As the drug overdose epidemic continues, leading to over 108,000 fatalities in 2021, states are considering how organizational approaches to policy and funding across state agencies can support innovations to reduce these deaths.

Many states developed task forces or workgroups that focused on addressing the substance use disorder (SUD) epidemic in the previous decade, bringing relevant agencies together to consider state needs, as well as opportunities for collaborative initiatives. These state workgroups — and the policy priorities that they established — provide an infrastructure for decision making that often involves otherwise siloed policy and funding.

Over time, as new funding for SUD has been introduced through opioid abatement settlements and enhanced federal dollars, the complexity of managing multiple funding streams to drive prevention, treatment, and recovery efforts has increased. With new dollars come new rules, and policymakers are challenged to avoid duplicating efforts across systems and resources. In anticipation of these challenges, NASHP interviewed leaders in three states — Kansas, Maine, and Pennsylvania — to understand current thinking about how existing state structures and relationships can support the administration of funding over time.

Key Lessons Learned from Case Study States

1. Intentional partnerships across agencies are driving investments in access to treatment.
2. States are using interagency collaborative projects to support advances in data exchange.
3. Multiple federal and state resources are being blended for treatment for parents and families.
4. States are using other state and federal dollars to complement Medicaid funds in support of SUD treatment providers.
5. States are solidifying approaches for administration of opioid settlement funds.
6. State-led stakeholder convenings are providing forums that drive funding priorities.

State Profiles

Kansas began aligning state OUD/SUD work in 2014 through participation in a Prescription Drug Abuse Policy Academy hosted by the Substance Abuse and Mental Health Services Administration (SAMHSA). Noting the increasing need for SUD services among parents, the Kansas Department for Aging and Disability Services (KDADS) focused the state’s work within the policy academy around the development of tools to address services for this population. The following year, two federal grants supported continued cross-agency initiatives: KDADS was awarded a Partnership for Success grant from SAMHSA, and their sister agency, Kansas Department of Health and Environment (KDHE), was awarded a Data-Driven Prevention Initiative grant from the Centers for Disease Control and Prevention (CDC). Because both state agencies were required to develop statewide strategic plans under these grants, the agencies decided to combine efforts in 2016 to create the statewide Kansas Prescription Drug and Opioid Advisory Committee and a singular strategic plan. Leveraging these federal grant funds, the agencies contracted with the Douglas County Citizen Committee on Alcoholism (DCCCA), a local stakeholder, to administer the group and organize stakeholders around SUD issues across the state. This approach promoted interagency collaboration, ensuring that the Advisory Committee was not housed within a single state agency.

The Advisory Committee began as a small steering committee of key staff representing the agencies that had participated in the SAMHSA policy academy in 2014. Over time, as the Committee conducted a statewide needs assessment, additional members were added. Ultimately, the Committee used the results of the completed needs assessment to create the Kansas Prescription Drug and Opioid Misuse and Overdose Strategic Plan in 2018. The four-year plan was based on five priority areas provider education, prevention, treatment and recovery, law enforcement, and neonatal abstinence syndrome (NAS), with each priority area led by a subcommittee. The most recent iteration of Kansas’ plan, released in 2021, maintains these priority areas and expands strategies with quantifiable objectives to guide policy and clinical efforts to reduce the impact of SUD in the state. Current committee membership includes both stakeholders and state agencies with diverse funding sources, creating a platform to consider all funding outcomes during the planning process, particularly for grant development. Committee meetings are open invitation, and the meeting listserv currently includes over 100 individuals representing a range of stakeholders. As new funding and opportunities emerge — particularly opioid settlement dollars — and priorities evolve, the Committee will refocus and adjust annual recommendations accordingly. 

