Perspectives and Priorities on the Opioid Crisis by State Alcohol and Drug Agencies Robert Morrison, Executive Director/Director of Legislative Affairs Shalini Wickramatilake-Templeman, Manager, Federal Affairs National Association of State Alcohol and Drug Abuse Directors (NASADAD) June 8, 2018

Topics to Cover Overview of NASADAD Role of State Alcohol and Drug Agencies Substance Abuse Prevention and Treatment (SAPT) Block Grant Selected provisions from previous milestones that include CARA and Cures Current considerations on pending legislation

Overview of NASADAD Mission: To promote effective and efficient State substance use disorder prevention, treatment, and recovery systems. Office in Washington, D.C. with Policy Department and Research Department. Governed by Board of Directors Cassandra Price (GA), President Arlene Gonzalez-Sanchez (NY), First Vice President Mark Stringer (MO), Chair, Public Policy Committee

Role of State Alcohol & Drug Agencies Placement in State government – varies by State May be in Departments of Health, Human Services, Social Services, etc. Develop annual State plans to provide prevention, treatment, and recovery services Ensure service effectiveness, quality, improvement and coordination Collaborate with other State agencies Child welfare; criminal justice; drug courts; medical system; transportation; job training/placement, etc. Represent key link to substance use disorder provider community Convene stakeholder meetings Manage the Federal Substance Abuse Prevention and Treatment (SAPT) Block Grant

$1.8 billion formula grant administered by SAMHSA Program Priority: Substance Abuse Prevention and Treatment (SAPT) Block Grant $1.8 billion formula grant administered by SAMHSA Supports treatment for 1.5 million Americans per year 20% set-aside for primary prevention Flexible program that allows each State to direct resources for prevention, treatment and recovery to meet their own needs Infrastructure for efficient and effective management and allocation of funds Without any significant funding increases over the past decade, the SAPT Block Grant has lost about 30% of its purchasing power

Comprehensive Addiction and Recovery Act 2016: Major Milestones 21st Century Cures Act Comprehensive Addiction and Recovery Act

21st Century Cures: State Targeted Response (STR) to the Opioid Crisis Grants Cures Act created $1 billion account to address opioids Allocates $500 million in each FY 2017 and 2018 as approved by the Appropriators SAMHSA released application in December 2016 State alcohol and drug agency directors identified as eligible applicants 80 percent required to go to treatment/recovery Remaining 20 percent allowed for prevention, other initiatives

What Are States Doing with State Targeted Response to the opioid Crisis (STR) Funding? All States are focusing on expanding availability of treatment. Greatest number of treatment initiatives are working to expand medication-assisted treatment (MAT) – mostly through expansion of office-based opioid treatment (OBOT). Most States proposed to improve effectiveness of OBOT care through ensuring linkage with counseling; care management assistance; and recovery support specialists.

What Are States Doing with State Targeted Response to the opioid Crisis (STR) Funding? Second most common type of treatment-related initiative is developing/expanding “hub & spoke” model. Nearly every State has a reentry/treatment initiative for CJ-involved populations with opioid use disorders (OUD). All States proposed at least one prevention initiative. Nearly all States proposed at least one overdose/naloxone initiative that provides naloxone, supports training about opioid misuse, safe/appropriate use of opioid medications, and use of naloxone to reverse effects of overdose. Most common recovery-related initiative is peer recovery supports.

What Are States Doing with State Targeted Response to the opioid Crisis (STR) Funding? Half of States proposed initiatives focused on opioid prescribers (e.g. cancer, pain and primary care docs; PAs) with training on SUDs: alternatives to opioid pain meds, safe and effective prescribing practices, and effective treatment for OUD. Half of States proposed outreach efforts to the persons with opioid use disorders, provide expedited access to treatment (often MAT), and/or make strong efforts to engage them in treatment.

Year Two of State Targeted Response to the Opioid Crisis (STR) Grants Final FY 2018 funding level: $500 million for year 2 of the State Targeted Response (STR) to the Opioid Crisis (level funding). Omnibus report language: “The agreement notes concern that SAMHSA has restricted State's flexibility for addressing the opioid crisis by limiting the amount of funding that can be used for opioid prevention activities. The agreement recommends States be given flexibility within the existing grant program authorized in section 1003(b)(3) of the 21st Century Cures Act (P.L. 114-255) to direct resources in accordance with local needs. The agreement requests a report to the Committees on Appropriations of the House of Representatives and the Senate on such plans and evaluation results available on this program, one year after enactment of this Act.”

In addition to Year Two of State Targeted Response to the Opioid Crisis (STR) Grants – Congress Added… $1 billion in new funding for “grants to States to address the opioid crisis.” Omnibus report language: “State Opioid Response Grants”- “The agreement provides $1,000,000,000 in new funding for grants to States to address the opioid crisis. This funding is in addition to the $500,000,000 provided in the 21st Century Cures Act… In addition, the agreement provides a 15 percent set-aside for States with the highest age-adjusted mortality rate related to opioid use disorders. The Assistant Secretary is encouraged to apply a weighted formula within the set-aside based on state ordinal ranking. The agreement urges the Assistant Secretary to ensure the formula avoids a significant cliff between States with similar mortality rates.”

