and collaborating with health providers, enforcement becomes more effective and safer for both patients and officers. When cities apply behavioral insights to design roads that naturally cue drivers to reduce speed—like using roundabouts instead of traditional intersections, as Golden, Colo., did—speeds and crash severity decline without relying on police presence. In healthcare, supervised consumption sites in Calgary, Alberta, Canada, have managed overdoses on-site, preventing deaths while reducing ambulance calls by 700 each year and saving more than $2.3 million annually in emergency costs. These examples spanning different sectors share the same underlying logic: measure concrete outcomes, coordinate across systems, and reduce avoidable harm.

This same logic can be successfully applied to housing, urban planning, education reform, governance, and beyond. By aligning their goals, data, and evaluation methods, agencies can prevent duplication, save public resources, and craft policy approaches that reinforce, rather than undermine, one another. 

Reason Foundation’s Interdisciplinary Harm Reduction Framework is built on that logic. Drawing on established models—including the National Harm Reduction Coalition’s core principles, continuum-of-care approaches used in public health, and Continuous Quality Improvement methods—it defines harm reduction as a pragmatic and evidence-informed approach to reducing avoidable harms across multiple areas of public policy, including health, housing, education, technology, finance, governance, and public safety. The framework provides policymakers with a guide to identify preventable harms, design proportionate responses, and evaluate their effectiveness in reducing risk for individuals and communities. Ultimately, it moves harm reduction policy design from theory to practice, creating a shared, interdisciplinary language for effective and measurable reform.

How to use this framework

This guide provides a clear explanation of the Interdisciplinary Harm Reduction Framework and its application across different areas of public policy. We begin by outlining the framework’s core principles and defining each one in the context of real-world decision-making. We then walk through the process of operationalizing these principles, offering a step-by-step guide for identifying harm, designing proportionate interventions, aligning incentives, and measuring outcomes. Each section is designed to be accessible for readers, whether or not they have a background in harm reduction or public policy. The ultimate goal is to translate this framework into a practical decision-making tool applicable to any policy area, from health and housing to education, governance, and technology.

Core principles

1. Outcome-Informed Decision-Making: An effective harm reduction approach must be grounded in reliable data, empirical research, and rigorous evaluation. This means prioritizing interventions with a demonstrable record of success in real-world conditions, using measurable indicators of harm reduction to track progress, and maintaining a willingness to adapt as new evidence emerges. Simultaneously, policies must proactively anticipate and minimize unintended consequences, such as fueling illicit markets, displacing harms to other populations or settings, or creating perverse incentives. This requires both pre-implementation analysis and ongoing monitoring to identify and correct harmful trends early. The emphasis should be on facts over ideology, ensuring that policy choices remain tethered to outcomes rather than political whim.

2. Risk Minimization Without Blanket Restrictions: This principle advocates for policies aimed at reducing the severity and likelihood of preventable harm without resorting to one-size-fits-all or authoritarian policy interventions. Overly broad restrictions affect entire populations, often imposing costs on the majority because a relatively small minority engages in higher-risk behaviors or encounters higher-risk conditions. A harm reduction approach focuses instead on identifying higher-risk individuals and areas to tailor interventions to have the greatest positive impact without unnecessarily limiting the freedoms of the general public.

3. Individual Autonomy and Voluntary Action: This principle prioritizes empowering people to make voluntary, informed choices about their own lives, so long as those choices do not cause direct and demonstrable harm to another person. Rather than relying on coercive mandates, the focus is on removing barriers to support and safeguarding personal agency. This allows individuals to voluntarily adopt safer behaviors when they are ready. This approach also recognizes that individual decisions can have ripple effects for families, communities, and broader society, and that these effects must also be addressed to strengthen both personal and collective outcomes. Lasting change is most effective when it is chosen willingly, not compelled. This principle acknowledges that responsibility for outcomes ultimately lies with individuals.

4. Targeted, Context-Specific Solutions: One-size-fits-all approaches are rarely effective and impose high costs, burdens, and harms on the general public. Harm reduction requires a nuanced understanding of specific communities, environments, and markets to tailor strategies that meet their unique needs. Whether applied to health, housing, finance, or technology, interventions should be proportional to the scale of the problem, appropriate for the target population, and feasible for sustained implementation.

5. Cross-Disciplinary Application: Harm reduction needn’t be confined to public health and drug policy. It offers a versatile framework applicable to housing stability, educational access, financial resilience, technology safety, governance reform, and public safety initiatives, among other issues. Viewing harm reduction through multiple policy lenses ensures more comprehensive solutions, prevents siloed thinking, and helps identify overlapping areas where small, well-designed policy changes can yield compounding benefits.

6. Practicality and Real-World Application: Proposed solutions must be operationally feasible, cost-effective, and workable in the real world. This requires an objective assessment of cost-effectiveness to ensure that both public and private resources are directed toward policies that deliver the greatest reduction in harm per dollar spent. Rather than pursuing unattainable ideals, this principle prioritizes tangible, incremental improvements that can be implemented within existing legal, economic, and cultural contexts. The goal is meaningful, sustainable progress over large-scale, disruptive changes that carry a high risk of both failure and unintended consequences.

7. Incentive Alignment: Sustainable harm reduction requires aligning the interests of individuals, communities, and institutions. Policies should be structured so that all stakeholders share a vested interest in achieving positive outcomes. This can be done through market-based incentives, regulatory flexibility, or public–private collaboration. Equally important is ensuring that policies do not create additional harms, allowing harm reduction efforts to gain long-term support based on shared value rather than enforcement or compliance mandates.

Step-by-step operational playbook

A successful operational playbook translates the Interdisciplinary Harm Reduction Framework into a six-step process that moves from problem identification to coordinated solution implementation. It begins with defining the policy problem and desired outcome, clarifying the harm being addressed, what measurable improvement looks like, and who is responsible for leading the effort. The next step involves mapping the systems and actors involved to visualize how different agencies, organizations, and individuals interact across health, justice, and community sectors. This step also includes establishing a steering committee composed of representatives from each partner agency and at least one community member with direct experience with the specific issue being addressed (e.g., substance use, homelessness, or navigating the justice system) to guide coordination and monitor progress.

Once these overlapping dynamics are mapped, the process turns to identifying points of risk, friction, or missed opportunity—areas where harm accumulates, or coordination fails—and recording them in a simple risk register to ensure accountability. After these risks are identified, teams apply the framework’s principles to decision-making, using the seven harm reduction principles as a lens to test whether proposed actions are practical, proportionate, and evidence-based. The fifth step focuses on designing coordinated interventions and evaluation plans that align funding, roles, and outcomes across systems while creating shared metrics to track progress transparently. Finally, the process concludes with implementation, learning, and adaptation, during which the steering committee meets regularly to review data, adjust strategies based on results, and share updates publicly to promote accountability and continuous improvement. 

Step 1. Define the policy problem and the desired outcome

Begin by clearly describing the specific problem and what measurable improvement would look like. Define the harm you are trying to reduce and how success can be measured. Before moving forward, assign a preliminary lead agency and identify all necessary stakeholders that should be involved in defining the problem. Early clarity about ownership of the issue prevents confusion later.

Questions to consider:

• What harm or challenge are you trying to reduce?
  
• Who is most affected, and in what environments or circumstances?
  
• What would improvement look like in both the short- and long-term?
  
• How will you measure success?
  

Step 2. Map the systems and actors involved

List and visualize all systems, organizations, and individuals that influence this issue. Include public agencies, community groups, non-governmental organizations, private entities, and informal supports, such as families or peer networks. Mapping reveals how decisions in one ambit of life can affect outcomes in another. As you map, identify who has authority, who provides data, and who will make final decisions. Assign a sponsor with budgetary or legal authority, an accountable lead for daily coordination, a data steward for evaluation, and at least one community representative to ensure real-world experiences inform every stage of the process.

Questions to consider:

• Which systems or organizations currently influence this issue?
  
• Where do people most often fall through the cracks?
  
• Who are the main decision-makers, funders, or gatekeepers?
  
• Where do responsibilities overlap or duplicate?
  

Step 3. Identify points of risk, friction, or missed opportunity

With the systems mapped, identify where harm accumulates or where efforts are misaligned. These are the points where coordination fails, incentives conflict, or barriers prevent access to support. Political or community pressures can also limit coordination, especially when proposed changes are controversial or misunderstood, and these should be identified as part of the same risk landscape. Recognizing these intersections early allows attention and resources to be focused where they can make the greatest impact.

Once identified, document these friction points in a simple tracking table or “risk register” that summarizes potential risks. For each, include its likelihood, impact, early warning signs, mitigation strategy, and responsible party. Review this document regularly in coordination meetings to ensure potential harms are identified early and addressed proportionately.

Questions to consider:

• Do any current or proposed laws, statutes, or ordinances create barriers to implementing coordinated policies?
  
• Where does harm most often occur within or between systems?
  
• Are there communication gaps or conflicting priorities among agencies?
  
• Do any current policies create or worsen unintended harms?
  
• Which groups or communities are most likely to be overlooked?
  
• What new risks could arise from this intervention?
  
• How will we monitor for unintended effects or privacy issues?
  
• Who is responsible for updating the risk register?

Step 4. Apply the framework’s principles to each decision area

Once the risks are identified, use the seven harm reduction principles to guide decision-making on how to address them. This framework is not meant for exclusive use by government officials. It is better understood as a shared checklist that independent actors can use when they convene to weigh tradeoffs, compare options, and discard approaches that do not work in practice. When public agencies participate, their role is primarily to bring partners together, share existing data, and remove unnecessary regulatory or administrative barriers so that those closest to the problem are free to test and refine solutions.

Apply each principle to the systems and decisions you have mapped to help ensure that responses are realistic, coordinated, and effective. The principles act as a filter to check whether proposed solutions reflect outcome-based, context-specific, and collaborative thinking grounded in local knowledge rather than top-down assumptions.

Every principle should be reviewed through the lens of those directly affected and those implementing support on the ground. Invite both service recipients and frontline practitioners to comment on how each principle applies in practice. When discussing context-specific design, confirm that diverse populations and geographic realities are represented.

Questions to consider:

• Are desired outcomes clear, measurable, and evidence-based?
  
• Is the proposed intervention proportional to the level of harm?
  
• Does it respect individual choice and autonomy?
  
• Is the approach tailored to local needs and contexts?
  
• Are agencies and partners collaborating toward a shared goal?
  
• Can it be implemented with available capacity and resources?
  
• Are incentives aligned to reinforce positive outcomes rather than process?
  
• Have affected communities been asked how proposed changes may impact them?
  
• What accommodations are needed for language, disability, or access?
  
• How will feedback be tracked and reported back?
  

Step 5. Design coordinated interventions and evaluation plans

With the principles applied, move from mapping to planning. Develop coordinated interventions across systems, assign clear roles, and clarify how each participating organization chooses to contribute. In an interdisciplinary harm reduction landscape, partners include public agencies, private providers, philanthropic funders, and community organizations. Each of these actors controls its own mission, budget, and internal accountability structures. Public officials may revise the way public programs are funded, contracted, or evaluated, but they do not direct or supervise the internal operations of independent institutions.

Within that constraint, “aligning funding” means using the tools that each actor legitimately controls to support the shared goals identified in earlier steps. Public agencies can decide how to structure their own grants, contracts, or reimbursement rules so that public dollars reward reductions in avoidable harm rather than simple service volume. Philanthropic organizations can voluntarily support parts of the effort that align with their missions. Service providers and community groups can decide how to allocate their own staff time and resources to participate in the coordinated response. No single institution sets funding levels for the others. Coordination emerges because different actors see value in the shared objectives and choose to orient some of their resources toward them.

Accountability is created similarly. Each partner remains accountable first to its own constituents, boards, donors, or voters. To make collaboration workable, partners can record their voluntary commitments in simple memoranda of understanding, contracts, or grant agreements that specify who is responsible for which activities and what indicators will be used to judge success. Where public funds are involved, outcome measures and reporting expectations should be defined clearly and published in advance, so that participation is both informed and voluntary. For purely private or philanthropic efforts, this framework still offers a template that organizations can adopt internally to clarify expectations and track results.

Once roles and commitments are clear, establish a shared evaluation plan that integrates information from these efforts and tracks progress across relevant sectors, not just within a single agency. The goal is to create a transparent picture of whether the overall approach is reducing harm, while respecting the independence of each participating institution.

Establish a feedback loop where results, risks, and community feedback are reviewed together at defined intervals. This integrated review structure replaces fragmented reporting and ensures that decisions remain transparent and data-driven.

Questions to consider:

• Who will lead and coordinate implementation across systems?
  
• How will roles and responsibilities be shared?
  
• What data or evaluation tools will be used to track progress?
  
• How will feedback and learning be used to improve the program over time?
  
• What process is in place for identifying and correcting unintended harms?

Step 6. Implement, learn, and adapt

Implementation should include a standing review meeting—monthly during pilots—to compare data to benchmarks, discuss new risks, and document lessons learned. Decisions about scaling up, sustaining, modifying, or stopping an initiative should be based on those reviews, not on intuition or politics. Publish concise progress reports regularly so partners and the public can follow the evidence and stay invested.

Questions to consider:

• Are we meeting regularly enough to detect problems early and adjust accordingly?
  
• What evidence or benchmarks will guide decisions about scaling, modifying, or discontinuing the intervention?
  
• How will we document lessons learned so they meaningfully inform future decisions?
  
• Are any political, organizational, or resource pressures influencing implementation decisions?
  
• How will we ensure transparency so partners and the public can track progress?
  
• Do we have a clear process for deciding when and how to adapt the approach if circumstances change?

Hypothetical example: applying the framework to post-release overdose prevention

This section demonstrates how the Interdisciplinary Harm Reduction Framework can be applied to a real-world issue: preventing overdose deaths among people recently released from prison.

Step 1. Define the policy problem and desired outcome

In this example, we begin with a clear definition of the harm to be addressed, which is the sharp rise in overdose deaths that occurs in the first two weeks among those released from prison, a period when overall mortality can be up to 10 times higher than in the general population and overdose deaths up to 15.5 times higher. 

In one Colorado cohort of 905 people released from state prison, nearly 78 percent of people had a chronic medical or psychological condition, yet only about 10 percent had even a single outpatient visit within 30 days of release, and only 31 percent used any health service at the main safety-net system within 180 days. Upon release, individuals frequently face delays in reinstating Medicaid coverage, securing stable housing, or reconnecting with treatment providers secondary to loss of access to medication, housing, or support networks they once had, thereby disrupting the continuity of care. 

These administrative and logistical barriers create dangerous interruptions in care precisely when overdose risk is highest. Using the framework, policymakers first define the problem as avoidable harm linked to gaps in post-release coordination. The desired outcome might be to reduce fatal and non-fatal overdoses within 90 days of release and increase access to and voluntary use of medication for opioid use disorder (MOUD).

Applying the principle of outcome-informed decision-making, the team might identify measurable targets as: (1) a 15 percent reduction in 90-day overdoses; (2) a 20 percent increase in MOUD initiation within 14 days of release; and (3) a decrease in emergency department visits or emergency calls related to overdose. These outcomes are clear, evidence-based, and trackable across systems.

Step 2. Map the systems and actors involved

Mapping this issue involves correctional health, probation, public health, community clinics, pharmacies, emergency medical services, and peer recovery organizations. It demonstrates that, while each system plays a role, none are responsible for the transition from custody to care, revealing a high-risk gap in care upon prisoner release.

To operationalize the principle of cross-disciplinary collaboration, the example establishes a shared governance model for addressing the target problem. The sponsor (county public health) holds decision-making authority and funding. The accountable lead (correctional health) manages daily coordination. The data steward and evaluator ensure data integrity and oversight. The team also establishes a steering committee composed of representatives from each lead agency, the data steward, and a community advisor. The committee oversees progress, reviews data, and ensures that decisions remain transparent and evidence-based throughout the project. This clear structure transforms the mapping exercise into a functional plan for coordination.

This shared governance structure reflects real-world models that have already reduced deaths after release from prison. For example, Rhode Island’s statewide corrections-based MOUD program is sponsored by a cross-agency overdose task force, with the Department of Corrections as the operational lead and community treatment providers and public health officials jointly responsible for data and evaluation. In that program, everyone entering custody is screened for opioid use disorder, offered all forms of medication treatment while incarcerated, and connected to community clinics and Medicaid coverage before release. Evaluations found that this coordinated approach was associated with a roughly 61 percent reduction in overdose deaths among people recently released from incarceration and a 12 percent decline in overdose fatalities statewide, illustrating how clearly defined roles, shared accountability, and continuous data review can translate into measurable reductions in avoidable harm.

Step 3. Identify points of risk, friction, and missed opportunity

Once the systems are mapped, policymakers can then identify key friction points where harm accumulates. In our example, the team identifies significant harm associated with evening releases that occur after treatment clinics and community providers have closed, leaving individuals without immediate access to medication or follow-up care; inconsistent naloxone access; inadequate data exchange between correctional facilities, community health providers, and social service agencies; and stigma encountered during the initial stages of treatment engagement in the community. 

Each of these issues is logged in the risk register with ratings for likelihood and impact, early indicators, and assigned mitigation responsibilities. For example, risks tied to evening releases may be reduced through partnerships with mobile response teams, while data-related risks are mitigated by implementing role-based access to shared records to protect privacy and improve continuity of care. This keeps risk management transparent, targeted, and proportionate to actual harm.