Maine has organized SUD work from within the state’s governor’s office. On February 6, 2019, less than one month into her term, Maine’s governor signed Executive Order 2, establishing a Director of Opioid Response position to identify and coordinate funding for SUD prevention, treatment, and recovery initiatives in the state and directing agency commissioners to work in conjunction with the Director on SUD initiatives. This approach effectively positions the Director to lead alignment agencies across both initiatives and funding. The EO also established a Prevention and Recovery Cabinet, chaired by the Director of Opioid Response. This cabinet is composed of all of the agencies that touch SUD in any capacity and includes the state’s Attorney General and Chief Justice of the Supreme Court. This foundational structure underscores the Governor’s expectations that all state agencies take part in addressing SUD.

State leaders describe cross agency collaboration on SUD funding and planning in Maine as “embedded” as a standard part of the daily workflow. The Director of Opioid Response coordinates with agency leaders and staff, representing the governor’s office as a partner in funding and policy decisions. Maine’s 2021 Strategic Plan reflects this intentional and transparent approach, outlining strategies and objectives that span state agencies and acknowledge multiple funding opportunities for the state. Coordination of these opportunities, and applying funds to agreed-upon strategies delineated in the state plan, led to the Maine Department of Health and Human Services proposing nearly $30 million in addition to federal grant funds and Medicaid treatment dollars for SUD in the state’s FY22-23 biennial budget.

Pennsylvania established an Opioid Command Center in 2018. Composed of 16 state agencies, the Office of the Attorney General, and the region’s High Intensity Drug Trafficking Area (HIDTA), the Command Center is led by Cabinet secretaries. The Command Center’s 2020-2023 Strategic Plan focuses the state’s efforts within four priority areas — prevention, rescue, treatment, and recoverys — which include specific goals of reducing stigma associated with SUD, increasing harm reduction, and reducing policy barriers to treatment. Pennsylvania’s agency leaders describe the group as benefitting from the “unsurpassed leadership” of those secretaries because of their ability to bring the agencies together. Command Center leaders foster a “let’s work together, not apart,” collaborative environment, and differences of opinion on funding and priorities are explored rather than discouraged.

Since its inception, the Command Center has served as a platform to convene agency leaders and Cabinet secretaries at regular intervals in order to provide near-real time discussion of state strategies to address the overdose crisis in Pennsylvania. Over time, Pennsylvania’s Command Center has evolved to become a “policy response team,” described by agency leaders as having developed a more systemic, long-term approach to mobilization around legislation, grant, and policy decisions. This reflects a priority expressed by Governor Wolf to broaden this collaborative work beyond SUD by looking at the crisis, and other emerging issues, with a full scope behavioral health systems perspective. Recognizing the systemic interactions that foster co-occurring conditions, this approach offers an opportunity to address workforce shortages, critical infrastructure needs, and new resources that require cross-agency collaboration.

Key Lessons Learned from States

1) Intentional partnerships across agencies are driving investments in access to treatment. The overdose crisis has left no community untouched, and Kansas, Maine, and Pennsylvania actively coordinate state agencies in the information sharing, data sharing, and decision-making processes in order to gain a comprehensive understanding of the crisis as well as how to strategically address it. Collaboration across agencies and sectors has provided platforms for discussions that support coordination and reduce duplication in both funding and programming. This approach has inspired conversations that have extended the focus of opioid-specific work into stimulant/polysubstance use disorder, suicide prevention, and mental health crisis services.

Corrections and Medicaid

Partnerships across state agencies can support specific state strategies, like coordination of treatment for incarcerated and reentering populations. State Medicaid and corrections agencies have been able to use statewide coordinating bodies to facilitate eligibility, provider access, and support services to ensure safer transitions out of incarceration for individuals with SUD, a strategy encouraged by the Centers for Medicare and Medicaid Services (CMS). In Maine, for example, the state Medicaid agency and Department of Corrections (DOC) are working together not only to increase access to medications for opioid use disorder (MOUD) in state prisons and local jails, but also to promote safer reentry through eligibility system improvements. Maine’s Department of Health and Human Services (DHHS) has worked with the state DOC to align Medicaid applications with release dates to ensure coverage upon reentry, and the agencies have ensured that reentering individuals are connected to opioid health homes. Similarly, Pennsylvania has implemented an intra-agency data exchange among the state’s DOC, the Department of Human Services (DHS), and the Pennsylvania Justice Network to ensure automatic application to the state’s Medicaid program on behalf of individuals reentering the community. Individuals who voluntarily enrolled in the DOC’s Medication-Assisted Treatment (MAT) program also become Medicaid enrolled upon release. Pennsylvania DOC, in turn, notifies DHS of newly incarcerated individuals, facilitating a rapid pause in benefits.

