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Here's how states should use opioid settlement funds


On August 16, 2022, Sarah Wakeman, MD, shared her perspective on how the United States is taking the wrong approach to dealing with the drug overdose crisis. As part of MedPage todayAfter reviewing the major events of the past year, Wakeman continues his thoughts on how states can fix the current flawed approach and make the best use of opioid regulation funds to have real impact.

As hundreds of millions of dollars begin to flow into states from opioid settlement funds, it’s critical to spend those dollars wisely. The significant errors in how tobacco settlement funds have been used offer a lesson in what can go wrong when these huge sums of money are not used to meaningfully address public health gaps related to substance use and addiction. States have a crucial opportunity to respond differently and, fortunately, a considerable amount of research to guide funding priorities.

The urgency to get it right is evident in the numbers; the nation surpassed 110,000 provisional overdose deaths per year in March 2022, the bleakest outlook our country has ever seen. Tragically, racial and ethnic disparities in overdose deaths have only worsened, with the highest death rates seen among American Indians and Black Americans. These hundreds of thousands of lives lost are all the more heartbreaking because they are the result of decades of failed policies, stigma and problematic approaches to substance use and addiction.

So what works and where should the funding be directed? The science is clear that to reduce deaths, we must expand the availability of effective treatments, including access to opioid agonist medications and full-spectrum harm reduction services. We must also undo harmful policies and address structural inequalities and social drivers of chaotic drug use. Within each of these compartments are concrete and bold efforts that States should undertake.

Expand access to treatment and harm reduction services

To expand access to buprenorphine and methadone, we need legislative action to remove barriers to prescribing and the restriction that methadone can only be dispensed through opioid treatment programs. In a major victory for the treatment of opioid addiction, the recently passed Government Spending Bill repealed the x waiver requirement for the prescription of buprenorphine.

However, other reforms are also essential. While funding may not drive the necessary legislative changes, states could use funding to incentivize providers and institutions to offer these treatments more easily, even in the current restrictive landscape. For example, states could provide funding to health care facilities such as hospitals, emergency departments, primary care practices, drug treatment facilities, and community health centers. These funds could be used to hire additional staff; providing capital for space renovations needed to deliver treatment such as methadone; raise salaries to recruit the best and the brightest in providing treatment for opioid use disorder; offset the cost of providing services that are not well reimbursed; and providing technical assistance and administrative support to complete the onerous application processes currently required to obtain an opioid treatment program license.

Another crucial element to providing effective treatment is having a well-trained workforce. Currently, there are limited sustainable funding pathways for fellowships in addiction medicine or psychiatry to train physicians to become specialists. Many programs depend year after year on unpredictable philanthropy and time-limited grants to train this essential medical workforce. States could use opioid settlement funds to create and maintain addiction medicine and psychiatry fellowship programs for physicians. Also, new scholarship programs for psychologists, nurse practitioners, and social workers are being phased in and need sustainable sources of funding.

Harm reduction is an essential component of any response to address the opioid overdose crisis and has long suffered from a lack of funding and support. Opioid settlement funds could be directed to fund bold efforts like overdose prevention sites, which have been successfully implemented in countries around the world and have a demonstrated ability to reduce overdose mortality.

States like New York and Rhode Island have taken the lead on pilot sites, and others could follow suit with funding to drive implementation and overcome political and community support barriers. Additionally, expanded drug control resources, including but not limited to fentanyl test strips and expanded drug control services, are a critical tool in reducing the harm caused by the unpredictable supply. in drugs. Needle service programs, safer smoking supplies, and continued access to naloxone are other harm reduction efforts that continue to require sustained funding.

Update policy and address structural inequalities

Addressing the glaring lack of affordable housing and needed congregate and non-congregate housing options for unhoused people is another crucial step in addressing the overdose crisis. Unstable housing can lead to chaotic substance use and increase the risk of overdose, and the lack of safe housing can make it nearly impossible for people to engage and stay connected to effective treatment.

The only solution to homelessness is housing. The intersecting challenges of the overdose and homelessness crisis have only been made more difficult by rising income inequality and housing prices, coupled with restrictive policies related to drug use and opposition “not in my backyard” to affordable housing. Funding should be invested in a range of low-threshold supportive housing models that integrate harm reduction and addictions services and meet the needs of people who use drugs.

Finally, to effectively address the overdose crisis, racial justice efforts must be focused. The ongoing harms of the War on Drugs are evident in historical and current approaches to drug use and addiction that have criminalized communities of color. In contrast, the current opioid-related overdose epidemic has been widely portrayed as an issue affecting white individuals in the media, and the resulting softer, sweeter public health narrative illuminates a patchwork approach to drug crises. past. It is fundamentally important to end the racist war on drugs. Opioid settlement money could spur needed policy change and innovation around alternatives to incarceration and true family support for families impacted by substance use, instead of the punitive welfare system model. existing childhood.

This funding could also be used to invest in strategies to address racial and ethnic disparities in overdose mortality. These could include investments to build a diverse substance abuse and harm reduction workforce through strategies such as salary incentives, start-up packages for new faculty, loan repayment programs and pipeline efforts to create early internships and addiction medicine student and trainee experiences.

Funding could also be used to support partnerships between drug treatment providers with trusted community partners like faith-based organizations and to develop community-centered models of care that bring treatment into non-traditional and accessible settings. , such as local organizations or mobile care. Additionally, funding could be directed to communities hardest hit by the war on drugs to invest in initiatives such as restoring derelict buildings and land, building parks and libraries, creating jobs and expanding educational opportunities.

There are many opportunities to direct the large sums of money from opioid settlement funds toward interventions that have been shown to save lives and improve health. The hope is that states will do just that.

Sarah Wakeman, MD, is Medical Director for Substance Use Disorders at Mass General Brigham and Associate Professor of Medicine at Harvard Medical School.



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