Every Thursday afternoon at a small storefront on Detroit Avenue in Cleveland, Ohio, the staff at Thrive for Change hands out naloxone and safe-use supplies to the mostly low-income and often unhoused population who walks through the door.
They do their best to make everyone feel welcome. One wall of the space is covered in photos, another a bulletin board with resources. Music plays. It’s a lot of ’80s music — heavy on the Fleetwood Mac.
“It’s music that everyone knows and recognizes and can sing along to,” according to Ashley Rosser, Thrive’s harm reduction education coordinator.
The vibe, she said, is chill.
For people on the margins, people bouncing around from one place to another, it’s important to feel welcomed and to feel relaxed, because Thrive is a life raft in a tumultuous sea. Last year alone, naloxone – an emergency medication that rapidly reverses an opioid overdose – distributed by the organization was used to reverse at least 289 overdoses.
Read more: Overdose deaths are falling nationwide. Why?
Other times, they are out and about Cleveland’s Cuyahoga County, hosting outreach events and working to equip people to distribute naloxone and test strips in communities around the state. Right now they reach 50 counties. They distribute harm reduction supplies in rural areas to people who can’t reach them otherwise.
“We’ve saturated the state,” Rosser said. “We have so many lay people. Different targeted efforts. It’s getting into the right hands. People are saving their friends.”
In 2024, Thrive distributed 20,583 naloxone kits and 61,939 fentanyl testing strips across 75 of Ohio’s 88 counties.
But overdose deaths in the United States have been declining dramatically.
Provisional data from the Centers for Disease Control and Prevention’s National Vital Statistics System predict a nearly 24% decline in drug overdose deaths in the United States for the 12 months ending in September 2024, compared to the previous year. If this holds, this would be the fewest overdose deaths in any 12-month period since June 2020.
In a news release, Allison Arwady, director of the Centers for Disease Control and Prevention’s National Center for Injury Prevention and Control, cited the CDC’s public health work, improved data collection and public safety partnerships for improved overdose responses around the country. But that may be just part of the reason overdose deaths have fallen nationwide: The Drug Enforcement Administration (DEA) cited its work targeting cartels, and the presence of fentanyl in the drug supply appears to have fallen dramatically.
Rosser said she was surprised by the drop in overdose deaths, and a little worried.
“It makes it sound like everything is great, like we’re on the right track – which could be true,” she said. “Like we’re done. The work is done.”
But the work is not done, Rosser said.
People are still struggling. Maybe there are fewer deaths, but people are still overdosing.
Thrive’s Executive Director Bethany Roebuck said, “We’re seeing decreases in overdose. Drug supply change. But we’re still seeing overdoses from people who are using stimulants and not expecting, and racial disparities increasing.”
Overdose remains the leading cause of death for all Americans aged 18-44, and overdose rates are still high or increased for Black, Latino, and Native American populations, according to the Drug Policy Alliance.
But for some doing community-based harm reduction work, it’s a tenuous moment for other reasons as well.
Federal funding changes, including the federal funding freeze in January, the Department of Government Efficiency’s (DOGE) cuts to numerous federal entities like the National Institute of Health, the CDC and Housing and Urban Development, and proposed cuts to Medicaid could threaten these gains.
Read more: ‘Temporary’ federal spending freeze may affect some Licking County programs
When Roebuck learned about the federal funding freeze – announced on Jan. 27, blocked by a federal judge on Jan. 28, and reconfigured by the Trump administration in early February – she was on a much-needed vacation.
At first she couldn’t figure out if it would affect the work of Thrive for Change. One email from a funder said that things were fine. Then a few days later the same funder said their funding was on hold.
It was, she said, a moment of uncertainty.
“We had four different grants that they were sure about. It was mostly CDC money.”
Roebuck and her colleagues prepared for the worst.
“I’ve worked so hard to apply for this funding,” Roebuck said. “You apply for it and don’t know if you’re going to get it and then you hear that it might be taken away.”
Now things are moving forward, but that moment was a whirlwind and it made them think about how much they depend on government funding and ways to diversify their funding.
And they are stocking up. One of the companies that supplies them with rapid-HIV tests is in Canada. They put in an order before the tariffs kicked in just in case.
Harm reduction efforts will be affected by federal spending cuts, both indirectly and directly.
President Trump’s order to place a 15% spending cap on indirect costs for National Institutes of Health (NIH) research will hurt institutions that conduct important medical research. These indirect costs pay for building and labs as well as equipment. For now these cuts are on hold, but if they were implemented it could hurt significant research on substance use disorder and harm reduction.
DOGE has already fired 5,200 probationary employees from the Department of Health and Human Services and proposed cuts at Housing and Urban Development, Centers for Disease Control, and the Department of Veteran Affairs – all of which would impact agencies that support harm reduction and provide safety nets for vulnerable populations at risk of overdose and substance use disorder.
This week alone, more than 10,000 staffers at U.S. health agencies – including at the CDC, the NIH and the Food and Drug Administration – have been laid off, according to Reuters.
And proposed staffing cuts at the Substance Abuse and Mental Health Services Administration (SAMHSA) could leave between 50 and 70% of employees there without work.
One of the biggest impacts on harm reduction could come from cuts proposed by Congress to Medicaid, a source of health insurance to many people with substance use disorder. These cuts will affect the ability of people who are in recovery getting access to care, short- and long term.
About one in five Medicaid beneficiaries has a substance use disorder, according to the 2020 National Survey on Drug Use and Health.
If congressional budget cuts are approved, Ohio stands to lose up to $31.37 billion in federal funding for Medicaid. Almost a million people could lose their health insurance.
Kay Spergel, executive director of the Mental Health and Recovery Board of Licking and Knox County, told The Reporting Project that there is not enough information to go on at this point. Spergel said that there is not enough information available about federal cuts and not a clear understanding about changes to the Ohio state budget to know what will happen to people who rely on Medicaid to treat addiction.
Gov. DeWine’s proposed state budget includes work requirements for Medicaid users. However, there are proposed waivers for people participating in an alcohol or drug addiction treatment program and for those with “serious mental illness,” according to the language published by the Ohio Department of Medicaid.
“It’s hard to say how that’s going to impact and who that’s going to impact,” Spergel said. “We just have to keep moving forward.”
Spergel said that Medicaid expansion was important because it allowed adults with substance use disorder to get help.
“Addiction is not a disability under law. It became income-based so it allowed adults who had no other way to cover care to obtain care. We don’t know how this is going to affect people with Medicaid,” Spergel said. “Bottom line: We don’t know what’s going to happen.”
In some places, access to addiction treatment is already limited. The Health Policy Institute of Ohio reported in January that every year 35,507 Ohioans need alcohol or drug treatment but don’t receive it because of cost, transportation, unaccepted insurance or lack of provider availability.
Nonprofit work is hard, often tenuous, Roebuck said – especially so when that work is coupled with overdose prevention and crisis-centered work.
“To have the mental strain that the rug is going to be ripped out from under you from an entity that you have no say over all the time, just adds another layer of stress,” Roebuck said. “When you’re on this roller coaster, it’s kind of like a trauma response. You become a little bit numb to the highs and lows. It’s hard to celebrate the wins because you don’t know when things are going to be brought down.”
Jack Shuler writes for TheReportingProject.org, the nonprofit news organization of Denison University’s Journalism program, which is supported by generous donations from readers. Sign up for The Reporting Project newsletter here.