Parental and Child Health

Pennsylvania’s efforts to support families affected by SUD has been driven, in large part, by interagency collaboration. A series of collaborative agency workgroups and co-located department programs combine multiple data sources to track the percentage of pregnant people enrolled in Medicaid who are receiving MOUD as well as annual rates of Medicaid covered newborns presenting with NAS symptoms in Pennsylvania hospitals. These cross-agency and inter-organizational partnerships enable the state to track disease trends, identify geographic hotspots, and allocate resources accordingly.

NAS has also been a key driver of Kansas’s efforts to address opioid use and was one of the five priorities in its initial strategic plan; at the time of the initial convening of the advisory council, Kansas had experienced a 900 percent increase in NAS incidence over the preceding decade. Much of the advisory committee’s preliminary work focused on NAS, which brought together agency bureaus that might not otherwise have had a seat at the strategic planning table – including the Bureau of Family Health. The advisory committee’s initial strategies to mitigate NAS included better NAS data collection, conducting a needs assessment to better understand statewide treatment capacity for pregnant people with SUD, and collaborating with the state’s Perinatal Quality Collaborative and Wichita State University to implement training, education, and evidence-based care. Kansas’s NAS sub-committee has continued to successfully implement the strategies identified in its action plan, as a result of the state’s collaborative efforts, the NAS incidence rate has dropped to 2.9 per 1,000 births (down from 3.7 in 2017) and 55 percent of Kansas birthing centers have implemented the state’s approved NAS training program.

2) States are using interagency collaborative projects to support advances in data exchange. Interagency collaboration on programming, policies, and funding can help foster formal initiatives for data sharing to support treatment access. Sharing data across agencies, including those that maintain treatment, emergency response, and overdose data, helps to create a comprehensive picture of state overdose crises and responses. Pennsylvania has done this using the NAS work as a form of a use case. The Department of Health (DOH) and the Office of Children, Youth, and Families (OCYF) have entered into a data use agreement under which the DOH manages and supports data related to lower risk pregnant people with OUD, and the OCFY maintains data on services for those with higher risk. The state’s interagency data exchange between the DOC and DHS similarly allows Pennsylvania to allocate resources and funding strategically and efficiently, aligning policy with evidence-based practice.

Data collection is also a key function of state leadership groups. Kansas used data from the results of its initial needs assessment to establish the priority areas for its strategic plan, and the state conducts stakeholder surveys annually and has convened an evaluation workgroup that is reviewing the results to tailor recommendations accordingly. One recommendation that consistently appears in the state’s annual reports is to increase medication assisted treatment (MAT). Based on data analysis conducted by KDADS, 41% of Kansas counties now have an MAT provider, compared to only 19% of counties in 2018. Although stakeholder survey results continue to identify inadequate numbers of providers and geographic access as barriers to engaging in treatment, Kansas attributes this increase in part to the coordinated efforts of the Advisory Committee, the Governor’s Behavioral Health Services Planning Council, and state agencies. Kansas also identified several opportunities for data coordination in its initial strategic plan, including integrating prescription drug monitoring program (PDMP), electronic health record (EHR), and pharmacy management systems and using Medicaid benchmark data to improve rates of Kansans with OUD who receive MOUD.

