News & Updates — Grantee Spotlight

With funding from FORE, the National Academy for State Health Policy (NASHP) established itself as a resource to states as they respond to the opioid crisis. NASHP’s State Policy Center for Opioid Use Disorder Treatment and Access shares strategies for coordinating the work of different state agencies and tracks changes in Medicaid policy and other state regulations that affect access to treatment and harm reduction services. During the pandemic, NASHP partnered with state policymakers to identify and respond to emerging issues, including ways of ensuring uninterrupted access to OUD treatment. With a new grant, NASHP will be monitoring how states are using their Medicaid programs, grants from federal opioid abatement programs, and the settlements they’ve reached with pharmaceutical companies and distributors to increase access to treatment, recovery, and prevention services. FORE spoke with Jodi Manz, M.S.W., the project’s director, about the challenges states face in coordinating their opioid responses and the opportunities that lie ahead.

You’ve pointed out that states are uniquely positioned to address the opioid crisis. States are the single largest funder of behavioral health services and regulate commercial insurers as well as health care providers. Where have states made progress and where do they struggle?
Manz: It’s a considerable challenge to coordinate the work of different agencies with different funding streams, but it’s critically important because effective policy cannot be accomplished with one-time infusions of funding or singular programmatic interventions. Policies and programs have to work in concert so that when, for example, a judicial system mandates treatment, the treatment infrastructure has the capacity to help. By the same token, a robust Medicaid benefit is only effective if workforce capacity and provider standards align with regulations. The states that do this well tend to have leadership that has shown an investment in this issue and has set an expectation around results. They engage many government agencies including Medicaid, law enforcement, and emergency response in designing solutions, but they have a central locus of control that creates accountability. As an example, Pennsylvania has two cabinet-level secretaries at the helm of an opioid command center that meets every week. Some states have a drug czar who brings together agencies and legislators.

This year, more than half of states will be holding gubernatorial elections, raising the possibility of administration changes. With that, do you expect to see changes in the ways states approach the opioid crisis?
Manz: It’s totally normal for there to be shifts in the way you approach a problem or what conclusions you draw about it. That why it’s so important to have a clear locus of control and a shared understanding of what roles agencies play in the response. Some states have developed public–private partnerships that bring together government agencies with nonprofits or other organizations to sustain programs through changes of administration. Another approach is to mirror what states are doing at the local level — to create the same administrative cohesion and strategic thinking within communities.

Over the next two decades, most states will be receiving tens of millions of dollars each year from settlements with pharmaceutical companies and others. How do these funds compare to what states receive from the federal government to support opioid response efforts and access to care via Medicaid programs?
Manz: When you break it down year over year, the settlement money is a little less than those federal funds, but the dollars that come from the federal government come with pretty significant limits on how the money can be used. The settlements give states the option to spend those dollars differently or enhance programs that are already working. It’s an opportunity to pay for things that might otherwise not be funded, such as data exchange.

What problems might this solve?
Manz: One opportunity is improving data systems. In the substance use disorder space, people touch so many different systems and are represented in so many different datasets. The systems public health agencies, local treatment organizations, and prescribers all use aren’t interoperable. This also applies to prescribing data. If there are certain providers who are prescribing substances that are identified in overdose victims, the prescriber would want to know that, but there isn’t always interoperability among public health data sets, prescription monitoring programs, and Medicaid claims data. Combining this information would offer a much clearer picture of where intervention is needed but it is very expensive to do.

What are some other investments states might make?
Manz: Expanding the behavioral health workforce. This is something that comes up in every conversation we have with states. It was a challenge before COVID and since then, the needs have increased and the workforce has decreased. States could use settlement dollars to invest in training and certifying peer recovery specialists who want to do the work. We also need to think about how to retain people who are working in the public health system and help more providers become comfortable with prescribing medications for opioid use disorder. If there were dollars put into mentorship, training, and resources, I think we could see some change in that space.

How are states deciding how to use the money?
Manz: States are establishing abatement workgroups or other abatement authorities, often led by a coalition of state and prevention, treatment, and recovery leaders. Those groups will be reviewing options for spending but must be mindful of other funding resources in states to avoid duplication.

We understand states are trying to avoid some of the missteps that occurred with distribution of tobacco settlement funds. What pitfalls are they hoping to avoid?
Manz: There were fewer parameters put on those dollars and what ended up happening is that tobacco settlement dollars became very focused on economic development and didn’t get to tobacco use disorder. People see the opioid settlements as an opportunity to do things differently. The settlement language itself requires that states use at least 70 percent of the money solely for OUD.

What steps are states taking to ensure transparency and accountability?
Manz: North Carolina was a very early mover in this space. The state created a website that shows how its settlement funds are being distributed and has taken a very thoughtful approach to allowing local communities to use the money as they see fit. Their memorandum of agreement with local communities lays out an array of options with guardrails to ensure communities focus on evidence-based strategies. South Carolina produced a book that helps communities think through the continuum of services and supports they might pursue. This kind of tangible guidance can be helpful in developing a coordinated response.

As part of the FORE grant, you’ll be hosting webinars that showcase how different states are managing the settlement funds. What do you hope the webinars accomplish?
Manz: The webinars are an opportunity to share best practices. We also know states like to share their experiences and learn from peers. Our first focused on Maine. The state has been very deliberate in assessing how their dollars are currently being used and where the gaps are. One of the governor’s first acts in office was to sign an executive order that established the expectation for interagency work. She also established a position for an opioid coordinator who works as a community organizer of sorts for state government. The distribution of settlement funds is being overseen by a 15-member council that includes not just representatives of public health, public safety, and other state agencies, but also representatives of the treatment and harm reduction community, as well as people affected by the crisis or their families. Together, they will make binding recommendations that aim to align the state’s strategic plan with local action.

What advice would you give to providers and community-based organizations interested in using settlement funds to advance their efforts?
Manz: As states are appointing or deciding who sits on these workgroups, it’s really important to know who the players are and how to reach them. I also recommend finding like-minded people, the champions in the community who want to see the same things funded as you do. When people come together and submit a well thought out plan, that piques the interest of legislators. The last thing I’d say is be prepared to present the evidence base for your intervention as clearly and concisely as possible.