Step 4. Apply the framework’s principles to decision areas

This step illustrates how the framework’s principles inform design choices:

• Outcome-informed decision-making anchors each intervention to a specific measure.
  
• Risk-minimization keeps the focus on key transition moments without adding barriers.
  
• Individual autonomy ensures the program remains voluntary and participant-driven.
  
• Targeted, context-specific solutions allow scheduling and staffing to adapt to local needs.
  
• Cross-disciplinary collaboration connects correctional, clinical, and community systems.
  
• Practicality and real-world application keep interventions feasible with existing resources.
  
• Incentive alignment ties payments to performance measures, including successful post-release care coordination, treatment initiation, and retention in recovery services.

In the worked example, these principles directly shape the policy response: naloxone is offered at release, next-day MOUD appointments are reserved, peer recovery coaches facilitate linkage, and data dashboards track both health and justice outcomes.

Embedding input from people who have personally navigated the reentry process is also built into this step. The framework emphasizes participation from those most affected. In this example, individuals who have recently been released from custody review program materials, test the discharge workflow, and highlight gaps such as transportation and stigma.  Their feedback is formally documented and integrated into revisions, making engagement an accountability tool, rather than a symbolic exercise.

Step 5. Design coordinated interventions and evaluation plans

Here, the framework moves from planning to execution, including a pilot study for the proposed interventions. The mapped systems and agreed principles guide the design of an integrated pilot:

• Screening and identification: At the time of incarceration, individuals are screened for opioid use risk during the correctional health intake process and monitored throughout custody and release.
  
• Harm reduction at transition: Naloxone is provided at release, with a brief training before discharge.
  
• Linkage to treatment: Peer recovery coaches meet people at release or within 24 hours to connect them with clinics.
  
• Continuity of care: To prevent treatment interruption, pharmacies issue short-term bridge prescriptions, which are temporary supplies of medications like buprenorphine, to cover the period between release and a confirmed clinic appointment.
  
• Monitoring and evaluation: Public health and correctional partners share de-identified data through a secure dashboard.
  

Evaluation follows the framework’s rule of evidence before expansion. The pilot uses a stepped-wedge design, which means the program is rolled out in phases—starting with one jail and gradually expanding to the others. This allows researchers to compare outcomes before and after implementation at each site and see whether improvements, such as fewer overdoses and stronger treatment connections, are linked to the program rather than other changes over time.

Step 6. Implement, learn, and adapt

The final stage in the framework emphasizes learning as an ongoing function. In the worked example, the steering committee meets monthly to review performance data, risk indicators, and community feedback. New challenges, such as transportation gaps or clinic delays, trigger minor course corrections. Decisions to expand, sustain, or stop the intervention depend entirely on whether the predefined data-driven outcomes are met, ensuring that changes are based on evidence rather than assumptions. Transparent reporting ensures that progress, setbacks, and adaptations are documented and shared with partners and the public.

Outcome of the example

If the coordinated pilot is implemented effectively, the county might see promising indicators within the first year—more people accessing treatment, fewer overdose-related emergency responses, and improved coordination across systems.

However, if these outcomes do not materialize, the framework still provides a structure for identifying where breakdowns occurred, what barriers—political, operational, or resource-related—interfered, and how the approach should be adapted or scaled back. The purpose of the example is to illustrate how the framework guides both improvement and course correction.

Final note for policymakers and advocates

This framework is both a mindset and a method. It encourages policymakers to move beyond assumptions toward evidence, collaboration, and continuous learning. By clearly defining harms, designing proportionate responses, measuring outcomes, and adjusting based on results, public systems can reduce avoidable suffering and wasted public resources while preserving choice, privacy, and dignity.

The goal is progress that is practical, measurable, and humane. When public responses expressly recognize that knowledge is dispersed across individuals and institutions, approaches can be tested through evidence and refined through feedback, officials are able to not only reduce harm but also strengthen trust and accountability across every system they touch.

The post Interdisciplinary harm reduction: A practical guide appeared first on Reason Foundation.

In Ohio, lawmakers have taken a tentative step toward addressing this gap with House Bill 542, which would require all jails and prisons to report pregnancy outcomes—a proposal prompted by Linda Acoff’s preventable miscarriage while in the custody of Cuyahoga County Jail in 2024. However, the bill, sponsored by state Representatives Terrence Upchurch (D-District 20) and Josh Williams (R-District 44), does not define what constitutes a “pregnancy outcome,” leaving it unclear whether facilities must report live births, miscarriages, stillbirths, other medical conclusions, or all of the above.

There is a significant gap in the oversight of pregnancy in prisons. The Bureau of Justice Statistics’ most recent report found that more than 700 pregnancies were recorded in U.S. prisons in 2023, with 91 percent resulting in live births, 6 percent in miscarriages, and about 2 percent in abortions. The report did not include data like preterm deliveries, cesarean rates, and maternal complications, making it impossible to understand whether those births were healthy or whether complications were preventable. The report also did not determine how often incarcerated women actually received the prenatal care, nutritional support, or postpartum follow-up that state facilities claim to provide.

Data from the Prison Policy Initiative show that almost half of pregnant women who are incarcerated never receive prenatal testing or basic dietary adjustments during pregnancy, and some are forced to give birth without medical assistance. Without a comprehensive way to track this information, policymakers and health officials are left with an incomplete picture of what care looks like in practice in correctional settings, making it impossible to measure progress or hold individuals accountable.

In February 2024, 30-year-old Linda Acoff was 17 weeks pregnant and detained at the Cuyahoga County Jail in Cleveland. According to an investigation by The Marshall Project and News 5 Cleveland, she screamed in pain for hours, pleading for help as her condition worsened. A nurse, later fired, gave her Tylenol and sanitary napkins but did not call for medical care. When her cellmate eventually alerted a guard, Acoff was taken by stretcher to a hospital, where doctors confirmed she had already miscarried. An autopsy of the fetus later revealed that she lost her pregnancy due to a common infection that went untreated. The baby’s death became the catalyst for the introduction of House Bill 542. Acoff’s death exposed what happens when there is no system for tracking what goes wrong or why. And the “why” really matters—each pregnancy carries unique risks that require timely, evidence-based responses.

Poor outcomes like Acoff’s are not isolated. Across the country, reports of women giving birth alone in jail cells reveal a pattern of preventable harm. A ten-year review of jail births found that among the women who gave birth inside cells, nearly two-thirds delivered only after repeated pleas for medical help went unanswered, and one in four infants was stillborn or died within two weeks. Many of these tragedies stem from untreated infections, premature labor, and delayed medical response.

Beyond maternal healthcare, the risks for infectious diseases are magnified in correctional environments where pathogens spread far more easily than in the community. Studies show that people in custody experience infectious diseases at rates four to nine times higher than the general population. Crowded living spaces, inadequate ventilation, limited screening, and delays in care all heighten the risk. For pregnant women, these conditions can turn manageable illnesses into life-threatening emergencies, as in Acoff’s case. Yet infection control is rarely prioritized, and access to preventive care remains inconsistent across facilities.

On top of these failures, incarcerated people are still charged medical copays to access care, with rates up to $13.50, including for prenatal visits. For someone earning an average of just 55 cents an hour in wages, according to a 2024 analysis of state prison labor data, medical copays of up to $13.50 represent several full days of work. Although some skilled production jobs pay modestly higher rates, these positions account for fewer than 5% of all prison jobs. A 2021 study in the Journal of Correctional Health Care, a peer-reviewed healthcare journal, found that women in prison were 50% more likely than men to forgo medical treatment because of these fees, even when they had greater health needs. When medical care requires copays that exceed what people can realistically pay, it discourages responsible health decisions and undermines the stated goal of reducing long-term healthcare costs. For pregnant women whose health needs are urgent and often unpredictable, this creates another layer of disincentive that worsens an already fragile system.

Further policy recommendations

Data collection alone will not prevent harm if it does not inform intervention. House Bill 542 establishes the foundation by requiring correctional facilities to begin reporting pregnancy data. To make that reporting more meaningful, the state should ensure the data collected is consistent and detailed enough to identify where care is breaking down.

Define and Standardize Data Collection: Pregnancy outcomes and milestones must be clearly defined and standardized across all facilities to ensure accuracy and comparability. These measures should include live births, stillbirths, miscarriages, preterm deliveries, cesarean sections, untreated infections, and maternal complications. Recording these outcomes in a consistent and structured way will allow state health agencies to identify weak points in care—whether that involves inadequate prenatal screening, delays in treatment, or gaps in postpartum follow-up.

Create a Data Review and Oversight Process: To maintain trust and ensure objectivity, lawmakers could allow the data collected under HB 542 to be reviewed by an independent third-party organization—such as a public health research institute, auditing firm, or university partner. These external reviewers could assess the completeness and consistency of the reporting and publish statewide summaries that identify trends without compromising privacy. Independent evaluation promotes transparency while avoiding conflicts of interest that arise when agencies assess their own performance.

Mandate an Annual Public Report: HB 542 should require the Ohio Department of Rehabilitation and Correction to publish an annual public summary of statewide pregnancy data. The report should include total pregnancies, outcomes, and any identified patterns in medical care or response times, while maintaining de-identified and aggregated data to protect privacy. A publicly available brief would allow lawmakers, journalists, researchers, and community organizations to assess progress and hold institutions accountable. 

When implemented together, these policies can turn data into a mechanism for accountability and reform that not only tracks harm but actively prevents it.

Ohio’s House Bill 542 is an important first step toward transparency and accountability in a system where too many pregnancy outcomes still go unrecorded. By simply requiring correctional facilities to document and report this information, the bill fills a long-standing gap in maternal healthcare oversight behind bars. With consistent reporting, independent review, and public access to findings, Ohio can begin to build a framework that not only tracks outcomes but helps reduce the harm already occurring in its correctional facilities.

The post Tracking pregnancy behind bars: Why Ohio’s House Bill 542 could save lives appeared first on Reason Foundation.

These rules are often shaped by professional and regulatory organizations like the American Medical Association, whose influence on state and medical boards, as well as legislatures, affects who is authorized to prescribe and manage MOUD care. While rural areas frequently lack clinicians due to lower population densities, these restrictions make existing shortages worse by preventing qualified providers from offering care where it is most needed. 

Beyond these restrictions, outdated regulations on how and where patients can receive care, such as limits on telehealth and medication delivery, further compound access barriers. Reducing these unnecessarily restrictive occupational licensing and delivery barriers is a practical and evidence-based way to close these gaps and expand access to lifesaving care.

Nurse practitioners (NPs) are already a significant part of the solution. In 2016, Congress passed a law enabling some NPs to prescribe buprenorphine, one of three approved medications for opioid use disorder. However, in 22 states, NPs are not permitted to do so without a supervising physician. This limitation reduces access to MOUD, especially in areas where doctors are in short supply. In states that grant NPs autonomy in prescribing, the number of available MOUD prescribers roughly doubles and significantly increases local treatment access. A national analysis shows that expanding prescribing to NPs had a particularly significant impact in very rural areas, where NPs and physician assistants were responsible for 1.3 times more buprenorphine prescriptions than in urban areas. 

Additionally, the study found that areas where NPs were allowed to prescribe had roughly twice as many registered NPs compared to regions where NPs are barred from prescribing. This may be due in part to the fact that the lack of prescribing authority makes NPs seem less valuable to employers, who then instead opt for physicians. Because NPs are more likely than physicians to relocate to rural communities and to remain there long term, granting them prescribing power would be a meaningful step toward closing treatment gaps where they are most severe.

Pharmacists undergo the most extensive training in pharmacology of any healthcare professional. Idaho has successfully authorized pharmacists to prescribe medications for a range of conditions. Through House Bill 191, which passed in March of 2017, the state granted the Idaho Board of Pharmacy the authority to determine when pharmacists can prescribe medications independently using clinical judgment consistent with the standard practices of healthcare providers. This applied to minor or time-sensitive conditions that did not require a new diagnosis. Within the first year, pharmacists were able to treat over 20 common ailments, and the state reported no safety complaints, showing that pharmacist-led prescribing can safely expand access to care in underserved areas. 

At the national level, the 2021 Mainstreaming Addiction Treatment Act (MAT Act) eliminated the requirement for clinicians to register for and receive a waiver from the Drug Enforcement Administration (DEA) to prescribe buprenorphine for opioid use disorder. Any clinician who can prescribe DEA Schedule III drugs, such as buprenorphine, may now prescribe them in states that recognize pharmacists as prescribers. Within the first year of implementation, pharmacist-issued prescriptions increased eightfold, rising from about 0.1 percent to 0.8 percent of all buprenorphine dispensations nationwide. The increase was most pronounced in states that had already authorized pharmacist prescribers, such as Idaho, New Mexico, and Rhode Island. Still, 90 percent of states continue to restrict pharmacists from prescribing buprenorphine independently. Where pharmacists can prescribe independently, they primarily serve rural and medically underserved areas, increasing the number of filled buprenorphine prescriptions by 5 to 10 percent in counties that previously had no such prescribers. 

The Department of Veterans Affairs (VA) offers a clear example of how pharmacist prescribers can operate successfully as part of a coordinated healthcare team. Veterans experience disproportionately high rates of chronic pain and opioid dependence. Overdose deaths among veterans increased by more than 50 percent between 2010 and 2019, and as many as one in three service members prescribed opioids during active duty met the criteria for dependence. 

Building on the flexibility established under the MAT Act, the VA authorizes clinical pharmacist practitioners (CPPs) to initiate and manage buprenorphine treatment for opioid use disorder under collaborative practice agreements. In 2023, the first full year after the MAT Act’s passage, 110 CPPs prescribed buprenorphine to 1,090 veterans across 36 states, accounting for 4.8 percent of all veterans receiving buprenorphine in the VA system and 4.2 percent of total treatment episodes. Collectively, CPPs issued more than 5,200 prescriptions, over half delivered through telehealth, and served as the sole prescriber in 16 percent of cases. 

International approaches provide additional examples, with Canada, Australia, and the United Kingdom integrating pharmacists into the MOUD treatment infrastructure. 

Psychologists often serve as the first and most consistent point of contact for patients with addiction due to their role in addressing underlying mental or emotional health issues, and could serve as an important access point to medication for addiction treatment. The U.S. Department of Defense (DoD) demonstrated as early as 1991 that psychologists can be trained to safely prescribe medications. An independent review of the program found that the prescribing psychologists trained by DoD filled critical gaps in care, reduced patient wait times for treatment,  and safely managed medications with no reported adverse events linked to their prescribing. 

Today, just seven states allow psychologists with specialized training to prescribe medication. However, most of these states still prohibit them from prescribing the controlled substances that form the foundation of medication-assisted addiction therapy. In Illinois, for example, psychologists are barred from prescribing Schedule II drugs, including methadone—one of three FDA-approved drugs that serve as the foundation of medication-assisted addiction treatment. Granting psychologists this authority could create a crucial new pathway to treatment, especially for individuals managing co-occurring mental health and substance use challenges. 

These profession-specific reforms are a practical and low-cost way to expand access to treatment and care, but they are not the whole answer. These reforms must be paired with broader changes necessary to update America’s health delivery system. America needs to maintain telehealth access for addiction treatment and remove outdated licensing and delivery barriers that restrict how and where patients can receive care.

One of the most entrenched obstacles in expanding access to addiction treatment is the federal system governing methadone delivery. The current system, designed in the 1970s and changed little since, stipulates by law that methadone for opioid use disorder can only be dispensed through opioid treatment programs (OTPs) certified by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the DEA. OTP clinics operate under strict requirements, including daily observed dosing for new patients, regular drug testing, and frequent in-person counseling. 

Though intended to boost safety, these requirements often have the opposite effect by limiting the number of clinics patients can access. Clinics are concentrated in urban centers, forcing rural patients to travel daily, sometimes hours away for a single dose of medication—an impossible burden for many in rural areas. In many states, methadone access is severely limited—Wyoming has no opioid treatment programs at all, while West Virginia prohibits new clinics from opening, leaving some patients to cross state lines or travel hours each day to receive care.

During the COVID-19 pandemic, the United States implemented emergency waivers that allowed patients to take home several days’ worth of methadone instead of reporting daily to a clinic in person. The change proved safe and effective, improving patient retention without sacrificing safety outcomes or diverting the medication into the illicit market. 

These changes proved effective enough that SAMHSA made the COVID-19 flexibilities permanent. In its 2024 final rule, SAMHSA authorized prescribing up to 28 days of take-home methadone doses for stable patients and 14 days for less stable patients. It also permitted first-time prescribing of buprenorphine via telehealth, as well as expanded authorization for mobile medication units—mobile components of OTPs that can dispense medications at remote locations—to operate without requiring separate DEA registrations, improving access to care in rural and underserved communities.

Telehealth reform offers another opportunity to greatly increase access to care. Before COVID-19, clinicians were required to see patients in person before prescribing buprenorphine. The DEA temporarily waived this rule in March 2020, allowing treatment to begin through telehealth, including audio-only visits. A 2025 JAMA Network Open study analyzing more than 228,000 buprenorphine initiations from 2020 to 2022 found that about 10 percent occurred via telehealth, and roughly 20 percent of those would not have been possible under the DEA’s proposed post-pandemic rule requiring an in-person visit before or within 30 days of tele-initiation. Patients treated through telehealth had similar or better engagement and lower overdose rates than those treated in person, echoing earlier findings from JAMA Network Open and the Journal of General Internal Medicine. Telehealth tools have enabled clinicians to reach patients in rural communities, single parents unable to travel, and others who otherwise would have gone untreated.