3) Multiple federal resources are being blended for treatment for parents and families. States coordinate various funding sources to provide SUD treatment and support services to parents, youth, and families. In order to streamline services and reduce duplicative care, state child protection/child welfare agencies frequently collaborate with state Medicaid agencies and departments of behavioral health to coordinate the provision of SUD services for parents and families experiencing the impacts of SUD.

States are tapping into federal Family First Prevention Services Act (FFPSA) dollars to support these services in different ways. Pennsylvania has “opted-in” to the Family First Title IV-E Prevention Program, and the state’s Five-Year Prevention Plan includes the provision of mental health treatment, substance use prevention and treatment, and in-home family support services. One product of Pennsylvania’s Family First approach is the Family Engagement Initiative, a partnership among the OCYF, the Office of Mental Health and Substance Abuse Services, the Juvenile Court Judges Commission, and the Administrative Office of the Pennsylvania Courts. Together, these entities work to coordinate care and placement for youths that both meet their treatment needs and address any in-home threats while minimizing out-of-home placements. The Kansas Department for Children and Families (KDCF) partners with community organizations to ensure family treatment services. The agency allocated over $1 million of its FY21 Family First Prevention Services Act dollars to organizations that provide substance use and mental health services to youth and their families, support families in their recovery, and prevent children being removed from their families due to substance use. Across all of Kansas’s Family First programs, 93.4% of the 507 families referred to Family First Services were successfully maintained at home. Maine’s Family First Prevention Services State Plan supports the provision of methadone as a prevention service for parents with OUD, and treatment is funded through Medicaid for individuals who qualify for MaineCare and SAPT grant dollars for individuals who are uninsured. Maine’s Office of Child and Family Services (OCFS) is coordinating with MaineCare to develop a comprehensive index of SUD services available across the state. OCFS is collaborating with the state’s Behavioral Health and Supportive Services Workforce Stakeholder workgroup to select training opportunities that will support Maine’s behavioral health workforce in serving families as they navigate SUD.

States are also able to fund dedicated treatment initiatives through the Medicaid Maternal Opioid Misuse (MOM) model developed by the CMS Center for Innovation. A total of eight state grantees (Colorado, Texas, Indiana, Tennessee, West Virginia, Maryland, New Hampshire, and Maine) are using MOM project funds to integrate and coordinate prenatal and postnatal care, including OUD treatment, for Medicaid eligible pregnant and postpartum people. Key components of these programs include efforts to address stigma, transportation and geographic barriers, and other social determinants of health that may exacerbate challenges to access to treatment for OUD. The MaineMOM project, run by the Office of MaineCare Services, seeks to create a “no-wrong-door” system of care for pregnant people with OUD — Maine’s Department of Health and Human Services has initially partnered with five MaineMOM providers to ensure statewide access to MaineMOM services. MaineCare offers technical assistance and best practices training for MaineMOM providers, as well as a public awareness campaign highlighting available services and encouraging connection to treatment.

4) States are dedicating funding to support SUD treatment provider capacity. While Medicaid funds support a significant portion of SUD treatment services across states, states also rely on a combination of other funding sources to train, reimburse, and develop the SUD treatment workforce. 

• Federal Block Grant and State Opioid Response (SOR) Grants. Federal dollars for SUD can be used by states with considerable flexibility to address state needs, though both grants carry unique requirements. Both SABG and SOR dollars may be used to supplement but not supplant other federal funds for SUD treatment services, which means that states must coordinate across funding sources and prevent duplicative services. In order to fund treatment in the state, Kansas uses both SUD block grant and SOR grant dollars to allow providers to bill for treatment services. Kansas used block grant dollars to support not only a community coalition structure, but also a group of approved providers in the state who could deliver services using grant funds. Over time, this approach has been refined to become a funding system in which the services themselves are funded through the block grant, and administration of the provider network is supported by a contracted managed care organization using SABG funding, creating a billing mechanism for providers. Kansas also recently increased reimbursement rate for services billed to the block grant, raising it to match the Medicaid reimbursement rate.