A number Of Other Provisions in 21st Century Cures Act (including but not limited to…) Creation of Assistant Secretary of Mental Health and Substance Use (Sec 6001) Creation of Chief Medical Officer Position (Sec 6003) Reauthorization of SAMHSA’s Center for Substance Abuse Prevention (CSAP) (Sec 6002, 6007 others) Reauthorization of SAMHSA’s Center for Substance Abuse Treatment (CSAT) (Sec 6002, 6007 others) Authorization of Center for Behavioral Health Statistics and Quality (CBHSQ) (Sec 6004) Creation of new SAMHSA Policy Lab for MH and SUD (Sec 7001) Six (6) Provisions related to SUD and MH workforce (Secs 9021, 9022, 9023 and 9024) Four (4) provisions related to implementation of Mental Health Parity and Addiction Equity Act (MHPAEA) Reauthorization of SAPT Block Grant (Secs 8002 – 8004) For a Section by Section of Cures, please see http://nasadad.org/wp-content/uploads/2017/02/21st-Century- Cures-Section-by-Section.pdf

A number Of Provisions in CARA (including but not limited to…) Creation of Task Force on Pain Management (Sec. 101) Authorization of Awareness Campaigns (Sec 102) Community-Based Coalition Enhancement Grants (Sec 103) Evidence-based Opioid & Heroin Treatment Demonstration Grants (Sec 301) Reauthorization of SAMHSA’s Residential Treatment Program for Pregnant and Postpartum Women (Family Treatment) and Pilot for State Alcohol and Drug Agencies for Innovations in Family Treatment (Sec 501) Comprehensive Opioid Abuse Grant Program (DOJ) (Sec 201) First Responder Training (Sec 202) Seventeen (17) provisions impacting Dept. of Veterans Affairs For a Section by Section of CARA, please see http://nasadad.org/wp-content/uploads/2016/07/CARA- Section-by-Section-July-2016-1.pdf

Authorization set in CARA: $19 million. Spotlight on CARA’s Sec 501: Reauthorization of SAMHSA’s Residential Treatment Program for Pregnant and Postpartum Women (Family Treatment) and Pilot for State Alcohol/Drug Agencies for Innovations in Family Treatment SAMHSA/CSAT program supports grants to providers to support comprehensive residential substance use disorder treatment services for pregnant women/women with young children (family treatment). Historical funding levels at approximately $15 million Allowed SAMHSA to earmark 25 percent of the program above to creation of a pilot program for grants to State alcohol and drug agencies to support innovations in family centered services – with a focus on non-residential services. Authorization set in CARA: $19 million. FY 2017 Funding: $19 million with 3 States receiving pilot (Mass, N.Y. and VA) FY 2018 funding: $29 million Authorization set in S. 2680: $29 million

Specific Initiatives of Interest Legislative Activity NASADAD Principles Specific Initiatives of Interest Final Considerations

NASADAD Principles for Legislation Ensure provisions work through and coordinate with State alcohol and drug agencies Ensure consistent, predictable and sustained federal resources to avoid creating a fiscal cliff by… Extend the duration of federal grants beyond typical one or two year cycle Allow States more time to expend dollars by STR and other large investments Continue to address the opioid crisis but also elevate efforts to address all substance use disorders Maintain investments in SAMHSA as the lead agency within HHS focused on substance use disorders service delivery

Avoiding the financing Cliff: What next after STR? Senate (S. 2680, Sec 101): Authorizes $500 million for each of FY 2019-2021. Authorizes a 5% set-aside for Indian tribes 15% set-aside for States with the highest age-adjusted opioid-related mortality rate based on the CDC’s age-adjusted overdose mortality rates. House E and C: No equivalent Vehicle: Presumed to be FY 2019 Appropriations

Coordination and Continuation of Care for Drug Overdose Patients Utilizing Recovery Coaches Senate (S. 2680, Sec 402): Would authorize the Sec. of HHS to award 5-year grants to eligible entities to support implementation of voluntary programs for the care and treatment of individuals after an opioid overdose. Eligible entities are (A) a State alcohol or drug agency; or (B) an entity that offers treatment or other services for individuals in response to a drug overdose, in consultation with a State alcohol and drug agency. House H.R. 5176, Preventing Overdoses While in Emergency Rooms (Power) Act: Similar but current language defines eligible entities as hospitals or other health facilities.

Comprehensive Opioid Recovery Centers: House (H.R. 5327) and Senate (S. 2680, Sec 401) Would authorize Secretary of HHS, acting through the Assistant Sec. for MH & SU, to establish a grant program to develop at least 10 “Comprehensive Opioid Recovery Centers” (CORCs). $10 million authorization CORCs would—either directly, through referral, or through contractual arrangements—have to provide: Intake, evaluation, and assessments Full continuum of treatment services, including: all three FDA-approved MAT drugs, plus medically supervised withdrawal management, including patient evaluation, stabilization, and readiness for and entry into treatment Residential rehabilitation Recovery housing Community-based and peer recovery support services Job training; job placement assistance On-site pharmacy and toxicology services Secure, confidential, and interoperable electronic health information system Periodic patient assessments to ensure sustained and clinically significant recovery, as defined by the Assistant Secretary for MH/SU … and more

Examples of Other Provisions Some differences/Similar Idea Loan Repayment for Substance Use Disorder Treatment Providers: House (H.R. 5102) and Senate (S. 2680, Sec 415) Promulgation of National Recovery Housing Standards/Best Practices: House (H.R. 4862) and Senate (S. 2680, Sec 409)

Final Consideration In an effort to help all States with all substance use disorder challenges, begin to increase SAPT Block Grant Especially important for primary prevention – SAPT Block Grant represents 70 percent of State alcohol and drug agencies prevention budgets

Contact: rmorrison@NASADAD.org Questions? Contact: rmorrison@NASADAD.org