The potential for telehealth to expand access to care, however, greatly depends on clinicians’ ability to practice across state lines. During the COVID-19 pandemic, many states temporarily permitted cross-state practice, allowing out-of-state healthcare providers in good standing elsewhere to deliver telehealth services when in-person visits were not possible. Those emergency measures demonstrate that interstate care can be safe and effective. Many states are making this flexibility permanent with universal recognition laws.” These laws permit licensed health professionals in good standing from other states to begin practicing immediately, whether they relocate to the state or provide care remotely. Twenty-eight states and Puerto Rico have already implemented such reforms. 

Research from the National Bureau of Economic Research shows that universal recognition improves physician distribution and increases access, particularly in underserved regions. Allowing addiction psychiatrists in Boston to treat patients in Nebraska or West Virginia without redundant licensing barriers could immediately relieve provider shortages in high-need areas.

These reforms form a coherent strategy for expanding access to evidence-based addiction care. Modernizing rules on methadone delivery, protecting access to telehealth, and enabling licensed healthcare providers to care for patients across state lines would allow trained clinicians, including pharmacists, psychologists, nurse practitioners, and physician assistants, to put their skills to work to treat opioid use disorder.

The path forward includes:

Leveraging underused professionals: Empower pharmacists, psychologists, and advanced practitioners to prescribe within their training, building on successful state and federal models such as Idaho’s pharmacist framework and the VA’s clinical pharmacist program, which achieved 87 percent retention among veterans treated for opioid use disorder.

Modernizing methadone delivery: Authorize office-based prescribing and pharmacy dispensing for stable patients under appropriate monitoring, following models proven in France, the U.K., and Canada.

Making telehealth permanent: Codify pandemic-era flexibilities for initiating buprenorphine virtually and reimburse telehealth visits for addiction care at parity with in-person treatment.

Promoting license portability: Expand universal recognition laws to allow qualified clinicians to serve patients across state lines without redundant requirements.

The opioid crisis is not a single-issue problem, and it cannot be solved by one profession alone. But we can drastically reduce the toll on individuals, families, and communities. By embracing practical, evidence-based reforms, we can strengthen the national response to the opioid epidemic. When more qualified people are empowered to provide care, more people survive.

The post Modernizing addiction regulations: How licensing, telehealth, and delivery reform can expand access to care appeared first on Reason Foundation.

Opioid settlement funds have already been used for concerts, law enforcement equipment, and budget backfilling, among other purposes. These uses fall short of the settlements’ intent to remediate the crisis. With billions still to be spent over the next decade, it is crucial to establish better financial controls and reporting structures for the use of these funds to ensure they are deployed transparently, efficiently, and in compliance with their legal restrictions to advance evidence-based interventions proven to save lives.

The opioid epidemic has claimed more than 800,000 lives since 1999. As the crisis intensified, policymakers and the public sought to identify its causes. State and local governments filed thousands of lawsuits against opioid manufacturers, distributors, and retailers, accusing them of fueling the epidemic through misleading marketing and inadequate oversight. These lawsuits ultimately led to the national settlement agreements.  More than a dozen companies that manufactured, distributed, or aided in the prescription of painkillers, including McKinsey, Johnson & Johnson, Walgreens, CVS, and Walmart, reached settlements totaling approximately $50 billion, to be distributed to various state and local governments over nearly two decades.

The settlements stipulate that funds must be used to support opioid prevention, treatment, and recovery efforts. However, since receiving the funds, many jurisdictions have not provided the transparency, accountability, and prioritization of evidence-based strategies that genuinely address the needs of those most impacted by the crisis. Each state receives a designated portion of the national settlement based on factors such as opioid-related deaths, the volume of opioids shipped, and population size, with funds then subdivided between state agencies and local jurisdictions according to negotiated formulas.

To guide spending, the National Opioid Settlement Agreement includes Exhibit E, which stipulates a non-exhaustive list of approved uses centered on prevention, treatment, and recovery from opioid addiction, and harm reduction programs. States must allocate at least 70% of settlement funds toward these opioid remediation efforts, and some have gone further by committing to use 100% of their funds accordingly. The remaining 30% is allocated as follows: up to 15% for administrative costs and up to 15% for any other purpose.

Core priorities for the use of these funds include developing prevention efforts through supporting different evidence-based education programs; expanding training and increasing access to naloxone, a life-saving opioid overdose reversal medication; increasing education around and the availability of medication-assisted treatment (MAT) such as methadone and buprenorphine or other opioid-related treatment; supporting syringe service programs that reduce the spread of HIV and other infectious diseases through clean syringe distribution; and investing in wraparound services that offer coordinated, comprehensive care for individuals in recovery. Other allowable uses involve peer recovery support, workforce development, care for pregnant and postpartum individuals, and programs addressing the needs of those in the criminal justice system. The strategies listed are evidence-informed and designed to respond to the drivers and consequences of the crisis directly.

While the settlement agreement outlines preferred uses with an emphasis on remediation, the guidelines leave significant room for interpretation—creating wiggle room for states and localities to circumvent evidence-based treatment entirely.

This is what has happened in New Jersey, where state investigators uncovered how the Township of Irvington exploited the flexibility of the guidelines to fund events that had little connection to harm reduction, addiction treatment, or public health.

A report from the New Jersey Office of the State Comptroller revealed that over $632,000 was spent on two “Opioid Awareness” concerts in 2023 and 2024. As reported, thousands were spent on “generators, an ice maker, popcorn machine, cotton candy machine, four flavors of shaved ice, a hot food display stand, and catered food.” These events included celebrity performers and DJ sets. One township employee, Antoine Richardson, received $368,500 in unaccounted payments and steered nearly $470,000 in contracts to businesses linked to himself and his wife. The report concluded that Irvington’s actions violated the intent of the settlement and referred the matter to several state agencies for further review.

There have been issues elsewhere in how the funds have been spent. Scott County, Indiana, used over $250,000 to pay salaries for health and emergency services staff, effectively freeing up their local budget to buy a new ambulance and build a financial cushion for the health department. This is achieved through supplantation, where new dollars are used to fund existing programs, thereby making more general fund revenues available for governments to spend as they wish. This practice is not explicitly prohibited in Exhibit E of the settlement fund agreements. Still, it serves as a workaround that can undermine the intended goal of building service capacity through these funds. A similar example occurred in New York, where advocates noted that the state shifted millions from its addiction agency’s base budget and replaced it with opioid settlement dollars—substituting existing funding rather than using the settlement funds to enhance care. Blair County, Pennsylvania, directed $320,000 toward a long-standing drug court, using the funds in part to cover salary shortfalls for probation officers and aides due to limited state grants and probation fee revenue, rather than investing in new or expanded services.

Other states have directed the money toward law enforcement. Southington, Connecticut, used $18,000 to buy cellphone-unlocking technology for police. Ohio County, Ohio, spent nearly $43,000 on new K-9 and EMT equipment. Michigan counties, including Kalamazoo and St. Clair, purchased jail body scanners, infrastructure that experts argue should be funded through general law enforcement budgets. In West Virginia, $364 million, which is more than half of the state’s total opioid settlement spending for the year, went to police vehicles, jail bills, and salaries, while just 6% supported treatment and recovery. Jackson County took this further by using 90% of its $566,000 allocation to expand a first responder training center, including building a shooting range.

Although the opioid settlements stipulate that funds should be used for specific opioid remediation purposes, they contain no binding requirements, enforcement mechanisms, or clawback provisions if jurisdictions misuse the money. Oversight is left entirely to state and local discretion. Each state executed its own Memorandum of Agreement (MOA) defining how funds are distributed and what reporting, if any, is required.

As much of these funds currently remain unspent, it is incumbent on state and local governments to enact better financial controls and reporting mechanisms to ensure money is used consistently with its designated purpose—remediating the effects of the opioid epidemic.

Uncommitted settlement funds across states

According to the Johns Hopkins Opioid Settlement Expenditures Tracker*—developed by Johns Hopkins, Shatterproof, and KFF Health News—roughly one-third of the opioid settlement dollars tracked from 2022 to 2023 were allocated for specific uses.

The share of funds with reported uses varies significantly by state. Many states provide only limited information, leaving large portions of their initial allocations—sometimes more than 75%—without clear documentation of intended use. By contrast, a handful of states, such as Colorado, Washington, and Delaware, have published detailed reports showing how funds are being allocated.

Most settlement agreements do not require states or localities to publicly disclose how they spend the funds awarded to them. Twelve states had initially pledged to be “100% transparent,” meaning they would report on every dollar of settlement funds and how it is used. Only a few have followed through.

Among the handful of states that provide accessible and detailed descriptions of their uses of the funds is the state of Minnesota, which has a dashboard allowing anyone to track what will be done with the $117 million awarded. The dashboard breaks spending down by county, outlining who received the money, for what purpose, whether the grantee is using an evidence-based program, and the outcome of this spending.

Other dashboards include those maintained by the states of Michigan, New York, and North Carolina. New Jersey and Indiana, instead, publish annual reports outlining county-level spending.

Lessons from the tobacco settlement

The 1998 Tobacco Master Settlement Agreement (MSA) is the closest precedent to today’s opioid settlements, serving as an important cautionary tale. The MSA was a deal between four major tobacco companies and 46 states (plus D.C. and American territories). In exchange for releasing the companies from future Medicaid lawsuits related to smoking-related illnesses, the firms agreed to modify their marketing practices and make annual payments to the states in perpetuity, tied to cigarette sales.

Although the MSA was intended to offset public health costs and fund smoking prevention, it placed no restrictions on how states used the money. Most legislatures diverted payments into general budgets, infrastructure, or debt service rather than public health.

According to a United States Government Accountability Office Report, from Fiscal Years 2000 through 2005, the 46 states party to the MSA received $52.6 billion in tobacco settlement payments. However, only 30% of the funds were allocated to health care, and another 3.5% to tobacco prevention. The rest was split between covering budget shortfalls (22%), debt service on securitized funds (5.4%), infrastructure (6%), education (5.5%), tax reductions (1%), and others.

States are still receiving these settlements. According to the Kaiser Family Foundation, states received $6.8 billion from the MSA in 2024. 

Several states securitized the future tobacco settlement cash streams, which means selling the right to receive years of cash flows for a smaller upfront amount, while also passing to bondholders the risk that the companies settled with may not honor the agreed-upon future payment streams, or that tobacco sales would be lower than expected.

This practice is already under discussion for opioid settlements. Some municipalities, such as the Wisconsin Counties Association, have considered securitizing their opioid settlement funds, which would enable them to capture upfront the payment stream that extends through 2038 at a discount.

Securitization is problematic because it trades decades of future remediation dollars for a one-time cash infusion at a steep discount. Governments forfeit long-term funding streams that could sustain treatment and prevention infrastructure. The tobacco experience showed that securitization left many states with little or no settlement revenue in later years, even as smoking-related harms persisted.

Local officials may also be tempted to invest opioid bond proceeds, anticipating that market returns will surpass debt service costs—an approach akin to pension obligation bonds, which carries significant risks.

The outcomes of the tobacco settlement provide clear lessons for the use of opioid settlement funds: Absent binding guardrails and rigorous transparency, both state and local governments face strong incentives to divert or front-load funds in ways that undermine their intended purpose.

Policy recommendations for strengthening opioid settlement spending

When governments are entrusted with funds to address the opioid crisis, they take on a moral obligation to act accordingly. That means investing in what works: expanded access to medication-assisted treatment, naloxone distribution and education, syringe service programs, recovery housing models, and other approaches rooted in evidence and outlined in Exhibit E, including the development of potentially novel treatments.

Misallocating these dollars undercuts both public health outcomes and fiscal responsibility. When rehabilitation-eligible interventions are underfunded, communities miss out on life-saving programs like MAT and harm reduction. Instead, overdose deaths rise, and criminal justice systems bear the cost of repeated recidivism. By contrast, well-targeted settlement spending has the potential to save lives, strengthen communities, and ease the burden on public systems.

Below are recommendations to ensure that the awarded funds are used effectively.

1. Discourage supplantation through clear spending principles

Supplantation, or using settlement funds to replace existing public health dollars, weakens the impact of these resources. State budget officials and attorneys general should issue clear guidance encouraging local governments to deploy settlement funds as a supplemental expansion of care rather than an alternate method of financing existing services.

2. Prioritize external providers for efficiency

Governments should prioritize contracting with external providers rather than providing harm reduction services themselves. Building new publicly operated service programs tends to be costly and slow, while specialized providers are likely to deliver evidence-based care more efficiently and at lower cost.

Partnering with external providers also reduces the risk of budget supplantation, ensuring settlement dollars fund new services rather than displace existing expenditures. Service providers who receive these funds should be held accountable for their use and required to provide an independent auditor’s report detailing the use of these funds if they exceed a minimum threshold. For instance, recipients of federal grants in excess of $750,000 in any year must complete a federal single audit to account for the use of those funds.

3. Prohibit securitization

States should consider adopting explicit bans on securitizing opioid settlement revenues—that is, selling the right to future payments in exchange for upfront cash.

While securitization may appear to offer immediate budget relief, the tobacco settlement experience has shown that it strips away long-term remediation funding, often resulting in communities losing access to dollars even as their needs persist. Prohibiting securitization ensures that settlement payments remain available over time to sustain treatment, prevention, and recovery infrastructure, rather than being consumed in a single budget cycle.

4. Support voluntary frameworks for evidence-based spending

State governments can offer spending guidelines that prioritize effective, research-based strategies such as medication-assisted treatment, naloxone access, syringe service programs, and recovery housing. These frameworks should be developed with input from people with lived experience and members of the affected community to ensure they reflect real needs and can be adapted to local contexts. Highlighting these approaches helps localities focus on interventions that directly reduce harm and improve recovery outcomes.

5. Increase spending transparency

Local governments should regularly publish clear and accessible data showing how settlement funds are spent and what goals they aim to achieve. This can be achieved through either interactive dashboards, such as those used by the state of Minnesota, or yearly reports, as seen in the states of New Jersey and Indiana.

6. Allocate a portion of funds to innovative and emerging treatments

To drive long-term progress in addiction care, state and local governments should dedicate a portion of opioid settlement funds to support the research, development, and piloting of innovative treatment modalities. This includes exploring the therapeutic potential of ibogaine, a psychedelic alkaloid showing promise in interrupting opioid dependence, and GLP-1 receptor agonists, initially developed for diabetes and weight loss, which are being studied for their ability to reduce drug cravings and compulsive use. While more clinical trials are needed, strategic investment in these areas can help expand the future treatment toolkit beyond traditional approaches. Prioritizing innovation ensures that settlements can remediate current harms and foster breakthroughs that reshape addiction care for the next generation.

7. Invite independent spending reviews

Localities can partner with independent institutions to review how funds are allocated and whether spending aligns with the original purpose of the settlements. These reviews help identify areas for improvement and add an extra layer of accountability without requiring new laws or regulations.

8. Include community voices in spending decisions

People affected by addiction should have a role in shaping how funds are used. Community input ensures that spending decisions reflect local needs and improve outcomes for those most directly impacted.

The opioid settlements present a real opportunity to reshape how states support addiction care. Real impact comes from honest reporting, directing funds toward new and innovative treatment options, and strengthening what already exists on the ground. Many harm reduction and recovery programs already serve their communities, sometimes without formal recognition or support. These funds can help legitimize and expand their reach while empowering new groups to fill gaps where services do not yet exist. When used this way, the money can build sustainable systems that save lives and restore trust. The choices made now will determine whether these funds drive lasting progress or fade into missed potential.

*Correction: This piece has been updated to reflect that the data used from the Johns Hopkins Opioid Settlement Expenditures Tracker shows settlement funds received and committed in 2022–2023, not cumulative totals as previously described.

The post Best practices to prevent misuse of opioid settlement funds appeared first on Reason Foundation.

Philadelphia Mayor Cherelle Parker signed a law that would restrict mobile health vans providing critical support, such as clean syringe access and naloxone for overdose emergencies, from operating in Kensington. The measure limits vans to just two pre-approved sites, caps each stop at 45 minutes, and requires providers to obtain a permit to operate. Groups that violate the rules face fines of up to $1,000—and if they incur three violations, they become permanently ineligible to obtain the required permits. 

Though the Philadelphia City Council has described the ordinance as a response to congestion and litter, many community complaints center on concerns about people who use drugs gathering near the vans. Regardless of the framing, these restrictions undermine the very purpose of making care mobile, which is to deliver care where it is most urgently needed.

Mobile health units exist mainly to serve people who use drugs, who often struggle to access traditional healthcare. But they also offer other kinds of support, like basic medical care and community outreach, to anybody, not just drug users, who would otherwise go without care. Between July 2022 and June 2023, Prevention Point Philadelphia’s mobile and stationary syringe services reached more than 30,000 people, provided 1,103 wound care visits, enrolled 357 new participants in medication-assisted treatment for drug addiction, and distributed over 95,000 doses of naloxone, the medication that reverses opioid overdoses. Demand for these services has surged, with the organization’s client numbers more than tripling over the past three years. 