Pennsylvania, a Medicaid expansion state, funds most treatment services through Medicaid dollars, which frees up SOR and block grant dollars to pay for other supports. This includes cross-agency activities like provider training, diversion programs, and stigma reduction campaigns. Pennsylvania DDAP credits the state’s Medicaid State Plan, which includes MAT as a mandatory benefit, supplemental payments to facilities with Emergency Departments that treat large numbers of individuals with OUD, and residential and inpatient SUD treatment services within institutions for mental disease (IMD), with providing a robust service structure reimbursed by Medicaid that allows SOR and block grant funds to be focused on supportive components of treatment, prevention, and recovery.

• American Rescue Plan Act (ARPA) funds. States are using enhanced Medicaid matching funds through ARPA to support SUD workforce recruitment, retention, training. Maine has dedicated $15 million of its ARPA enhanced match to health care workforce development, including direct payments to providers of behavioral health services, substance abuse treatment facility services, and community residences for individuals with mental illness services. The state is considering a variety of strategies to encourage entrance into the healthcare workforce, including decreasing licensing barriers, providing reciprocal licenses, and recruiting professionals from other states, but acknowledges that it takes time to develop professional pipelines for more highly trained providers. Pennsylvania is using ARPA enhanced matching funds, in addition to other COVID-era federal funding, to offer recruitment and retention incentives and rate reimbursement to behavioral health providers, scholarships for individuals pursuing peer specialist certification, and training for opioid treatment programs (OTPs) to focus on quality improvement.
• State revenue resources. Because federal funds can rarely be used for capital expenses, several states are working to identify more flexible funding sources and strategically allocate them to fund projects, from infrastructure to delivery of care. In Maine, a 2020 law increased licensing fees for opioid manufacturers from $200 to $55,000 per license, a statutory change that generated an additional $2.1 million in state revenue the following year. Funds generated through these fees in 2021 supported existing and new harm reduction and recovery services, access to low barrier treatment in rural Maine, and training for and additional SUD service providers. Through this policy change, Maine created a new, flexible funding source that can be used to support a variety of SUD treatment and support services, including for those who are not Medicaid-eligible, while freeing up other dollars to be put toward alternative uses. Notably, Minnesota has enacted a similar law with an opioid manufacturer license fee, while New York has imposed an excise tax on the first sale of opioid units by registered manufacturers.

5) States are solidifying approaches for administration of opioid settlement funds. Opioid settlement dollars present an opportunity for states to collaborate across agencies and engage stakeholders to support a broad range of initiatives  — many of which are not allowed as part of federal grant spend (see global settlement language). Further, states have latitude to decide how funds will be allocated at both state and local levels, and they are approaching this differently.

Many states are coordinating the use of settlement funds in line with a specific legislative directive or within budget bills, and states are making determinations about how much funding will be administered at a state level and how much will be drawn down by local and regional entities. For example, the Kansas state legislature established that 75% of settlement dollars will be allocated to a new “Kansas Fights Addiction Fund” and created a grants review board for state spending, and that 25% will go to a “Municipalities Fight Addiction Fund.” Both funds are administered by the Office of the Attorney General, and the enacted bill also dedicates a specific $200,000 to the Kansas prescription monitoring program. Taking a different approach, Pennsylvania’s statewide settlement funds, which make up 15% of the total allowable spend, are allocated within a state Trust alongside 70% of funds that go to localities and a dedicated 15% held for litigating counties, subdivisions, district attorneys, and special districts. (For further detail, view NASHP’s accompanying chart outlining how Kansas, Maine, and Pennsylvania are administering their settlement funds.)

