In late July the Substance Abuse and Mental Health Services Administration (SAMHSA) announced which 11 states were the winners of about $1 million each in grant funding to expand treatment for opioid use disorders.
The Targeted Capacity Expansion grants are going to the single state agencies (SSAs) with authority over the Substance Abuse Prevention and Treatment (SAPT) Block Grant in the following states: Indiana, Iowa, Kentucky, Maryland, Massachusetts, Missouri, New Jersey, Vermont, Washington, Wisconsin, and Wyoming. SAMHSA’s Center for Substance Abuse Treatment (CSAT) conducted the award process.
Thanks for the $11 million should go to Congress, which added the money in the appropriations bill for fiscal year 2015 last December. From report language accompanying the bill, which actually referred to $12 million:
“The agreement includes $12 million for discretionary grants to States for the purpose of expanding treatment services to those with heroin or opioid dependence. The agreement directs CSAT to ensure that these grants include as an allowable use the support of medication assisted treatment and other clinically appropriate services. These grants should be made to States with the highest rates of primary treatment admissions for heroin and opiates per capita, and should target those States that have demonstrated a dramatic increase in admissions for the treatment of opiates and heroin in recent years.”(Boldface added for emphasis.)
Sylvia Burwell, secretary of the Department of Health and Human Services (HHS), announced the grants when speaking at the National Governors Association annual meeting July 25. Many people were taken by surprise—SSAs hadn’t even received their official notices of awards yet. Normally, the announcement would have come from SAMHSA.
Will OTPs Have Access?
How much of the money will be allocated to opioid treatment programs (OTPs) depends on what each state chooses to do with the grant. “If you’re an OTP, it’s natural to ask why the dollars aren’t going to you,” said Robert Morrison, executive director of the National Association of State Alcohol and Drug Abuse Directors, the association representing all SSAs. “It’s natural to ask why the state wouldn’t look at its back yard and come up with a plan that’s coordinated and targeted to the needs of the state.”
Mark W. Parrino, MPA, president of the American Association for the Treatment of Opioid Dependence (AATOD), was told by CSAT and by Robert Lubran, MS, MPA, director of SAMHSA’s Division of Pharmacologic Therapies, that if OTPs wanted to access the grant fund, they could do so by working with the SSAs.
“I mentioned this to my board, and said that if their programs or associations had an interest in accessing these funds, they should be working immediately” with the SSAs, Mr. Parrino told AT Forum. Mr. Lubran and CSAT also made the point that both private for-profit and public not-for profit OTPs would be able to access the money, said Mr. Parrino. “It all depends on how the states set up getting the grants.”
How the States Were Chosen
We asked Mr. Lubran how SAMHSA selected which states would receive the grants. “We followed the congressional language,” he said, referring to the appropriations report for fiscal year 2015. (The complete language is in the fifth paragraph above, describing the directions to CSAT).
The funding can be used for any of the three medications approved by the Food and Drug Administration for the treatment of opioid use disorders: methadone, buprenorphine, and naltrexone. “The funding isn’t just for medication,” said Mr. Lubran. “The grants include screening, assessment, and case management.”
Mr. Lubran noted that SAMHSA requested another $13 million for medication-assisted treatment (MAT) in the fiscal year 2016 budget. The $11 million is for the current fiscal year, fiscal year 2015. He also said that the grant program for this year is supposed to be continued in fiscal years 2016 and 2017, so that would be an additional $11 million a year for two more years. But there is no guarantee that Congress will approve that money.
We asked why it makes sense to give grants to these states in particular. “Why Iowa? Why Wyoming?” asked Mr. Lubran. “We used the formula requested by Congress, which may or not be the best formula, but it’s what Congress asked us to look at,” he said. “Certainly there are other states that you could argue have a bigger problem, because more people are addicted to opioids, but this is how it worked out.” The formula is based on per capita opioid admissions and the recent increase in opioid use.
Some states are using the funding for OTPs, said Mr. Lubran. “But we did not ask them to specify medications, and who’s going to get what. Everybody said they’re going to do MAT.”
In Maryland, where overdose survivors in emergency departments will be targeted, the grant will fund interim methadone maintenance, said Mr. Lubran.
Another state is proposing to use COR-12—the Hazelden Betty Ford model combining the 12 steps and buprenorphine treatment. In another state, office-based opioid treatment will be funded.
We talked with SSAs from Vermont and Missouri to find out more about how their states are planning on using their respective $1 million.
Barbara Cimaglio, deputy commissioner for the Vermont Department of Alcohol and Drug Abuse Programs, and the state’s SSA, is using almost all of the funding for OTPs, which, in Vermont, constitute the “hubs” of the “hub-and-spoke” system. All new patients are assessed in the hubs, where methadone, buprenorphine, and extended-release naltrexone are provided to patients who need the OTP structure, and buprenorphine inductions are done.
Patients on methadone stay in the hub; once stable, patients on buprenorphine or extended-release naltrexone are treated in the spokes, which are physician offices. Two of the locations are hubs (OTPs), and the third is a hospital that delivers MAT, said Ms. Cimaglio.
“We’re not doing anything brand new, just building onto our existing network,” Ms. Cimaglio told AT Forum. The focus is on areas with the largest populations needing treatment—Chittenden County and Franklin County in Northwest Vermont, and the Rutland area.
In addition, Vermont will focus on the criminal justice population, where people coming out of jail or prison need to be linked to treatment. In many cases, people in the criminal justice system will want extended-release naltrexone, said Ms. Cimaglio, but if they do want methadone or buprenorphine, they can have those instead. Finally, the grant will also focus on parents in the child welfare system.
“This money will help us quite a bit,” she said. “We need to bring down our waiting list.”
The grant will also give Vermont the opportunity to hire more people in recovery, who can act as recovery support to the hub and spoke sites, said Ms. Cimaglio.
“One million dollars seems like a lot of money, but it doesn’t stretch that far,” Mark Stringer, director of the department of mental health, and the state’s SSA, pointed out. So one provider in each of the two hardest-hit areas—Southeast Missouri and St. Louis—was chosen. In Southeast Missouri, there are no OTPs. And in St. Louis, the two OTPs that contract with the state had shorter waiting lists than the program that will be getting funding.
The two contracted St. Louis OTPs had waiting lists of 11 (Center for Life Solutions) and 240 (West End Clinic), but Bridgeway Behavioral Health, also a state-contracted provider, but not an OTP, had a waiting list of 768 opioid users. “The belief was that the grant funds would provide the most relief there,” said Mr. Stringer.
“Bridgeway may provide referrals to either of the St. Louis OTPs as part of this grant project, but the OTPs will not receive grant funds for the cost of care,” he said. “As always, the OTPs will have access to Medicaid, state general funds, and SAPT Block Grant funds.”
The decision to limit funding to one provider in each of the service areas was made because of the limited funding of the grant, ease of coordination, and the need to have good outcomes and evaluation data, he said.
Bridgeway was already serving the highest number of opioid users in St. Louis, and reporting the highest number of intravenous drug users on their waiting list, said Mr. Stringer.
If the grant lasts for three years, the total of $3 million will treat an additional 607 people for opioid use disorders, said Mr. Stringer. On any given day, 2,500 people are on a waiting list for treatment for a substance use disorder in Missouri. “The need for treatment is so overwhelming that I’m glad to get any help,” he said.
The grant programs must start October 1.