Restricting vans to two fixed locations undermines their core strength: mobility. Outreach teams deploy based on real-time need. Much of Kensington falls within the 19134 zip code, where the Philadelphia Department of Public Health recorded 193 overdose deaths in 2022. A rigid permit system will leave many blocks without timely access to care. 

This policy also disrupts the trust and continuity that are the foundation of successful harm reduction services. Patients who might avoid hospitals or doctors’ offices because of past mistreatment—an exceptionally common experience for people who use drugs—might be willing to accept naloxone from a familiar outreach worker. That small act of trust may also allow the patient to receive wound care and, perhaps later, a discussion about treatment options. 

Philadelphia can address legitimate quality-of-life concerns without constraining lifesaving services. For example, it could establish rotating service zones for mobile vans to prevent clustering in one area, set voluntary sanitation and reporting standards, and offer grants to providers that meet sanitation standards. Programs like Project Reach already work alongside mobile harm-reduction providers to remove thousands of bags of trash and tens of thousands of discarded syringes from city streets each year, showing that public health and public space improvements can go hand in hand. 

The city can also better address the root causes of the problems mobile units seek to address by expanding low-threshold treatment programs and supportive housing. 

As a strategy, mobile outreach has demonstrated effectiveness in saving lives, building community trust, and improving neighborhood safety. Limiting these services to just two fixed locations—especially when Philadelphia is still losing nearly four residents a day to overdose—risks reversing the marked decrease in overdoses that the city has seen. Mayor Parker and city councilmembers should amend this new ordinance and collaborate with providers and the community to design a better approach that can preserve both neighborhood dignity and access to the types of flexible care on which our most vulnerable neighbors rely.

The post Restricting mobile health vans in Philadelphia will lead to more overdose deaths appeared first on Reason Foundation.

Despite $2.7 trillion in public spending to address the drug overdose crisis, the United States continues to experience alarmingly high death rates, strained emergency systems, and ineffective intervention pathways. Current strategies that are largely centered on enforcement and abstinence-only treatment are not meeting the scale or complexity of the drug problem. Public systems remain reactive rather than preventative, leaving taxpayers to fund a revolving door of crisis care that fails to produce meaningful or lasting outcomes.

This policy brief presents a case for integrating harm reduction into the federal response, not as a replacement for drug treatment, but as a pragmatic complement. Harm reduction includes proven tools like naloxone distribution, syringe service programs, fentanyl test strip access, and supervised consumption sites. These interventions reduce healthcare costs, lower disease transmission, and improve individual and community outcomes without requiring drug abstinence. They represent low-cost, high-impact strategies that support public health and public safety alike.

To assess the current drug policy landscape, the brief includes a 50-state matrix evaluating implementation of five core harm reduction policies, including: syringe service programs (SSPs), naloxone access, legality of fentanyl test strips, Good Samaritan laws, and supervised consumption sites (SCSs). While two states meet all five benchmarks, others fall short due to outdated paraphernalia laws, inconsistent naloxone access, and surveillance practices that discourage participation. These gaps reduce effectiveness, create preventable costs, and deter early intervention by eroding trust in care systems.

Key policy recommendations in this paper include decriminalizing essential health tools, strengthening “Good Samaritan” protection laws, limiting surveillance in service delivery, and funding flexible, community-led initiatives. These policy reforms do not expand federal authority or create new regulatory structures. They promote local autonomy and make room for innovation by empowering the organizations best positioned to serve people on the ground.

Harm reduction is a public health approach that prioritizes safety, dignity, and evidence-based care, aiming to build trust in healthcare systems and ensure public resources are used effectively. It’s a practical path forward that aligns with the core principles of reducing government waste, investing in what works, and protecting individual liberty.

Based on the existing evidence, Reason Foundation concludes that expanding access to harm reduction services may be one of the most cost-effective, community-driven uses of funds designated to reduce the harms of the opioid crisis.

Introduction

The United States is confronting a multifaceted drug crisis that carries not only a significant economic burden but a devastating human toll as well. Opioid overdoses alone are projected to claim between 543,000 and 842,000 lives between 2020 and 2032. Beyond the personal loss, these deaths strain emergency response systems, drive up healthcare costs, and contribute to lost productivity and long-term societal expense.

Although treatment options exist, access remains uneven, and relapse rates continue to hover between 40% and 60%. Despite these challenges, many policies continue to prioritize a one-size-fits-all rehabilitation model—often centered around abstinence—which is not sufficient to meet the diverse needs of individuals struggling with substance use disorders.

Traditional treatments for substance use disorders include psychological therapies such as cognitive behavioral therapy, motivational interviewing, contingency management, and family therapy. Medication-assisted treatments (MAT) like methadone, buprenorphine, and naltrexone also offer effective options, as do mutual support groups. However, psychological therapies have an average dropout rate of 30%, and medication-assisted treatments often suffer from limited accessibility and a lack of coordination with psychological or peer-based support systems.

This current system is inefficient, as it fails to reach or retain many of the individuals most in need at great financial cost. For example, among those who inject drugs, preventable infections like HIV and hepatitis C are common due to unsafe injection practices like sharing needles. The average lifetime medical cost of one HIV infection is over $261,000, while hepatitis C treatment can exceed $38,000 per case. Preventable hospitalizations due to abscesses, infections, or overdoses also drive up costs, with each non-fatal overdose costing thousands in emergency department use alone.

In addition to their limitations in efficacy and accessibility, these approaches can unintentionally reinforce harmful stereotypes about people who use drugs. Abstinence-centered rehabilitation often assumes complete sobriety as the only path to recovery. This misconception perpetuates the false notion that one-size-fits-all treatment is effective for everyone. It shapes public opinion of substance use disorder as a moral failing instead of a health issue. It also drives policy and healthcare decisions that discriminate against people who use drugs and restrict access to harm reduction and treatment programs. The persistent ethical condemnation of drug use exacerbates the challenges of treating substance use disorder and prevents people from receiving or even seeking the assistance they need.

Substance use exists on a spectrum. Research shows that most drug use is occasional, short-term, and not associated with addiction. A clinical diagnosis of substance use disorder requires meeting specific criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), which classifies most drug use as “transient.” Unfortunately, treatment protocols often fail to reflect this definition, sidelining evidence-based approaches that could better align with actual patterns of use in communities.

Current research also supports the idea that addiction is not solely the result of individual behavior, but a complex condition influenced by biological, psychological, social, and environmental factors—including physical dependence. For many people with opioid use disorder, quitting abruptly can be dangerous. Unlike illnesses such as diabetes or cancer, which manifest with relatively uniform effects, the effects of addiction vary significantly from person to person. This complexity undermines the effectiveness of uniform treatment strategies. It also reinforces the importance of broadening public health responses to include harm reduction—a practical, compassionate approach that prioritizes health, safety, and human dignity without imposing immediate or total abstinence.

Harm reduction offers a pragmatic complement to existing treatment approaches. It prioritizes reducing the negative health consequences of drug use, particularly among individuals who are not yet ready or able to pursue abstinence. These programs include syringe service initiatives, naloxone distribution, and access to medication-assisted therapy—all of which have been shown to reduce emergency room visits, lower disease transmission, and improve long-term outcomes.

One illustrative example is Taiwan’s 2005 needle exchange program, launched during a surge in HIV among intravenous drug users. Despite the country’s strict anti-drug policies, the program reduced new HIV infections by 90% within four years—demonstrating the public health and fiscal power of targeted harm reduction policies. Similar evidence from cities like Vancouver and Lisbon supports this trend, showing how such approaches can relieve public health systems while improving the quality of life for individuals and families.

Despite the extensive data supporting harm reduction in mitigating drug-related harm, ongoing misinformation about drugs and those who use them continues to hinder widespread acceptance of these strategies in the United States.

However, other nations such as Portugal, Uruguay, the Netherlands, Canada, and Mexico have shifted towards more effective policies for mitigating the potential dangers of drug use. An international trend is emerging, with more nations adopting harm reduction approaches that uphold individual freedom and recognize the right of people to make informed decisions about drug use and treatment.

American policymakers should similarly refocus drug policies from the supply to the demand side and work primarily to reduce the harmful effects of drug use.

Full Policy Brief: Harm Reduction: An Evidence-Based Approach to the Drug War

The post Harm reduction: An evidence-based approach to the drug war appeared first on Reason Foundation.

Protecting children is essential, but reducing their future to a single toxicology report ignores the complexity of what’s truly at stake. One test cannot distinguish between untreated substance use disorder, medication-assisted recovery, or prescribed pain management. Each of these scenarios presents distinct risks, whether related to infant health, the impact of unnecessary family separation, or the consequences of inadequate treatment access, and should be addressed through appropriate, individualized responses.

While many state laws require hospitals to detain infants after a positive toxicology screen, there is often no requirement to conduct follow-up testing to verify the results. This is despite the fact that toxicology screens produce false positive results up to 50% of the time, lack context, and often reflect past use—not current use. Yet, they are often treated as the sole basis for governments to seize a mother’s newborn child.

A study done by Health Economics, a peer-reviewed journal focusing on the economic aspects of health and healthcare, shows that punitive policies, like those that define prenatal substance exposure as child maltreatment in child welfare statutes or as grounds for the termination of parental rights, were associated with a 10-18% increase in infants born with opioid withdrawal syndrome. When healthcare providers serve as part of a punitive system, it undermines trust for both the providers and patients and discourages families from seeking the support they need to remain stable, healthy, and safe.

In a 2019 University of Arizona survey, 35% of people who use drugs said they avoided needed healthcare over fears of being mistreated by medical providers because of their drug use, something nearly all of them said they’d experienced before. When pregnant mothers avoid this care, both maternal and infant health outcomes suffer.

Decades of public health evidence show New Mexico’s new mandate is a superficial fix that undermines effective, long-term solutions. Other states are seeking more effective answers. Nine states have adopted the Sobriety Treatment and Recovery Teams (START) model, which serves families in the child welfare system where a parent has been diagnosed with a substance use disorder. Families are enrolled within two weeks of a child welfare report and paired with a child welfare caseworker and a family peer mentor to guide long-term recovery. These professionals work as a team to coordinate care.

START Services include rapid connection to treatment, intensive recovery support, parenting and life-skills coaching, targeted case management, and counseling for parents, children, and other family members—all while keeping the family involved in decision-making. Evidence shows that START not only reduces child maltreatment and foster care placements but also strengthens parenting capacity. In Ohio, parents in START reported significant improvements in appropriate expectations for their children, healthier family role boundaries, and greater support for children’s independence. In interviews, parents described being more present, engaging in daily activities with their children, maintaining steady employment, and managing stress more effectively.

Nationally, more than 75 percent of children in START remain safely with their parents or reunify by program completion, mothers are nearly twice as likely to achieve sobriety compared to those in traditional services, and the model has roughly halved taxpayer expense overall by reducing foster care costs.

Similarly, the Native American Connections’ Patina Wellness Center in Phoenix, Arizona, is a culturally grounded residential treatment facility for pregnant and parenting women with substance use disorders. It incorporates core principles of the START model, with Indigenous healing practices, placing strong emphasis on the parent–child relationship throughout recovery. Their model achieves remarkable engagement, with 92 percent of participants completing treatment. Crucially, the model fosters lasting recovery, with 67 percent of pregnant and parenting women remaining substance-free six months post-treatment, rising to 75 percent at the 12-month mark.

Lasting progress will come from legislation that embeds family-centered recovery initiatives into state law. Such a framework would protect maternal autonomy by requiring informed consent for drug testing, prohibiting automatic removal of newborns based solely on toxicology results, and ensuring access to services like medication-assisted treatment, peer mentoring, and parenting support. When tied to proven models—such as START, which prioritizes family preservation, or residential programs like the Patina Wellness Center—these protections translate into higher treatment engagement, fewer foster care placements, and long-term cost savings while upholding individuals’ fundamental rights and dignity. This should be the way forward for New Mexico.

The post Why New Mexico’s newborn state custody directive is a harmful misstep appeared first on Reason Foundation.

The latest National Youth Tobacco Survey found that 5.9 percent of middle and high school students were using e-cigarettes in 2024, down from 7.7 percent in 2023 and the lowest level of youth use recorded in a decade, and nothing close to what could reasonably be described as an epidemic. Rather than using the notion of a “child vaping epidemic” to justify tighter restrictions, Makary should focus on the 28.8 million adult smokers who face the most significant health risks and expand the number of FDA-authorized alternatives that can help them transition from combustible cigarettes to far less harmful products. 

Why weren’t the needs of adult smokers mentioned in this interview? Makary’s one-sided treatment of the issue contrasts sharply with Health and Human Services Secretary Robert F. Kennedy Jr., who, speaking only days before Makary, made clear that while shrinking the illicit vape market and protecting youth is a top priority, nicotine itself is not a carcinogen and products like e-cigarettes and nicotine pouches are “infinitely preferable to smoking.” 

As Makary’s own agency acknowledges, nicotine products exist on a continuum of risk, and not all carry the same level of harm. Combustible cigarettes remain the most dangerous form of nicotine use, while other products present far fewer health risks and can play a valuable role in helping adults quit smoking. Alternatives such as e-cigarettes are not risk-free, but they are significantly less harmful than smoking and help those who are not able to quit with nicotine replacement therapies like gums, lozenges, or patches. Supporting these options is a step toward better health outcomes, especially when the alternative is continuing a behavior that causes severe and preventable disease.

Many adult smokers remain unaware that switching completely to e-cigarettes can substantially reduce their exposure to harmful chemicals. A recent survey found that only about one in five U.S. smokers believes e-cigarettes contain fewer toxic chemicals than cigarettes, and even fewer recognize them as less dangerous. This knowledge gap persists despite endorsements from respected medical journals and conclusive evidence that complete substitution lowers toxicant exposure. If Makary is serious about reducing smoking-related deaths, part of his focus should be on correcting these misperceptions through targeted, evidence-based public education for adult smokers. 

The National Institutes of Health and Cochrane Review have found ample evidence through systematic reviews of randomized controlled trials illustrating that those who use e-cigarettes are more likely to stop smoking for at least six months when compared to those who use traditional nicotine replacement therapies. Despite strong evidence and endorsements from some of the most respected medical journals, U.S. policy continues to heavily restrict e-cigarettes through product bans, flavor prohibitions, and limited market authorizations. This stubbornness on e-cigarettes often ends up causing an uptick in tobacco sales. 

On The Conversation, Makary focused particularly on the problem of illicit disposable products imported from China and framed the issue primarily around youth use, which, as noted, is at an all-time low. The problem with focusing on the illicit market is that this problem itself stems from federal policy choices that limit the legal market. When FDA authorizations exclude the products that adult users prefer, such as certain flavors, device types, and nicotine strengths, consumers are more likely to turn to the unregulated market.

Economic and policy research shows that restrictive measures often fail to reduce use as intended. A Yale School of Public Health study found that local flavor bans reduced e-cigarette sales but increased cigarette purchases, calculating that for each 0.7 ml of e-liquid sales suppressed, an additional 15 cigarettes were sold. In areas with flavor restrictions for more than a year, adult-preferred cigarette brand sales rose 10 percent, and brands popular with underage users rose 20 percent.

The policy takeaway is clear: To reduce the spread of illicit products and improve public health outcomes, the FDA should authorize a broader range of regulated, appealing alternatives. When adult smokers have access to legal options that match their preferences, the economic incentives for illicit trade diminish. 

Efforts that focus only on cracking down on illegal supply while limiting lawful access will continue to drive consumers toward unregulated products, undermining both safety and public health goals. Mackary’s call for collaboration and evidence-based regulation should fully extend to vaping policy, replacing fear-driven narratives with strategies grounded in public health evidence and economic insight.

The post Evidence, not fear, should guide the FDA’s vaping policies appeared first on Reason Foundation.

Compelled by mandatory reporting laws and concerns about personal liability, medical providers are increasingly being co-opted into acting as law enforcement rather than caregivers. The result is that nearly 40 percent of child welfare removals cite parental substance use as the reason, though most cases involve no imminent danger. Instead of support that might help families remain together safely, these families are subject to surveillance and punishment.  

Soon-to-be mothers are also at risk when they seek prenatal or other forms of care if they disclose drug use or are even suspected of it. Prosecutors in 45 states have filed charges related to prenatal drug use, relying on general child welfare or endangerment statutes because no state explicitly defines prenatal substance use as a standalone crime. This is especially concerning because the law doesn’t distinguish between illicit drug use and prescribed treatment, like methadone or buprenorphine, despite clear medical evidence that these treatments are appropriate for opioid use disorder during pregnancy. 

Between 2006 and 2022, over 1,379 women were arrested or detained for drug use during pregnancy. These prosecutions spiked following the Dobbs v. Jackson decision by the Supreme Court, which rolled back federal protections for reproductive rights. In the year post-Dobbs, prosecutors charged more than 200 people with alleged drug use during pregnancy, an 88% increase from the 25 cases the year before. More than 100 of those cases were in Alabama alone. Some states, like South Carolina, use “fetal personhood” laws to interpret child endangerment or neglect laws in ways that criminalize people for drug use during pregnancy, even when no harm to the baby occurred.