Though states vary in the specific composition of the group of leaders overseeing settlement funds, most have established an advisory group or board to decide how funds are spent and who receives them. Maine and Kansas both include representation across executive and legislative branches, office of the attorney general, and from stakeholders. In Pennsylvania, the Office Attorney General (OAG) participates in the state’s Opioid Command Center, creating a natural line of communication between the OAG and other stakeholders in the state. Existing state inter-agency workgroups that have developed strategic plans and established approaches to funding decision-making are in place as collaborative partners with opioid settlement groups; often, states report that they include many of the same individuals. This creates an opportunity to thoughtfully approach how these bodies interact to coordinate how states use funding across various streams with varying requirements.

Model Legislation for Opioid Settlement Funds
The Office of National Drug Control Policy (ONDCP) and the Legislative Analysis and Public Policy Association (LAPPA) released model legislation in October 2021 that seeks to mitigate the “missed opportunities” presented by the administration of tobacco settlement dollars. ONDCP’s model legislation suggests the creation of a dedicated and separate fund for opioid settlement dollars outside of the state general fund. This is a strategy to ensure that funds are used for SUD prevention, treatment, and recovery, and do not supplant existing funding – state or federal – for such activities. The model further suggests that states involve stakeholders in administration activities to guide the allocation of these funds.

6) State-led stakeholder convenings are providing forums that drive funding priorities. Convening stakeholders through annual conferences and summits can support consensus-building, providing communication channels between state leaders and stakeholders. While these convenings take significant time and effort to coordinate, they offer a forum in which to bring all stakeholders together at one time and help guide the work for the coming year.

Kansas, Maine, and Pennsylvania each host an annual day-long opioid response summit and maintain online archived recordings and content. DCCCA hosted Kansas’s fifth annual Opioid and Stimulant Conference in November 2021, which over 600 people attended. In its earlier years, the conference focused on prescription drugs, then shifted to illicit opioids, and is now organized around illicit psychostimulants. The 2021 conference agenda organized breakout sessions around prescribing, prevention, treatment & recovery, and law enforcement. Both KDADS and KDHE help fund the conference, and pre-pandemic, DCCCA collected registration fees which it kept for future conference sustainability. Maine has hosted four statewide annual Opioid Response Summits, with the most recent having taken place in July 2022. The 2022 Summit Agenda featured state and national OUD treatment and recovery policy leaders as well as breakout sessions on recovery friendly workplaces, Maine treatment courts, MOUD in corrections, and other related topic areas. Maine’s Summit, which attracted nearly 1200 attendees, was funded in part by the OUD Prevention and Treatment Fund. Local medical societies in Pennsylvania host their fourth Pain and Addiction Summit, entitled “Equitable Access to Care in a Post-Pandemic World,” in April 2022. The Summit Agenda included topics such as syringe service programs and harm reduction, pain management for people receiving MOUD and the elderly, and the role of the behavioral health workforce. Attendees were eligible to receive continuing education credit by virtue of participating.

Each of these convenings not only provides opportunities to elevate interagency and state-local collaboration, but also create feedback loops from state work to stakeholders. Creating this forum for information sharing and gathering allows states to be more response to the ever-evolving trajectory of the overdose epidemic and inclusive of everyone with a vested interest.

Looking Ahead

Understanding what is next for states in how they approach the complexity of SUD funding and policy hinges on identifying themes and innovations as states begin spending new dollars. Using lessons learned from existing structures, and tracking outcomes from the interventions that have been developed over time, state leaders have resources to understand the best next actionable steps. Policymakers can foster new partnerships and consider funding interventions and infrastructure that are known to work in their states – and may be able to newly support those that have not been funded before.

Acknowledgments

The National Academy for State Health Policy is providing this case study with the ongoing support of the Foundation for Opioid Response Efforts (FORE) and wishes to thank Project Officer Ken Shatzkes and FORE President Karen Scott for their continued guidance and direction. Further, the authors would like to thank state leaders from Kansas, Maine, and Pennsylvania for their time and thoughtful engagement as this case study was developed. NASHP also thanks Eliza Mette and Mia Antezzo for their work on this case study while they were on staff at NASHP.