A Spending Guide for States: How Local Governments Can Put Opioid Dollars Toward Proven Solutions

Bill Bradley had been in recovery and in Alcoholics Anonymous for five years when a doctor prescribed him opioids for pain caused by kidney stones. But Bradley found himself in a familiar pattern: The prescription ran out; he tried to get more; he couldn’t get more; he eventually turned to heroin. For years, he pinballed between using and not using. At bottom, he was living in his car.

“I was completely and totally homeless, and nobody would help me anymore,” said Bradley.

There are millions of stories like Bradley’s, making the opioid epidemic both intensely personal and extensively systemic. As the country continues to reel from the epidemic’s devastation, legal proceedings are under way to hold opioid manufacturers, distributors, and retail pharmacy chains accountable for the nearly 400,000 lives lost and the nearly trillion-dollar cost to state Medicaid programs alone. Already, there are verdicts and settlements in various stages. Over the next several years, these lawsuits may result in judgments or settlements worth billions of dollars that will go to states, counties, and cities that will, in turn, have to make decisions on how to allocate that money.

Those spending decisions will have widespread consequences. So Arnold Ventures is bringing together experts and practitioners from across the country to create a practical spending guide of evidence-based strategies for those funds. It will be a roadmap for state and local leaders, laying out potential expenditures for interventions that have been proven to improve outcomes for people affected by the opioid crisis.

One such proven solution was what finally worked for Bradley, 59, of Fairmont, W.V. The second time he sought help at the VA, he was given buprenorphine, an FDA-approved medication used to treat opioid use disorder that decreases cravings and blocks the effects of other opioids, as part of his patient-centered care.

“My treatment has been tailored to the way I think and the way I am. It’s been successful,” Bradley said. He has now been in medication-assisted treatment for 10 years and is an active Lutheran Franciscan.

With more than 130 Americans dying each day from opioid overdose and only a fraction of people with opioid use disorder getting the treatment they need, the opioid litigation dollars present promise — and potential pitfalls.

“This is an extraordinary opportunity to address the continuing harms of the opioid epidemic,” said Sarah Twardock, Public Health Manager at Arnold Ventures. ​“If those dollars end up going to programs that don’t work, then not only is that a huge missed opportunity to help people, it could also exacerbate those harms.” The aim is to give entities a framework to avoid what happened after the historic 1998 tobacco settlement, when hundreds of millions of dollars went to states that ultimately spent the money on activities unrelated to smoking cessation or prevention.

Proven Interventions

Richard Frank, Professor of Health Economics at Harvard, is leading the project and guiding the collaboration of experts within key areas, including prevention, primary care treatment, specialty addiction treatment, health care payment, the criminal justice system, and harm reduction. The aim is to consolidate the evidence within their fields in order to offer policymakers packages of proven interventions.

FDA-approved medicines such as buprenorphine, methadone, and naltrexone, often provided alongside counseling and social supports, have been proven to be the most effective form of treatment for opioid use disorder. Yet, there are eight state Medicaid programs that don’t reimburse health care providers for methadone and more that don’t reimburse for implanted or extended-release injectable buprenorphine. Nearly four in 10 non-elderly adults with opioid use disorder are covered by Medicaid, making those medications all the more difficult for people to access.

The settlement spending guide will not only put forward evidence-based strategies — like integrating medication-assisted treatment into primary care and specialty addiction treatment — it will also detail the infrastructure and context required for them to be successful. That includes rigorous cost estimates, analysis of existing funding streams, policy changes to be leveraged, and other cultural and political considerations. 

Frank has convened the team to agree on methodologies for evaluating research and measuring costs uniformly and consistently. From there, the experts will survey the existing literature, consolidate the evidence, and organize the information. The guide will be published in April 2020 and distributed to state and local government officials and policymakers.

“We are trying to bring the best evidence to people who have to deal with really practical problems,” said Frank. ​“We want to do so in a way that will help them in practice as opposed to tell them what they’re not doing right.” 

“We want policymakers to be able to say, ​‘These are the problems I’m trying to address in my community, and this is what’s politically feasible,’ and the guide will be a menu of options with associated costs or ​‘prices’ and information on implementation,” said Twardock.

To this end, the project team is convening an advisory board made up of litigators, state policy officials, and other practitioners who will oversee the project to ensure that the guide stays focused on pragmatic solutions that are truly useful within a variety of different settings.

“There are going to be lots of places that get funding that aren’t going to have the infrastructure to do what an addiction textbook might tell you, but they can still make things better,” said Frank. 

For example, in areas with an available workforce of psychiatrists, those specialty care providers can be trained and certified in addiction treatment. In other parts of the country where there is a shortage, primary care providers are much more involved in addiction treatment.

“We are all optimistic about the potential for real impact,” said Thomas McLellan, founder of the Treatment Research Institute and a consultant on the guide. ​“I think we are positioned perfectly to give impartial, scientific, practical advice that should inform the way these dollars are used.”

A Cautionary Tale

In 1998, the nation’s four largest tobacco companies reached a historic agreement with 46 states and territories: Over the next 25 years, they would pay $246 billion in damages to compensate for the cost of treating illnesses caused by tobacco products, and to fund tobacco control measures. But between 2000 and 2005, less than 4 percent of that money was spent for tobacco use prevention, cessation, or counter marketing. For those working to halt the current opioid crisis, the tobacco settlement is a cautionary tale.

“Our nation’s system for addressing opioid addiction remains woefully inadequate, from prevention and education through to treatment and then helping people maintain their sobriety and their recovery,” said Paul Samuels, Director and President of the Legal Action Center, a public interest law firm that specializes in legal and policy issues involving alcohol and substance use disorders. ​“As we look at the opioid litigation, the settlement funds should be used to strengthen that whole system and not go to fill budget gaps.”

The settlement with the tobacco industry didn’t dictate how states had to spend the money, or that it had to be spent on smoking prevention or health care at all. From 2000 – 2005, Missouri allocated more than one-third of its settlement payments to budget shortfalls. North Dakota spent $6.1 million of its payments on water projects. Colorado diverted funds to a literacy program.

“All of the key stakeholders are aligned in wanting to use the funds to address the opioid epidemic — it’s a huge problem for their communities,” Twardock said. ​“But there are all kinds of budget issues that come up, and you never know what might happen in budget-constrained environments.”

Although the guide will be a resource on the most effective strategies for abating the opioid epidemic, it alone can’t ensure that policymakers will prioritize addressing it. For that, watchdog and lobbying efforts from advocacy groups will be essential.

“It is a fact to say that we can prevent substance misuse,” said McLellan. ​“We can intervene early on in cases of misuse and prevent it from becoming addiction, and we can treat even serious cases of addiction effectively to full recovery. It is our hope that (the settlements) will be the impetus to institute a system of prevention, intervention, education, and treatment that can give the taxpayer the results they really need.”

Results like Ephraim Solomon, 23, saw after ongoing primary-care-based treatment at the Boston Medical Center — which included medication to support recovery given alongside vaccines, annual check-ups, and therapy.

“It took a few months to find the right dosage, but once we did, it obliterated my craving,” Solomon said. ​“As someone who had been defined by my cravings for so many years, I can’t overstate the difference it made … I wake up in the morning, and I go to my job, and I don’t think about substances 98 to 99 percent of the time, and that would have felt impossible before.” Solomon, who lives in Boston, is working as a community organizer and considering going back to school to study medicine. 

“Recovery is really possible when you give people the right supports,” Solomon said.