This punitive approach to mothers struggling with substance use disorders has backfired spectacularly. States that criminalize maternal substance use see 41% higher rates of Neonatal Abstinence Syndrome—where infants experience drug withdrawal—and worse health outcomes for both mothers and infants. Why? Because fear pushes pregnant people away from care and proper management of their substance use, putting both mother and child at extreme risk. States that offer voluntary treatment without the threat of legal punishment, by contrast, see higher engagement in treatment, better recovery outcomes, and healthier births. These policy differences aren’t just bureaucratic; they can determine whether families stay together or are torn apart and traumatized.

State-level approaches to maternal substance use tend to fall into two camps: punitive responses that involve criminal or child welfare systems and passive approaches that offer little to no support for pregnant people seeking treatment. While a handful of states protect pregnant people seeking drug treatment from prosecution, 24 states and the District of Columbia define prenatal drug exposure as child abuse or neglect under civil child welfare statutes. In 25 states, healthcare providers are forced to act as informants due to laws that require them to report suspected maternal drug use to child protective services, regardless of actual harm or context. 

Some states go even further by mandating drug testing for pregnant patients suspected of drug use or authorizing involuntary commitment for “pregnant drug abusers.” While the federal Child Abuse Prevention and Treatment Act (CAPTA) requires states to have procedures to address substance-exposed newborns, it does not mandate punitive responses. Yet many states interpret CAPTA in ways that prioritize surveillance and removal over support and care, deepening the legal and health disparities faced by pregnant individuals with substance use disorders.

Criminalizing pregnant substance users isn’t just cruel; it’s expensive. Incarcerating a single person costs states an average of $33,000 annually (and more than $70,000 in California and New York). If incarceration results in children in need of foster care placement, that costs taxpayers an additional $25,000 annually per child. Taxpayers must bear these expenses while the underlying policies fail to improve outcomes for substance use or maternal and infant health. 

In contrast, voluntary treatment-based approaches to substance use during pregnancy are far more likely to improve maternal and infant health and are also significantly more cost-effective. Care-based interventions, such as medication-assisted treatment, harm reduction services, parenting support, and housing assistance, encourage ongoing care throughout pregnancy. As a result, both mothers and infants have improved outcomes, with a reduction in costs associated with emergency services and hospitalizations.

A few states have passed legislation to protect pregnant women’s access to medications for opioid use disorder. For example, Louisiana passed a law in 2022 requiring licensed drug treatment facilities that serve pregnant women to offer at least one FDA-approved opioid agonist therapy (such as methadone or buprenorphine). Meanwhile, Maine and Pennsylvania have allocated funds to create family-based recovery housing, allowing mothers to stay with their children. This approach has been shown to increase treatment completion rates to as high as 81%, increasing the likelihood of long-term recovery and saving taxpayers from the costs associated with foster care placement. 

Keeping mothers and babies together, wherever it is safe to do so, eases the burden on overextended foster systems and allows taxpayer resources to be directed toward long-term wellness rather than short-term punishment. Especially in a time of stretched budgets and growing need, treatment-focused care provides a more effective and fiscally responsible path forward.

The legislative path forward: Evidence, dignity, and autonomy

Reason Foundation drafted model legislation to give states a clear and actionable roadmap for protecting families and improving maternal health outcomes. Titled “An Act to Protect Individual Liberty in Health, Recovery, and Harm Reduction Access,” the bill responds directly to the failures of punitive policies that treat substance use during pregnancy as a crime. Drawing on decades of clinical research and public health guidance, the legislation includes protections against non-consensual drug testing, safeguards for maternal privacy, and expanded access to peer recovery support. The proposed model legislation reflects what the evidence bears out:

• No one should be prosecuted or penalized simply for being pregnant and struggling with substance use.
  
• Drug testing during pregnancy must require informed consent, and positive results alone must not justify family separation.
  
• States should prioritize voluntary, trauma-informed services, such as medication-assisted treatment, prenatal care integrated with addiction support, and peer mentoring that help families stay together and healthy without relying on coercion or punishment.

Reason Foundation’s model legislation protects civil liberties by requiring informed consent for drug testing, prohibiting automatic reporting based on positive tests alone, and ensuring that substance use during pregnancy is not treated as grounds for criminal charges or automatic family separation.

The punishment of drug use during pregnancy has failed to reduce substance use, hasn’t improved outcomes for children, and violates the rights and dignity of those most in need of care. This legislative model provides states with a practical and evidence-based alternative, grounded in compassion, respect for human dignity, and the belief that every family deserves to thrive.

Full Model Legislation: An Act to Protect Individual Liberty in Health, Recovery, and Harm Reduction Access

The post Healthy families start with compassionate policy: Addressing drug use during pregnancy appeared first on Reason Foundation.

SCSs do not necessarily condone nor encourage drug use. Instead, they exist to minimize chaos in places where chaos usually rules: sidewalks, parks, alleyways, and public bathroom stalls. In lieu of reacting only after finding someone collapsed in one of these discreet locations, SCS serve as controlled environments that mitigate the risks of open-air drug scenes, discarded needles in public parks, and unnecessary emergency calls. In New York City, where two SCSs have been operating since 2021, officials report that more than 1,700 overdoses have been reversed without a single death on site.

The services offered at SCSs are simple, consistent, and rooted in practicality. Clients receive access to sterile supplies and safe disposal containers, helping prevent the spread of HIV, hepatitis, and other infectious diseases. Medical professionals are on site to respond to overdoses immediately, often within seconds. Many locations offer wound care, testing for different communicable diseases, and drug checking to detect lethal contaminants like fentanyl. These tools, when offered in a single setting, significantly lower healthcare costs and alleviate pressure on already overstretched emergency departments.

Hepatitis C infections, commonly associated with injection drug use, cost the United States over $10 billion annually. The financial burden grows when factoring in emergency response: ambulance rides can range from hundreds to tens of thousands of dollars if an air lift is needed or if the patient doesn’t have insurance. Emergency room visits add even more, with each visit averaging $1,800, contributing to an estimated $32 billion in annual costs. Every infection prevented, every ambulance ride avoided, and every emergency room bed freed up adds up to real cost savings to the taxpayers who have to subsidize the costs of public insurance. In one space, clients get what they need to survive today and what they might need to recover tomorrow.

Just as we accept seatbelts and smoke detectors as essential tools for reducing preventable deaths, supervised consumption sites provide a structured response to a crisis we can’t ignore. SCSs acknowledge the reality on the ground and respond with practical interventions that keep people alive. With local control and real-time data, municipalities can tailor these programs to fit their neighborhoods, saving lives, saving money, and reducing the visible chaos that too often accompanies untreated addiction.

A brief history of supervised consumption sites

SCSs were forged in moments of urgent local crisis. Switzerland opened the first sanctioned site, named Contact Netz, in Bern in 1986 amid a growing HIV epidemic and overdose surge. Results were immediate and impactful: fewer syringe purchases on the street, safer injection practices, reduced public drug use, and a significant drop in sexual assault incidents among vulnerable users. By 2022, Switzerland had established 14 SCSs across 10 communities, codifying harm reduction into national law through the Four Pillars Policy: prevention, treatment, harm reduction, and law enforcement.

Germany followed with its first facility in Berlin in 1994, largely to address visible public drug use in urban spaces. By 2011, a national assessment concluded that Germany’s SCSs had significantly reduced open-air drug scenes, cut down on HIV and hepatitis transmission, and saved lives by preventing fatal overdoses. Germany now hosts 29 SCSs, 27 fixed and two mobile, across 17 cities, averaging hundreds of supervised injections daily with no reported on-site deaths. 

In 2001, Sydney opened the Uniting Medically Supervised Injection Centre in the Kings Cross district in response to rampant public injection and overdose deaths in the area. Since opening, the center has supervised over 1.2 million injections, managed more than 10,800 overdoses, and recorded zero fatalities. The center also provides critical health care access for clients who have rarely engaged with other services. A second site opened in Melbourne in 2018. From 2018 to 2022, it oversaw 300,000 supervised injections, managed over 6,000 overdose events, and made more than 15,975 health and social support interventions, with zero overdose deaths reported on-site.

Canada became the first country in North America to legalize an SCS with Insite in Vancouver in 2003, following a dramatic spike in overdose deaths and HIV infections in the Downtown Eastside. In its first two years of operation, overdose deaths were reduced by 35% in and around the area. That immediate success sparked a national expansion, and as of 2022, Canada has the highest number of SCSs at 39.

Today, over 200 SCSs are operating across 18 countries, including mobile units and facilities that accommodate drugs delivered via inhalation along with injectable drugs, an important innovation in line with changing patterns of drug use.

International models: Discipline meets compassion

Germany’s model strikes a deliberate balance between public order and public health, with over 32 drug consumption rooms operating part-time as of 2023. Access to these sites is generally limited to adults ages 18 and over who are actively using illicit substances and unwilling to stop, often requiring a documented history of addiction or social marginalization. Registration systems in many facilities track visit frequency and allow for personalized health engagement, while ensuring anonymity and confidentiality. These requirements align with stipulations in Germany’s Narcotics Act, which was established to ensure harm reduction services adhere to public health and safety standards. Instead of working at odds, health providers, lawmakers, and law enforcement coordinate efforts under this act, building trust and improving outcomes on both sides. In 2023 alone, Germany’s drug consumption rooms recorded over 650,000 supervised drug use episodes, managed 650 medical emergencies without a single death, provided services to over 18,500 individuals, and facilitated 52,000 counseling sessions and referrals. Germany’s experience demonstrates how harm reduction services can link people to care while maintaining public order.

In Canada, the focus is on low-barrier access. At Insite in Vancouver, clients not only find a safe space to use substances but also gain access to detox services, primary care, and mental health support under one roof. While federal resistance and public scrutiny have fluctuated, Insite has consistently delivered results, having had over 4.6 million visits and 71,000 off-site service referrals since its inception. Over 11,856 overdoses have been reversed, not a single death has occurred on site, and support from both the public and law enforcement has steadily grown.

In the Netherlands, Switzerland, and Spain, Supervised Consumption Sites are thoughtfully structured to reach the most marginalized populations, following requirements similar to those in Germany. Across Europe, there are currently over 78 official drug consumption rooms operating across seven countries. Moreover, these countries’ approach has proved adaptable to shifts in drug use patterns, with inhalation booths becoming more common in Europe and gaining traction in Canada as fentanyl smoking has become more popular. In the U.S., both Rhode Island and New York’s programs include this feature.

Across these international models, results consistently show that SCSs implemented with clear protocols, integrated services, and community input lead to significant reductions in overdose deaths, lower rates of public drug use and syringe litter, and increased referrals to health and detox services.

Current U.S. landscape: Legal barriers and local action

Legal barriers remain the biggest obstacle to expanding Supervised Consumption Sites in the U.S. The most notable is 21 U.S.C. § 856, formally known as the Maintaining Drug-Involved Premises statute, commonly referred to as the “Crack House Statute.” Enacted during the Reagan era, this law makes it a federal crime to knowingly open, lease, rent, use, or maintain any place for the purpose of manufacturing, distributing, or using controlled substances, with no exception for efforts aimed at reducing overdose deaths or providing life-saving care.

In 2019, Safehouse, a nonprofit in Philadelphia, challenged this statute in court, arguing that the purpose of the site was not to facilitate unlawful drug use but to provide life-saving medical services. Their challenge was initially successful in the District Court for the Eastern District of Pennsylvania, but in 2021, the Third Circuit Court overturned the ruling, holding that the statute clearly prohibits operating any site where illegal drug use occurs, regardless of the operator’s intent or public health motivations. The Supreme Court declined to hear the case, leaving the ruling intact. With 1,200 overdose deaths in 2020, the ruling highlights the stark disconnect between the city’s public health crisis and the limitations of federal law. While the Third Circuit’s ruling reflected a strict interpretation of the statute, it also highlighted the need for legislative reform to allow innovative, life-saving interventions, like supervised consumption sites, to operate within a legal framework.

Some states and municipalities have moved to expand supervised consumption sites despite federal bans. New York City opened the first SCS in the U.S. in 2021, with two facilities operated by OnPoint NYC. In their first year, these sites intervened in over 636 overdoses during more than 48,000 visits by 2,841 registered participants. Rhode Island passed legislation to launch a pilot SCS program in 2021, opening a site in Providence in 2025. In its first two months of operation, 135 individuals visited the center over 420 times, 22 overdoses were reversed, and 50 people were connected to external health services. Other cities, including San Francisco and Philadelphia, have begun opening temporary or “pop-up” SCSs in response to local need.

Though SCSs are not federally sanctioned, the change in presidential administrations has led to some signs of evolving attitudes, at least within the executive branch. In 2022, under the Biden administration, the Department of Justice expressed openness to establishing “appropriate guardrails” around local SCS programs. Since then, however, little progress has been made at the federal level under the new Trump administration. Harm reduction services have faced significant federal funding cuts, including for naloxone distribution, and Congress has taken a more oppositional stance by introducing bills like the Defund Heroin Injection Centers Act of 2025, which seeks to bar federal funds from being used to support supervised consumption sites. While there’s currently no pathway for an SCS to gain federal authorization, these developments highlight the importance of local innovation and flexibility. Instead of waiting for top-down approval, cities and states have moved forward with targeted, community-driven solutions. If these efforts prove effective, especially when supported through voluntary public-private partnerships, they can build a stronger case for broader policy shifts.

Legislative recommendations: Moving forward with practical reform

Supervised consumption sites aren’t about growing government or endorsing drug use. Rather, they are a targeted, community-driven, and compassionate response to an urgent crisis.

Policymakers can support them by:

1. Amending the Crack House Statute: Congress should revise the Maintaining Drug-Involved Premises statute (21 U.S.C. §856)  to create a clear exemption for state- or locally-sanctioned SCSs. This amendment would resolve the current legal ambiguity that deters cities and nonprofits from launching these vital programs. As highlighted in the current version of the New York City Council Resolution 0313-2024, a formal call for Congress to amend the Anti-Drug Abuse Act of 1986, the fear of felony liability has chilled the implementation of SCS. In Canada, a similar exemption under the country’s Controlled Drugs and Substances Act allowed Insite to open in Vancouver legally.

2. Launching Time-Limited Pilots: States should follow Rhode Island’s example by piloting SCS programs with intermittent evaluation. Rhode Island authorized its first SCS in 2021, and in 2024, the facility opened in Providence with support from local officials and nonprofit operators. These pilots can be run at low cost with clear goals and benchmarks, allowing lawmakers to reassess after three to five years. Because the overdose crisis directly affects community health and safety, such pilot programs fall within the powers and responsibilities of state governments. State authorities are informed by their local authorities, who are closer to the front lines, witnessing the everyday impact of overdose in emergency rooms, public spaces, and neighborhoods.

3. Establishing Basic Standards Without Overreach: Regulations for supervised consumption sites should ensure safety without creating barriers to access. At a minimum, sites should have trained staff, emergency medical protocols, proper waste disposal systems, and age restrictions for clients. Oversight could be managed by state health departments, with quarterly inspections to ensure compliance. Staff should be trained not only in medical overdose response but also in how to de-escalate tense or potentially volatile situations, such as when someone is in crisis or exhibiting erratic behavior. They should also be equipped with trauma-informed care practices, which emphasize understanding the lasting effects of trauma and responding in ways that promote safety, dignity, and trust.

Apart from minimum safety standards, implementation should remain flexible to tailor solutions to local needs. Insite in Vancouver, for example, is a model site, run by local Vancouver Coastal Health and Progressive Housing Community Service Society. It maintains rigorous protocols, including trained medical staff, emergency response procedures, and strict hygiene standards. The outcomes from 20 years of operation show that, when implemented with the right controls, SCS can reverse nearly 12,000 overdoses—without a single death on site.

4. Prioritizing Local Control: SCSs should only be implemented where local officials and communities support them. Switzerland followed this model in the 1990s, allowing cities like Zurich and Geneva to set up services based on local needs. This local buy-in helped turn once-controversial initiatives into publicly supported health responses that cleaned up city parks and streets.

Supervised consumption sites are about reducing preventable deaths, easing the burden on emergency systems, and helping communities regain control of public space. Lawmakers can choose to maintain the current approach, but the evidence points to a better path. The SCS model is working. It’s saving lives—and that’s what public health initiatives and harm reduction are ultimately about.

The post Reducing harm, saving lives: The case for supervised drug consumption sites appeared first on Reason Foundation.

Erosion of due process and property rights

Civil asset forfeiture is classified as a legal proceeding against the property, rather than the individual who owns it. This can include cash, cars, homes, bank accounts, jewelry, cell phones, laptops, firearms, and even everyday items like clothing or gift cards. Because these proceedings are classified as civil, rather than criminal, Americans facing civil asset forfeiture don’t receive the same level of due process. The federal government and most states require a lower standard of proof than “beyond a reasonable doubt” to win civil forfeiture cases, often using standards such as “preponderance of the evidence” or even “probable cause,” which makes it significantly easier for the government to take ownership of property without a criminal conviction. 

Additionally, while there is a process for innocent owners to reclaim their property, the burden of proof often lies with the property owner to demonstrate their innocence and that they were not aware of any criminal activity. Most seizures involve low-value property—often not exceeding $1,300—making it more expensive to pursue a legal challenge than to simply walk away, even when the seizure was unjust. This flips Americans’ constitutional right to the presumption of innocence on its head.

In Culley v. Marshall, an asset forfeiture case that was fought all the way to the Supreme Court, two Alabama residents’ cars were used by others to conduct illegal drug transactions. The owners were unaware these crimes were happening, but Alabama police attempted forfeiture of the vehicles anyway. It took the owners many months to prove their innocence through state courts and reclaim their vehicles. During that time, they were left without transportation—affecting their ability to work, care for their families, and meet daily needs—and received no compensation for the loss of use. Although the Supreme Court ultimately ruled in Culley v. Marshall that no constitutional violation occurred, the case exposed a deeper issue: property owners can be left without critical assets for months, without a prompt hearing or any practical way to challenge the seizure. While the owners eventually reclaimed their vehicles through the courts, the drawn-out process—during which they had no access to essential property—reveals how current civil forfeiture procedures can be burdensome and one-sided. Even in cases where the property owner is innocent, navigating the system requires time, money, and legal knowledge that many people simply don’t have. Culley illustrates how the system can penalize people not just for actual guilt, but for proximity to those who are guilty.

In South Carolina, Mikee Albin’s RV, where he lived, was seized after officers purchased a small amount of marijuana in the restaurant Albin owned. A state appeals court eventually ruled the seizure invalid, though Albin had since died, but Albin’s estate never recovered the money spent fighting the case. In Wyoming, Phil Parhamovich was pulled over for improper seat belt use and a lane violation. After consenting to a vehicle search, police discovered $91,800 of his life savings hidden in a speaker—money he planned to use as a down payment for a recording studio. He wasn’t charged with a drug crime or any other serious offense. Nonetheless, police claimed the money was connected to drug activity and seized the cash, and Parhamovich had to fight through a lengthy legal process to get it back eventually. 

Unfortunately, these cases are surprisingly common. In 2018 alone, local and federal law enforcement seized over $3 billion in cash and property, with $2.5 billion coming through federal programs. Importantly, most of that federal forfeiture—nearly $2.1 billion—was conducted without any criminal charges. Over the past two decades, forfeiture has pulled in more than $68 billion nationwide, turning a system meant to fight crime into one that quietly strips people of their property, often without ever giving them a day in court.

Financial incentives encourage troubling law enforcement behavior

In 43 states, police departments and prosecutors’ offices are allowed to keep anywhere from 50% to 100% of the revenue generated through civil asset forfeiture. This creates a strong incentive to prioritize policing that also makes money, particularly in drug enforcement. Some states have seen public backlash against such practices, as abuses have drawn media attention and have led to reform. Such reforms include increasing the standard of proof, limiting what can be forfeited civilly, or requiring that forfeiture proceeds go to general funds or community programs instead of law enforcement budgets.

However, local agencies can often sidestep these state-level reforms by participating in the federal government’s Equitable Sharing Program, which is run by the U.S. Department of Justice and the Department of the Treasury. Under this program, local police can partner with federal agencies, such as the Drug Enforcement Administration, on forfeiture cases. When property is seized, even if it would usually be governed by state law, the case is instead processed under more permissive federal forfeiture rules. Once the property is forfeited, up to 80% of the proceeds are “shared” back with the local agency, regardless of what state law might otherwise require.

This loophole allows departments to bypass stricter state forfeiture laws and continue taking property under federal standards, which often require a lower standard of proof and impose fewer restrictions on how the money can be used. Because the federal government handles the legal action, state restrictions on how forfeited assets are distributed don’t apply; yet the local agency still receives a share of the proceeds.

While these forfeitures may generate revenue for police and prosecutors in the short term, the broader consequence is a distortion of policing priorities, where financial gain outweighs public safety. Rather than focusing on solving violent crimes or engaging in proactive, community-based policing, agencies are encouraged to dedicate time and resources to revenue-generating activities like roadside drug stops and property seizures. 

This misalignment comes at a cost: While officers are pulling over cars on the interstate in search of cash, clearance rates for serious crimes, like homicide, assault, and burglary, remain alarmingly low in many jurisdictions. Nationwide, police solve only about half of all homicides, and the clearance rates for property crimes are even lower. By prioritizing profit-driven drug enforcement, departments risk neglecting the very duties that most directly contribute to public safety. The result is not just a distorted drug policy, but a policing model that serves budgets over communities.

Forfeitures undermine effective drug policy and other public safety priorities

Civil asset forfeiture exacerbates existing inequalities perpetuated by the War on Drugs, reinforcing racial disparities and disproportionately affecting marginalized communities. Because forfeiture creates a financial incentive to pursue low-level drug enforcement, it often leads to overpolicing in poor and minority neighborhoods. This increased emphasis on seizure-based policing doesn’t just misallocate officer time; it also clogs courts with minor drug cases and places unnecessary strain on already limited treatment programs and correctional systems. As a result, individuals with the most urgent needs—such as those experiencing homelessness, mental illness, or substance use disorder—are often overlooked because they don’t present a financial incentive through forfeiture. Meanwhile, limited public health resources are diverted to pursuing low-level seizures, rather than being invested in prevention, treatment, or harm reduction strategies that address the root causes of drug-related harm. Far from reducing substance use or improving community safety, civil forfeiture fuels a cycle of mistrust and inefficiency in systems meant to protect and support the public.

According to the Institute for Justice, the median value of property seized in Michigan was just $423, and in Pennsylvania, $369. In both states, the vast majority of seizures involved small amounts of cash, hardly the kind of assets typically associated with major criminal enterprises. Instead, it appears that law-abiding individuals are targeted by law enforcement for forfeiture.

When law enforcement is seen as prioritizing property seizures over public safety, it erodes the relationship between officers and the communities they serve. Police depend on everyday people to speak up–to report crimes, share what they’ve seen, or help move an investigation forward. But when community members worry that a simple interaction with law enforcement could lead to losing their car or cash, they’re far less likely to speak up, even in serious situations. In the end, everyone’s safety is compromised.

In addition, forfeiture has not been shown to reduce drug use or improve public safety. A study by Seattle University economist Brian D. Kelly found that increased forfeiture activity didn’t lead to reduced drug use or better crime clearance rates, but it did correlate with rising unemployment. This aligns with findings from the Institute for Justice, which reports that equitable sharing revenues peaked in 2013, shortly after the Great Recession. This suggests that law enforcement agencies turned to civil forfeiture as a financial lifeline amid declining tax revenues and growing demand for public services. While it’s difficult to isolate a single cause, the timing indicates that forfeiture increases are often tied more to economic strain than to actual public safety needs. That this surge frequently occurs without any accompanying criminal charges only deepens concern that civil forfeiture is driven by revenue generation, not justice.

Legislative and judicial challenges to civil asset forfeiture

Several states have enacted significant reforms to limit or eliminate civil asset forfeiture. North Carolina, New Mexico, and Maine have gone the farthest, banning civil forfeiture altogether and allowing property to be forfeited only through criminal forfeiture, following a conviction. Utah prohibits forfeiture when the property owner is acquitted of the charges. Other states have taken steps to increase transparency, raise the standard of proof, or direct forfeiture proceeds away from law enforcement budgets.

However, even the most robust state-level reforms face a major loophole: the federal Equitable Sharing Program. Some states have attempted to limit participation in equitable sharing by requiring a criminal conviction for property to be forfeited, or by restricting how shared proceeds can be used, with variable levels of success. For example, despite New Mexico banning civil asset forfeiture entirely in 2015 and requiring a criminal conviction for any forfeiture to occur, law enforcement agencies in the state have continued to generate significant revenue through the federal Equitable Sharing Program by receiving a portion of the funds from assets seized by federal law enforcement. Between 2000 and 2019, New Mexico law enforcement agencies received over $50 million in forfeiture revenue from this federal program, with a significant portion of the revenue coming after the state’s ban. While annual payouts declined, from over $5 million in 2013 to under $1 million by 2019, they remained substantial. In 2015 alone, the year the reform was passed, agencies still pulled in over $2.1 million. This is a clear sign that, without federal reform, even the most ambitious state efforts can be quietly undermined.

Numerous judicial challenges have been launched against the practice of civil asset forfeiture. Many of these cases do not challenge the constitutionality of civil asset forfeiture itself, but instead how it is administered. Culley v. Marshall explained the due process rights of innocent property owners involved in civil asset forfeiture cases. In Timbs v. Indiana, the state used civil asset forfeiture to seize a Land Rover purchased with life insurance money after Tyson Timbs was arrested for selling drugs. The U.S. Supreme Court ruled that the Excessive Fines Clause of the Eighth Amendment applied to state civil asset forfeiture cases. Upon remand, the Indiana Supreme Court subsequently ruled that the attempted forfeiture of the Land Rover was grossly disproportionate to the underlying offense. 

While Timbs was a landmark ruling in affirming constitutional protections against excessive forfeiture, its practical impact has been limited. The decision did not ban civil forfeiture or establish clear standards for what constitutes “excessive,” leaving it to lower courts to interpret on a case-by-case basis. As a result, many of the systemic issues–lower standard of proof, insufficient due process, and financial incentives driving enforcement–remain intact. In practice, Timbs has provided an important legal tool, but not a comprehensive solution. The fundamental structure of civil forfeiture still allows property to be taken without a criminal conviction, and individuals often have to fight lengthy and expensive legal battles to get it back.

What’s next?  

There is growing bipartisan support for civil asset forfeiture reform, but resistance remains from local governments and law enforcement agencies that have come to rely on the revenue it generates. Often, the opposition is framed in terms of public safety, but at its core, this is a budgeting issue. For many cities and counties, civil forfeiture has become a means of funding operations without raising taxes. That might seem like a practical solution, but it’s a risky one. Relying on unpredictable, enforcement-based revenue creates harmful incentives and shifts the focus away from proper public safety. It also erodes trust, especially when property is taken from people who are never even charged with a crime.

To effectively reform civil asset forfeiture, specific measures should be pursued:

Increase Legal Standards: Raise the standard of proof required for asset forfeiture from “preponderance of the evidence” to “clear and convincing evidence” or require a criminal conviction before acquiring ownership of assets. New Mexico, for example, abolished civil forfeiture entirely in 2015, mandating criminal convictions before assets can be forfeited, which has resulted in reduced abuses without compromising public safety.

Remove Financial Incentives: End the practice of allowing law enforcement agencies to retain seized assets for their own use. Maine illustrates this reform by mandating that forfeiture proceeds be deposited into the state’s general fund, thereby removing direct profit motives for law enforcement. Before this change, Maine’s law enforcement retained nearly all forfeiture funds, totaling over $3 million between 2009 and 2019. In 2023, the total amount seized through civil asset forfeiture was just $26,439.50–demonstrating what happens when financial incentives to seize are removed. 

Establish Transparency and Accountability: Require comprehensive, standardized, and publicly accessible reporting on all forfeiture activities. This should include detailed information on what was seized (type, value, and quantity of property), whether the owner was charged or convicted of a crime, the legal basis for the forfeiture, the law enforcement agency involved, how proceeds were spent, and the timeline from seizure to final disposition. Transparent reporting is crucial for tracking patterns, assessing fairness, and preventing abuse. States like Maine and Minnesota have implemented measures to enhance transparency, leading to increased public awareness and scrutiny of forfeiture practices. These transparency initiatives have highlighted specific abuses and demonstrated the need for continued improvements in record-keeping accuracy, public accessibility, and meaningful oversight.

Guarantee Due Process: Provide accessible legal mechanisms for property owners to quickly and effectively challenge seizures and recover assets that have been wrongfully taken. Arizona and New Mexico serve as models by requiring a criminal conviction before property can be forfeited, restoring the presumption of innocence, banning coercion of property owners to relinquish their rights, abolishing non-judicial forfeiture, and ensuring prompt, post-deprivation hearings. These reforms significantly reduced wrongful seizures and enhanced the rights of property owners. Before these changes, Arizona law enforcement seized more than $530 million over two decades, often without criminal charges or convictions. The new protections have effectively decreased abuse and increased fairness in asset forfeiture practices. While it’s still early to fully assess the impact of these reforms, they were designed to increase fairness and reduce potential abuses in asset forfeiture practices.

Unify the Forfeiture Process: One major flaw of the current system is the two-track process used in civil forfeiture, where property is litigated in civil court while the person is tried separately in criminal court. This creates confusion and often leads property owners to default, especially when the legal process is too complex or costly to navigate. Most seizures involve property valued at less than $1,300—an amount too low to justify the cost of hiring legal representation or fighting in court. By shifting to a one-track criminal forfeiture process, where both the person and property are handled within the same criminal proceeding, due process is strengthened, and the system becomes more transparent and efficient. Public defenders could then represent property owners as part of the original arrest case, ensuring they are not left to navigate a civil system alone. 

Close Legal Loopholes: Congress should either end the practice of equitable sharing or prevent it from violating conflicting state laws. The federal equitable sharing program provides local law enforcement opportunities to still benefit from civil asset forfeiture even when their states ban the practices because federal law enforcement can share revenue with them. This situation presents the problem that state-level reforms may be largely ineffective if the federal government does not also reform itself. If Congress is unwilling to abolish the program itself, then it must at least prevent local law enforcement from circumventing their own state laws.

Real reform requires action from policymakers, legal advocates, community leaders, and the general public. Advocating for these concrete changes will protect constitutional rights, rebuild community trust, and support more compassionate, effective, and fair approaches to public safety and drug enforcement.

Editor’s note, May 6, 2025: This piece has been updated to clarify details about seizures, forfeitures, and the examples mentioned.

The post How civil forfeiture targets everyday Americans, not kingpins appeared first on Reason Foundation.

Beyond the failures of addiction policy, housing scarcity—driven by excessive government regulation—has made it nearly impossible for many to escape homelessness. Restrictive zoning laws, costly permitting requirements, and government-imposed limits on housing supply have driven up rent prices, placing housing increasingly out of the financial reach of many Americans. 

Homelessness and substance use disorders (SUDs) are deeply intertwined, with problematic use of opioids, stimulants, and alcohol disproportionately affecting unhoused populations. Those who are homeless face a significantly higher risk of fatal overdose. Studies show that a 10% rise in homelessness is correlated with a 3.2% increase in opioid poisonings in metropolitan areas. 

Government mismanagement of housing and development policies, marked by excessive zoning laws, building restrictions, and ineffective public housing programs, has made it increasingly hard for the vulnerable to find shelter. Secure housing, healthcare access, and harm reduction services are essential for reducing the risks of overdose and infectious diseases while enhancing the chance for a healthier life. When the challenges of life on the street are compounded by addiction, recovery becomes exponentially more difficult.

Integrating harm reduction strategies with housing first models may create a sustainable path forward that is both compassionate and effective in addressing this socio-medical crisis. However, for housing first to succeed, cities must remove the artificial barriers that prevent housing construction in the first place.

The failure of shelters and short-term solutions

Rather than serving as a refuge, many traditional government-funded shelters impose rigid rules and entry requirements that create barriers to access, particularly for those struggling with addiction. Strict sobriety requirements, curfews, and limitations on personal belongings deter many from seeking help, leaving them in unsafe conditions on the streets. While these policies are often considered safety measures, they fail to account for the realities of addiction and frequently push individuals into encampments as a last resort. When these encampments are forcibly cleared, people often lose critical medications, leading to severe health crises such as untreated diabetes, withdrawal-related complications, and increased overdose risks.

But as encampments grow, cities respond by treating homelessness as a public nuisance rather than a housing crisis, resorting to encampment sweeps to make homelessness less visible. While encampments can create public health and safety concerns—blocking sidewalks, occupying parks, and straining sanitation services—sweeps do not address the root of the problem. Instead, they create a cycle of displacement without providing stable alternatives. The underlying issue remains: Without adequate housing options, encampments will persist. Addressing the housing shortage is the only long-term solution to both homelessness and the challenges encampments pose to public spaces.

Housing first: A proven yet underused solution

Housing first takes a different approach to providing shelter by removing abstinence-based conditions and providing immediate, stable housing. Unlike traditional shelters, housing first prioritizes rapid placement into permanent housing without preconditions, recognizing that stability is a prerequisite for long-term recovery. This model is grounded in the idea that providing housing first makes it easier for individuals to engage in substance use treatment, mental health care, and employment services, rather than expecting them to achieve stability while living on the streets. While some worry that lowering barriers to entry could lead to disruptive or unsafe situations, housing first programs approach these challenges by incorporating case management and support services to help residents maintain housing stability and address behavioral issues as needed.

Evidence supports the effectiveness of this approach. In Boston, a harm reduction-focused transitional housing program successfully combined low-barrier housing with on-site substance use disorder (SUD) treatment. Unlike traditional shelters, this program did not require sobriety, yet 100% of participants engaged in case management, 49% received SUD treatment, and 25% transitioned to permanent housing within a year. This 25% transition rate is particularly impressive when compared to a systematic review of housing first programs, which found that only 27% of participants in traditional abstinence-based programs achieved stable housing within six months. It is particularly noteworthy that a single program achieved 93% of the combined outcomes of multiple programs. 

The Boston program also included a short-stay stabilization unit, allowing individuals experiencing withdrawal or medical complications to receive immediate care without needing to enter a hospital. Over the first year of the program, the number of opioid overdoses requiring emergency intervention decreased by 40% due to on-site care, and treatment retention significantly outpaced that of abstinence-based programs.

Similarly, a transitional housing program in Hawaii, where 74% of the homeless population had methamphetamine use disorder and 12% had opioid use disorder, demonstrated that integrating housing with on-site healthcare led to a 62% increase in mental health treatment engagement and a measurable decline in emergency room visits and overdoses.

However, the success of housing first approaches depends on proper implementation and support. Critics often point to Oregon’s Measure 110 as an example of failed drug policy reform. While Measure 110 decriminalized possession of small amounts of drugs, the treatment and housing programs central to its success were never fully implemented as planned. This delay created a situation where drug decriminalization occurred without the necessary support structures in place, leading to misleading perceptions about the policy’s effectiveness. Housing first is not a standalone solution but part of a comprehensive approach requiring proper integration with other social services.

Why housing first can’t succeed without zoning reform

These findings reinforce what harm reduction advocates have long argued: Housing must be a starting point, not a reward for sobriety. Housing first programs follow this same principle, providing immediate housing with low barriers to entry while offering voluntary wraparound services.

Despite its proven effectiveness, housing first programs cannot succeed at scale without an adequate housing supply. Restrictive zoning laws, excessive permitting costs, and government-imposed density limits make it nearly impossible to construct affordable housing in the areas where it is needed most. Local governments wield significant power in shaping housing accessibility through land use policies, determining what can be built and where. Historically, these policies were often designed to exclude low-income individuals and people of color, with tools like single-family zoning used to block the construction of apartments and other affordable housing options. 

Today, restrictive zoning codes continue to limit the development of multifamily housing, including housing designated for those experiencing homelessness. Beyond single-family zoning, parking minimums, parcel size regulations, setback mandates, and other requirements further drive up construction costs, making housing and essential support services—such as mental health care and addiction treatment—more difficult to establish. The result is a landscape where communities with strict zoning policies see higher housing costs, more significant barriers to affordable development, and deeper racial and economic segregation.

Houston, Texas, provides a compelling case study of how a combination of housing first policies and a more flexible approach to land use can create effective solutions to homelessness. Houston is unique among major U.S. cities because it has never implemented formal zoning laws. This absence of restrictive zoning has allowed for a more flexible approach to housing development. As a result, it is easier to construct various housing types, including affordable units and transitional housing, which has kept home prices and rents reasonable and made housing homeless individuals easier. 

At the same time, Houston successfully implemented a housing first strategy in 2011, prioritizing getting people into stable housing without preconditions like sobriety or employment. The success of this approach has been bolstered by the city’s ability to build housing more freely. Together, these policies have contributed to a 68% reduction in chronic homelessness since 2011—demonstrating that reducing barriers to housing construction and housing access can create a more effective and scalable solution to homelessness.

Houston’s success is a direct result of its flexible zoning laws and lower housing costs, which make it dramatically cheaper to place individuals in stable housing than in cities like San Francisco. Unlike California’s restrictive zoning policies, which drive up housing costs and limit the supply of low-cost units, Houston’s flexible land-use regulations have fostered a greater availability of naturally affordable housing.

This difference is reflected in the cost of implementing housing first policies: Houston’s homeless service providers report that the total cost of housing and supportive services for one individual is between $17,000 and $19,000 per year, with only $12,000 going toward rent. In contrast, San Francisco spends between $40,000 and $47,000 per person annually, with housing alone costing as much as $35,000—nearly three times Houston’s cost. The reason is simple: San Francisco’s high rents, driven by restrictive zoning and artificial housing scarcity, make it nearly impossible to scale housing first programs efficiently. On the other hand, Houston has been able to house over 25,000 individuals, partly because its zoning laws encourage more housing development, ensuring an ongoing supply of affordable units.

What policymakers must do to end this crisis

To effectively address the intersection of drug policy and housing instability, the following recommendations are crucial:

Drug policy recommendations

Invest in harm reduction-focused housing

Shelters and supportive housing programs should integrate harm reduction services, yet funding for low-barrier housing remains severely lacking due to systemic barriers. Many affordable housing subsidy programs are structured around developer-focused incentives that overlook harm reduction priorities, and Section 8 policies often lack the flexibility needed to support harm reduction services. Additionally, many nonprofit organizations face constraints such as insufficient funding, understaffing, and a shortage of available beds or housing units. Greater flexibility in existing funding structures would significantly expand access to vital services. Programs can be more effectively resourced by combining public dollars with charitable and private funding and leveraging local community organizations. Additionally, reallocating resources toward housing first models would further enhance service delivery. Research shows that harm reduction-informed housing leads to longer stays, greater health improvements, and higher rates of stable housing retention—outcomes that punitive models consistently fail to achieve.

Eliminate abstinence-based barriers to housing

Sobriety requirements exclude the very people most in need of housing stability, forcing many into unsafe encampments or public spaces. Homeless program policies should be reformed to ensure housing eligibility is not contingent on abstinence from drug use. Housing first models—which provide unconditional housing alongside voluntary treatment services—have higher retention rates, better long-term health outcomes, and lower overall public costs than abstinence-based programs. The idea is to help them get sober, not just demand that they do so on their own before providing help. Federal and local governments should incentivize the expansion of housing first initiatives that integrate harm reduction and medical care.

Expand access to medication for opioid use disorder (MOUD)

Despite being some of the only treatment methods for opioid use disorder (OUD) currently permitted by the FDA, access to buprenorphine, naltrexone, and methadone remains severely restricted for unhoused individuals. Shelters and housing programs should expand low-barrier MOUD access, removing unnecessary requirements that delay or deny treatment. Programs that co-locate housing with MOUD services have been shown to reduce overdoses, improve treatment retention, and support long-term recovery. 

Housing policy recommendations

Eliminate zoning laws that restrict housing supply

Restrictive zoning laws have artificially constrained housing supply, driving up costs and worsening homelessness. Cities should phase out many single-family zoning restrictions, which prevent the construction of multifamily housing, and remove excessive lot size mandates, height restrictions, and parking minimums that inflate construction costs. Updating these outdated land-use policies will create a wider variety of housing options, including smaller-scale infill projects, mixed-use developments, and affordable multi-family housing.

Streamline permitting and approval processes

Burdensome permitting and approval processes lead to delays and increased costs, discouraging private investment in affordable housing. We can significantly reduce bureaucratic obstacles by implementing by-right approvals for housing projects that comply with local zoning and safety standards rather than requiring discretionary approvals. Lowering excessive impact fees and regulatory costs for developers building affordable housing will further encourage private sector participation in addressing this crisis.

Expand adaptive reuse of existing buildings

Transforming vacant commercial spaces, underused office buildings, and hotels is a cost-effective way to expand housing options for individuals experiencing homelessness. However, zoning regulations and building code restrictions often prevent these conversions. State and local governments should ease regulatory barriers that hinder adaptive reuse while maintaining basic habitability standards. Converting existing structures into transitional and permanent housing provides a faster, lower-cost alternative to new construction.

Empower community-driven housing solutions

Government agencies should remove legal barriers preventing churches, nonprofits, and private property owners from developing transitional housing, tiny home communities, and other alternative solutions tailored to local needs. Rather than imposing top-down mandates, policymakers should support public-private partnerships that enable flexible, community-led approaches to housing instability.

Housing first works—if we let it

The link between homelessness and addiction is undeniable, yet policymakers continue to treat them as separate crises. The failure of traditional approaches—rigid shelter policies, punitive encampment sweeps, and abstinence-based housing—has only worsened conditions for those most vulnerable. Housing first policies have already proven their ability to break this cycle, but even the best programs cannot succeed at scale without the necessary housing supply.

The reality is simple: We must build more housing to reduce homelessness. Houston’s success shows that when barriers to housing development are lifted, housing first can thrive—housing more people at a fraction of the cost compared to cities with restrictive policies like San Francisco. Housing first works. The only thing standing in its way is bad policy.

The post How bad housing policy fuels homelessness, and how to fix it  appeared first on Reason Foundation.

The latest findings of the Cochrane Review—a gold-standard library of evidence to inform healthcare decision-making—could help steer the agency toward a smoking cessation approach that prioritizes equipping individuals with evidence-based solutions. Measures like capping nicotine in cigarettes, proposed by the Biden administration, create more problems than they solve, while harm-reduction tools like vaping are already proving effective in helping people quit smoking at higher rates.

For millions of Americans, vaping has succeeded where traditional smoking cessation methods have failed—offering an accessible, satisfying alternative that works. The Cochrane Review finds that nicotine e-cigarettes increase quit rates by 59% compared to nicotine replacement therapy (NRT) and 96% compared to behavioral support alone. Yet, instead of embracing this public health victory, e-cigarettes have been vilified, overtaxed, and regulated. By prioritizing abstinence-only messaging and waging war on vaping, we ignore real-world benefits and push people toward a far worse alternative—cigarettes.

Analysis from the National Health Interview Survey (NIHS), including data from 1990 to 2022, reveals that as e-cigarette use increased, smoking rates declined faster than expected—especially among younger adults. The groups most likely to vape—ages 18 to 34—saw the steepest drops in cigarette smoking, while those who didn’t take up vaping saw no significant acceleration towards quitting. This means that e-cigarettes are not keeping people hooked on smoking; they’re replacing it. 

Other countries are leveraging vaping and seeing its positive effects firsthand. The U.K.’s National Health Service (NHS) Better Health Report acknowledges vaping as “one of the most effective tools for quitting smoking.” They have the numbers to support their claims—with nearly three million people having quit smoking with a vape in the last five years. 

Why does vaping work so well as a cessation tool? It mimics the smoking experience, maintaining the hand-to-mouth motion and inhalation experience—unlike traditional patches and gums. Vaping also provides flexible nicotine control, allowing smokers to start at a higher nicotine concentration and gradually reduce their intake over time—tailoring the quitting process to their individual needs. It also reduces exposure to toxic chemicals. Regular tobacco smoke contains 7,000 chemicals, including tar and carbon monoxide, which cause cancer, lung disease, and heart disease. 

Despite the compelling data, the United States takes an extremely aggressive stance against e-cigarettes. The FDA has rejected countless vaping products and failed to adequately inform the public that vaping is a safer alternative to smoking. These actions give people zero incentive to switch, leaving many using traditional cigarettes or turning to unregulated black-market vape products. History has shown that these prohibitive effects are disastrous. 

With a new FDA head soon to take the helm, the agency has the chance to rethink its approach and offer a method to bridge the gap between traditional cessation aids and total abstinence. Instead of demonizing e-cigarettes, we should recognize them as a resource for public health. Not all nicotine products are created equal, so we shouldn’t regulate them like they are. 

As the Cochrane Review has demonstrated, nicotine e-cigarettes offer a significant advantage over traditional NRT, and public messaging must be clear and evidence-based: Vaping is significantly less harmful than smoking and is a viable smoking cessation tool. Will the FDA course correct? One can hope this new administration will bring policy decisions that reflect the best available evidence—rather than outdated fears.

The post Will Martin Makary’s FDA listen to the evidence on e-cigarettes? appeared first on Reason Foundation.

Addressing Medicaid’s shortcomings isn’t just about fiscally responsible solutions that make sense for everyone; it’s about empowering individuals to jumpstart their reentry to society in a productive way. When substance-addicted persons leave incarceration, they frequently relapse without care, leading to substantially higher public costs related to overdose or even reincarceration. These outcomes don’t just disempower individuals—they place unnecessary strain on public resources. Medicaid systems can achieve better cost control and generate better health outcomes by providing addiction treatment to these individuals during the period of their transition back into society.

The Reentry Act, first introduced in July 2021 by Sen. Tammy Baldwin (D-Wisc.), presents a potential solution by seeking to expand Medicaid coverage to incarcerated individuals beginning 30 days before their release.

A coalition of over 65 different organizations is calling for the passage of the Reentry Act and the Due Process Continuity of Care Act to address critical gaps in healthcare access for incarcerated individuals with substance use disorders (SUD). However, the success of this proposal depends not only on ensuring incarcerated people with SUD have access to health insurance coverage upon their release but also that this coverage coincides with access to actual healthcare. Addressing the latter requires more than extending Medicaid eligibility; it also requires addressing structural challenges within Medicaid that discourage healthcare providers like drug treatment programs from accepting Medicaid patients. These interconnected issues discourage providers from participating in Medicaid, ultimately restricting access to life-saving treatment for those who need it most.

Economics of Medicaid and structural challenges

Making Medicaid coverage available to incarcerated people upon release may boost access to care, but broader reforms are needed to ensure that care is adequate and affordable. To illustrate one problem, cost-shifting occurs when providers compensate for Medicaid’s low reimbursement rates or treat uninsured patients by inflating prices for privately insured individuals. This practice drives up premiums for private insurance holders, increases out-of-pocket expenses, and creates financial strain for employers offering health benefits. Over time, these rising costs can make healthcare less affordable for a broader population, exacerbate inequities, and place additional pressure on the overall healthcare system to control spending.  

The involvement of an increasing number of intermediaries—such as managed care entities and administrative contractors—extracting profits without delivering direct care leads to significant inefficiencies in the healthcare system. These inefficiencies lead to higher administrative costs, diverting resources from patient care and inflating overall expenses for individuals and the healthcare system. The system becomes bloated with redundant processes and slower decision-making as administrative layers multiply. This makes it harder for people to get the care they need and leaves less money for programs that provide direct help. Consequently, the system struggles to operate effectively and deliver timely, cost-efficient care to those who need it most. 

These dynamics are compounded by the lack of transparent pricing, which prevents consumers from making informed decisions and understanding the true cost of services. As a result, providers have less competition, keeping prices high. Instead of relying solely on expanding insurance coverage, focusing on structural reforms that reduce administrative waste and establish clear price signals is essential to addressing these systemic issues. 

Diminished provider participation and access gaps

One major factor influencing the availability of care and services for Medicaid patients is whether providers are willing to accept Medicaid. State Medicaid programs often try to control costs by paying doctors and healthcare providers a lower rate than the cost of their services. But, while limiting provider compensation rates reduces short-term expenditures, it simultaneously diminishes providers’ willingness to accept Medicaid. Medicaid reimbursement rates often fall far below those provided by private insurers or Medicare, which provides federally funded insurance for people over 65. In 2016, primary care providers who accepted Medicaid patients were reimbursed at only 72% of Medicare rates on average, with some states paying as low as 38%. 

These low reimbursement rates make participation in Medicaid financially untenable for many providers, who are forced to absorb the difference between the cost of care they provide and the rate at which they are paid. Consequently, nearly half of all SUD treatment programs in the U.S. do not accept Medicaid, which means that even though Medicaid covers substance use treatment on paper, many people still cannot get the care they need. Simultaneously, expanding Medicaid eligibility increases demand for services, creating a mismatch where coverage and demand for services grow, but access to care covered by Medicaid shrinks. For incarcerated individuals with SUD, this mismatch between coverage and care access exacerbates an already precarious situation, making it even more essential to focus Medicaid reforms on this high-risk group. By prioritizing reimbursement rates that incentivize provider participation, these systemic resource gaps can begin to close. 

Medicaid expansion and financial strains

The financial strain on states from Medicaid expansion has further complicated matters. Under the Affordable Care Act, passed in 2010, states could extend Medicaid coverage to those previously ineligible, including able-bodied adults without children or those earning just above the poverty line. Though this was initially supported with increased federal funding, that funding has been gradually phased out, leaving states to cover the mounting obligations resulting from the expanded Medicaid population. 

Many states turned to managed care models to control these costs and required prior authorizations. Managed care organizations act as middlemen between patients and providers to arrange and coordinate Medicaid recipient care. While helpful in capping expenditures, they add administrative complexity that can delay care and dissuade provider participation. Similarly, prior authorization requirements—which require patients to gain approval from their insurance provider before receiving certain treatments or medicines—can exacerbate access barriers by delaying critical interventions and placing additional strain on an already thin provider workforce. This can be especially detrimental to time-sensitive treatments for people with SUD, such as access to medications that prevent relapse. like buprenorphine.

To further control the cost of Medicaid expansion, many states have reduced their direct funding for substance use disorder (SUD) services. Between 2010 and 2019, state-funded SUD budgets in Medicaid expansion states were cut by an average of $9.95 million, even as demand for these services grew. This underfunding often forces individuals to rely on costly emergency departments or fall back into patterns of homelessness and incarceration, all of which place a significant financial burden on state systems and ultimately undermine long-term cost savings. By ensuring that sustained funding prioritizes vulnerable groups like prisoners with SUD, states can alleviate these financial strains while effectively addressing the root causes of high costs.

Prioritizing vulnerable populations: Incarcerated individuals

While extending Medicaid coverage to incarcerated individuals before release would be a first step in addressing gaps in care, Medicaid reform is more effective when targeted directly at those incarcerated individuals with SUD—a population at the highest risk of adverse outcomes and where the return on investment is clearest. The weeks following release from incarceration are particularly hazardous; individuals with SUDs are 12 times more likely than the general population to die from overdose or suicide during this period. Without access to care, many fall back into substance use, homelessness, and criminal behavior, perpetuating cycles that burden taxpayers through repeated interaction with healthcare and criminal justice systems. By prioritizing Medicaid coverage for SUD treatment both before and immediately after release from incarceration, these trajectories can be altered, reducing fatalities, lowering recidivism, and cutting state spending on avoidable high-cost interventions.

Solutions for effective Medicaid reform for those with SUD 

To support this targeted approach, Medicaid must make systemic adjustments that guarantee practical access to care. Increasing reimbursement rates for evidence-based SUD services would allow more providers to participate in the program sustainably. Making the process for getting doctors and treatment centers approved faster and easier would increase providers’ willingness to join the program, giving patients more options for care. Additionally, eliminating prior authorization requirements for critical treatments, particularly medications critical for recovery maintenance, such as buprenorphine, would ensure timely interventions when they are needed most. These reforms align with evidence from states that have removed administrative hurdles, showing increased treatment rates and lower overdose deaths.

In recent history, policymakers’ focus on Medicaid has often centered on expanding enrollment, with less attention given to addressing the systemic barriers that prevent access to care. But, increasing the demand within an already overburdened system does little to enhance the availability or affordability of care and treatment. A more prudent strategy would instead prioritize Medicaid resources for populations at the highest risk, delivering measurable benefits by targeting adverse outcomes like overdoses, hospitalizations, and reincarceration. Empowering these individuals with the tools to start building their autonomy back will ensure that public spending is used in the way it was meant to be used. The Reentry Act provides a good starting point to address critical gaps in care for incarcerated individuals with SUD by allowing for a foundation from which individuals can build.  

Health care costs can’t be fixed in the long term until market forces are re-introduced into the sector. However, focusing Medicaid resources in a cost-effective way, with targeted reforms like the Reentry Act, could achieve better outcomes and empower individuals to rebuild productive, independent lives. Now is the time to pivot from ineffective broad policies toward evidence-based reforms, creating more targeted and impactful solutions.

The post Medicaid is failing people leaving prison, and we’re all paying the price appeared first on Reason Foundation.

While Kennedy’s recovery journey may have worked for him, his plan overlooks other evidence-based approaches, like medication-assisted treatments (MAT), which have already helped millions of Americans struggling with addiction, and emerging therapies like ibogaine. 

The lived experience of people who use drugs can sometimes offer great insight for policy change, but not when that guidance is based solely on one person’s experience. Kennedy’s plan to address the opioid crisis is deeply personal, shaped by his 14-year struggle with heroin and other drugs. Rooted in the teachings of Swiss psychotherapist Carl Jung, 12-step programs, and faith-based therapy, his philosophy frames addiction primarily as a moral and spiritual crisis. While this perspective was once commonplace among anti-drug advocates, it has largely been replaced by a medical understanding of substance use disorders–one that recognizes addiction as a complex health condition requiring evidence-based treatment. 

During the hearing, Kennedy proposed the expansion of faith-based, labor-intensive rehabilitation centers, which he refers to as “healing farms.” His inspiration comes from San Patrignano-style recovery centers—known for their emphasis on long-term, abstinence-based treatment through vocational training and communal support, which have faced scrutiny for their use of coercion and retributive discipline. The emphasis on isolation, strict adherence to communal rules, and limited autonomy over personal decision-making raise ethical concerns about coercion and the long-term well-being of participants. Reports have also pointed to the exclusion of individuals with co-occurring psychiatric disorders, limiting access for those who may require integrated mental health support.

Research consistently shows that forced treatment is usually ineffective. Studies indicate that individuals subjected to involuntary treatment, such as civil commitment for treatment, relapse at alarming rates–often on the day they are released. These poor long-term outcomes stem from heightened institutional distrust, a lack of post-treatment support, and inadequate access to quality care. 

Many people struggling with addiction have a history of trauma, and coercive approaches can exacerbate that trauma, making individuals less likely to seek help and ultimately reducing long-term recovery rates. The facilities that house these programs often fail to provide comprehensive, trauma-informed care, as they lack appropriately trained staff and resources necessary to offer a full range of treatments, including medication, therapy, and wound care. 

While some individuals may benefit from short-term involuntary treatment in crisis situations, many do not, and many experience greater harm as a result of involuntary treatment. Creating a legally sound, ethical framework that protects individual rights while addressing the complexities of addiction remains a major challenge—one that Kennedy’s approach fails to resolve.

Medication-assisted treatment (MAT) is the only form of treatment currently approved by the Food and Drug Administration for treating opioid use disorder and should not be disregarded in favor of an abstinence-only approach. Medications like buprenorphine, methadone, and naltrexone have been extensively studied and shown to significantly reduce opioid cravings, prevent withdrawal symptoms, and decrease overdose risk. The main shortcoming with MAT, specifically methadone, is that patients are required to make daily visits to a clinic to receive medications for up to two years to achieve successful recovery from addiction. This demanding regimen contributes to high rates of treatment withdrawal and relapse.

Newly emerging treatments like ibogaine have shown potential as a possible replacement for MAT to help individuals overcome opioid use disorder because early evidence suggests high success rates after just a single administration. In one small-scale study, 75% of participating opioid addicts remained opioid abstinent for an entire year after a single ibogaine treatment. While still in the early stages of research due to legal restrictions and safety concerns, preliminary evidence suggests that ibogaine could be a breakthrough tool in addiction treatment, offering those struggling with opioid dependence a neurobiological reset. 

Rather than reverting to outdated, ideologically driven, and ineffective approaches, policymakers should prioritize expanding access to evidence-based treatments and investing in innovative treatments like ibogaine that could revolutionize addiction care. As secretary of Health and Human Services, Kennedy could make progress by pushing to allow patients to take some quantity of traditional MAT medications home with them to improve adherence to the regimen and expedite the development of ibogaine as an alternative treatment option.

The post RFK Jr.’s opioid crisis plan appeared first on Reason Foundation.

Virtua Health, one of New Jersey’s largest providers, is embroiled in a lawsuit after news stories revealed a systemic practice of secretly testing pregnant women for narcotics use. Despite Virtua Health having explicit policies requiring clinicians to obtain informed consent from their patients, those guidelines were disregarded, violating one of the core pillars of ethical medicine by stripping patients of their right to make informed decisions about their own care.

Informed consent isn’t just a bureaucratic checkbox but a cornerstone of medical ethics. Adopted in the aftermath of World War II when the world learned of the horrific medical experiments conducted on humans by Nazi doctors during World War II, the requirement to obtain informed consent protects patients from being forced to relinquish their rights to obtain medical care. It guarantees that patients, regardless of their background or position, are not coerced into care against their will and that they fully understand the risks, benefits, and alternatives before undergoing any medical procedure​.

These incidents of forgoing informed consent are not isolated. Instead, they reflect a broader trend in health settings where control is prioritized over compassionate care. It is particularly troubling in maternal health, where false positives can result in stress, trauma, and family separation, often with discriminatory effects. According to the lawsuit filed by the New Jersey Attorney General’s Division on Civil Rights, Virtua Health has practiced a policy of drug testing all patients admitted to its labor and delivery or high-risk obstetrics units since 2018, with staff regularly failing to obtain informed consent from pregnant patients before administering such tests. 

Such practices can lead to other harmful forms of discrimination that harm patients seeking reproductive healthcare. Research shows that women of color and those from low-income communities are far more likely to be subjected to drug tests despite the evidence that they are no more likely to use substances compared to other populations. This systemic bias not only perpetuates long-standing disparities in healthcare but also erodes trust in medical institutions.

The real-world consequences of these policies are devastating. False positives—sometimes triggered by something as innocent as eating a poppy seed bagel or taking a common medication such as Adderall—have led to invasive investigations and, in some cases, the separation of families.  

At Virtua Health, staff failed to perform the proper confirmatory testing needed to rule out false positives before reporting positive test results to child protective services, forcing mothers and families to endure stressful investigations at a time when they should be healing and bonding with their newborns. Instead, their birthing experience is marked with fear, alienation, and potentially long-term psychological trauma. This isn’t just a policy failure; it’s a betrayal of trust, a theft of dignity, and a stark reminder of how systemic practices can strip humanity from healthcare. Reforms like New York’s proposed ban on drug-testing pregnant people without informed consent outside of emergency situations are urgently needed. 

When hospitals act as enforcers for state agencies, they turn what should be a safe and supportive environment into a place of fear and control. This dynamic is not merely an ethical failure but a potential violation of constitutional protections. Supreme Court precedent, such as in Printz v. United States (521 U.S. 898, 1997), establishes that the government cannot compel private entities to perform actions they are constitutionally prohibited from performing directly. Furthermore, under the state action doctrine, private entities performing traditional public functions or working closely with the government may also be subject to constitutional limitations. By conducting drug tests and sharing the results with state agencies, hospitals may act as state agents even if their actions are voluntary, bypassing the Fourth Amendment’s protections against unreasonable searches and seizures.

As a result of these privacy violations, patients may hesitate to seek the care they need, fearing their personal information could be turned over to authorities. This fear doesn’t affect everyone equally—it’s especially pertinent to those who use drugs. When individuals avoid seeking medical care due to the fear of criminalization or judgment, the consequences include untreated health conditions, increased rates of preventable deaths, and the heightened spread of infectious diseases like HIV and hepatitis. This cycle of harm endangers individuals and undermines public health efforts on a broader scale.

These practices raise serious concerns about healthcare providers’ ethical and legal duties. When hospitals take on roles similar to law enforcement, they betray their core mission: delivering compassionate, patient-centered care. To address this issue, we need reforms that separate healthcare from state surveillance, safeguard patient rights, and ensure that medical settings remain spaces of trust and protection.

The healthcare system should not be about policing patients. Instead, it should assist people in improving their health and empower them to make their own choices, free from coercion or unnecessary interference. By championing policies that protect all patients’ autonomy, we can create a system that genuinely serves and supports everyone.

The post Nonconsensual drug testing raises serious ethical concerns appeared first on Reason Foundation.

Harm reduction, an approach focused on minimizing the adverse health and social consequences of drug use, is not only a pragmatic strategy but a moral imperative. It challenges the idea that drug use defines a person’s worth, rejecting the current notion that those who use drugs are beyond help or undeserving of compassion, recognizing that every individual deserves care and protection. Backed by decades of research, harm reduction offers an alternative framework that is more likely to yield the results everyone seeks: proven, compassionate solutions that save lives and foster healthier, more resilient communities.

In 2016, the first Trump administration focused on border security and law enforcement to combat the opioid crisis, hoping that limiting the influx of illegal drugs would decrease drug availability and opioid-related deaths. However, as reported by The Washington Post, the results from this punitive approach did not yield the desired results. Despite aggressive enforcement, overdose rates continued to rise. This outcome illustrates the limits of focusing solely on supply reduction and punitive measures; they fall short and may exacerbate the issues they aim to resolve.

The first Trump administration also attempted to address the opioid crisis by spending $6 billion to support treatment and prevention programs. Although this spending may have been more cost-effective than alternative outlays, it was still overshadowed by the immense focus on enforcement. While well-intentioned, this approach was both contradictory and overlooked key evidence. Heavy-handed enforcement can be counterproductive because it creates fear of legal repercussions among drug users, discouraging them from seeking treatment and accessing support services.

The new Trump administration should redirect its approach to combatting the dangers of drug use by keeping the focus where it should be: supporting people in need. The Office of National Drug Control Policy (ONDCP) under the first Trump administration emphasized the importance of balancing anti-drug efforts with resources for treatment and recovery for those battling addiction. Continuing to expand on that idea in the upcoming term has the potential to initiate a shift toward a harm reduction approach to the drug issue, one that cultivates the respect and care needed to foster healthier communities in the long term.

To address the opioid crisis effectively, the next administration should consider the following recommendations:

• Expand Access to Evidence-Based Treatment: Resources should be reallocated away from ineffective mechanisms and used instead to support a wide range of addiction treatment options, particularly medication-assisted treatment (MAT), which has been shown to reduce opioid-related harm significantly. In 2024, only about 10% of those battling substance abuse had access to personalized treatment options. Expanding access to these services is critical to prevent deaths. 
• Empower Communities To Address Their Local Drug Problems: Education, outreach, and support services–like safe consumption sites and peer support networks–can prevent drug-related harm and promote supportive environments that foster recovery. Unfortunately, the federal “crackhouse” statute (21 U.S.C. § 856) limits what states can accomplish and limits innovation in addressing drug use.  The administration should encourage Congress to amend this law to allow states the flexibility to pursue evidence-based harm reduction strategies.
• Remove Regulatory Barriers to Lifesaving Resources: Federal restrictions and grant limitations prevent naloxone distribution in critical settings like correctional facilities. It is imperative to eliminate unnecessary federal regulatory hurdles that limit access to harm-reduction tools. For example, some correctional facilities are mandated to offer naloxone upon release ”as funding allows,” but federal rules limit states’ ability to use grant funds. The administration should eliminate these funding restrictions and allow states, nonprofits, and private actors to use resources as they see fit–leaving room for innovative harm-reduction solutions to flourish. 
• Eliminate Federal Barriers To Fentanyl Test Strips And Other Harm Reduction Supplies: Under 21 USC 863, test strips–simple tools used to detect the presence of fentanyl in drugs–and other harm reduction supplies are considered illegal “drug paraphernalia,” making it difficult to distribute them. While Congress would need to amend the statute to fully resolve this issue, the administration can clarify enforcement priorities through enforcement discretion to ensure that individuals and organizations distributing fentanyl test strips are not targeted, allowing broader access to these lifesaving tools.
• Use Cost-Benefit Analysis: Investing in harm reduction measures can yield substantial cost savings by decreasing healthcare and law enforcement costs related to untreated addiction. For instance, a 2013 study in the United States found that providing naloxone to individuals at risk of overdose was highly cost-effective, with costs on average landing at around $53 per individual. With this investment, the initiative marginally enhances both the quality and duration of life by approximately 0.12 extra years of quality life. When the expenses are assessed against the advantages, it amounts to $438 for each quality-adjusted life year gained. This public health strategy not only aids in individual recovery but is also more economically sustainable in the long term.

As governments at the state and federal levels address drug-related issues, the next administration should embrace a harm reduction approach that prioritizes personal rights and societal well-being. By relying on proven solutions and empowering communities, leaders have the opportunity to build a comprehensive drug policy that makes meaningful strides toward reducing overdose deaths, supporting recovery, and fostering healthier, more resilient communities. It’s time for a change—one that prioritizes healing and rehabilitation over punishment and prejudice. 

The post Harm reduction recommendations for the Trump administration appeared first on Reason Foundation.

A recent article by The Marshall Project shed light on the heartbreaking consequences mother of five Susan Horton faced because she indulged in a salad with “everything bagel” salad dressing before giving birth. She said she was completely shocked to learn that she had tested positive for opiates, all because the salad dressing had poppy seeds in it. Without requesting a follow-up test for verification, Kaiser Permanente, the hospital where Horton gave birth, promptly alerted social services, leading to her baby being placed in protective custody. While this protective hold was only temporary, it was unjust and unnecessary.

Horton is far from the only mother to receive a false positive, and poppy seeds are not the only cause. Many common substances—like ibuprofen, antacids, and certain antibiotics—can trigger false positives. Research shows that false positives in urine drug tests can range between 5% to 15% depending on the substance tested and the methodology. This variability leaves countless mothers at risk of losing custody based on flawed test results. 

Medical professionals and federal officials have warned that urine tests are particularly prone to false positives and also cannot differentiate between occasional and chronic substance use. Regardless of this problem, many state policies and hospitals still treat primary urine drug screens as finalized evidence and proceed to tag in social services without ordering confirmatory testing. For example, a follow-up to a primary drug screen would include searching for thebaine—an organic compound used to differentiate consuming a tasty treat topped with poppy seeds from heroin. Healthcare systems aren’t required to complete this follow-up testing, which leaves us to question why such an imprecise test is used as a basis for governments to seize a mother’s child.

It is also concerning how frequently pregnant women are subjected to drug testing without consent in healthcare settings. A study of five Massachusetts hospitals revealed that only about a third of cases documented verbal consent for toxicology testing on expectant mothers. Such practices undermine trust between patients and providers, particularly when test results lead to police involvement or child welfare investigations. At a time when support is critical, these adversarial conditions create unnecessary barriers to care.

The economic impact of these false positives also cannot be overlooked. When families are torn apart due to hasty decisions based on flawed data, the costs can quickly add up. The judicial system gets bogged down with lawsuits, and social assistance programs are stretched thin as parents try to navigate the next steps to take to regain custody of their child. A report from the National Center on Substance Abuse and Child Welfare highlights how drug testing procedures, in an attempt to secure child welfare, not only misallocate already limited staff and funding but also deepen the crisis by forcing families into legal battles to reclaim custody of their own children.

A cost-effective and simple solution that the U.S. Department of Health and Human Services could adopt is to implement confirmatory testing, which would ensure custody decisions are based on reliable evidence, ultimately saving both financial and emotional resources. Furthermore, the performance of any test must be done with the informed consent of the patient. Keeping expecting mothers informed about what tests are being done and why (and allowing for the opportunity to say no) is an essential part of adherence to the Hippocratic Oath and respects the autonomy of the patient, leaving bodily control in their hands. State health agencies should also protect informed consent and adopt confirmatory testing.

In the current healthcare culture, which promotes “patient-centered” and “evidence-based” practices, the failure to use confirmatory drug testing in maternal care is unacceptable. Moreover, informed consent should be standard for any testing that could affect a mother’s parental rights. Beyond the ethical obligations of the healthcare system, studies from the Society for Research in Child Development show that wrongful separation of families has lasting detrimental psychological, emotional, and health effects on children, families, and communities. Advocating for reliable drug testing practices is not just a matter of policy; it’s about ensuring fairness and justice for all mothers.

The post Unreliable drug tests shouldn’t be used to separate mothers from their newborns appeared first on Reason Foundation.