The continued evolution of the substance use crisis — including the increasing role of fentanyl, stimulants, and other substances in overdose deaths — poses heightened political and policy challenges for states. Despite increased attention and investments related to the opioid crisis, and evidence of recent declines nationally, overdose deaths remain a leading cause of mortality across the U.S.
NASHP’s Annual Conference session “Recovery in Action: Addressing the Changing Landscape of Substance Use” examined how leaders in the substance use space are adapting prevention, harm reduction, and treatment services in the face of rapid change. Speakers from Washington, Oregon, and West Virginia shared their insights on how states are adjusting their priorities to respond to the new demands of the substance use paradigm. The wide-ranging conversation, spanning from unique strategies for increasing treatment capacity to the implications of decriminalization efforts, such as Oregon’s Measure 110, highlighted common priorities across the following subject areas.
Driving a Focus on Youth Populations and Preventing Substance Use Harms
Though substance use remains historically low for adolescents, the potency of the drug supply has caused overdose rates to increase, prompting a greater need for targeted education and resources catered for youth and young adult populations. Identifying partners at the community level, particularly schools, provides an opportunity to concurrently address both substance use and mental health needs, which are key crises states are juggling to address within youth populations.
In addition to increasing these direct touchpoints, states are employing both federal and state-created education campaigns alerting people of fentanyl-related risk factors. Investing in youth prevention was identified by Johns Hopkins as a key priority for opioid settlement funding, encouraging states to direct substance use funding sources to invest in these strategies to build infrastructure that addresses risk factors for substance use. For example:
- Oregon directs a significant portion of opioid settlement funding to primary prevention-related initiatives. Recently, this included $13.7 million to local organizations and counties to strengthen the substance use prevention workforce.
- West Virginia centers its prevention strategy in trauma-informed care to address some of the root causes of substance use. The West Virginia Bureau for Behavioral Health leads a statewide prevention network that assists schools and community organizations, among other partners, in funding prevention strategies at the local level. Specific to the opioid epidemic, the West Virginia Department of Education funds ReClaimWV, an initiative providing education agencies, schools, and community members with trauma, mental health, and substance use-specific resources to help address needs of school-aged children, instructors, and families.
Prioritizing Medications for Opioid Use Disorder (MOUD)
State leaders shared their experiences that the increased potency of fentanyl can hasten the progression of substance use disorders, leading to increased overdose risks and requiring states to increase harm reduction services and other intervention points that can link to treatment services. MOUD are recognized as the gold standard of treatment for opioid use disorder. However, access to Food and Drug Administration-approved medications for treating opioid use disorder (buprenorphine, methadone, and naltrexone) has historically proven difficult. Medication-first approaches allow for people who use substances to first be stabilized, which can then promote further engagement in care and support services. States are working to build a continuum of substance use care that caters to needs and support individuals through various states of recovery so that individuals can access care whenever they are ready. A few examples:
- 1115 waivers provide states a unique opportunity to cover a wider range of treatment services through Medicaid for individuals facing disproportionate effects from the opioid crisis, such as justice-involved populations. States use these waivers to cover medical services, including delivery of MOUD, for individuals 90 days prior to their release from incarceration. Oregon and Washington have approved 1115 waivers, and West Virginia has a waiver pending approval.
- Washington piloted contingency management, an evidence-based stimulant use disorder intervention that provides motivational incentives for meeting treatment goals, and now funds the program through a Medicaid 1115 waiver.
- West Virginia’s current 1115 waiver largely increased the state’s residential treatment capacity and treatment continuum of care, reflected in the state’s ranking as fourth best in the nation at connecting individuals to substance use care.
Maximizing Low-Barrier Access to Care
Difficulty with navigating the substance use care continuum, or lack of availability of low-barrier resources, often prevent individuals from engaging with treatment or harm reduction services. A survey completed at syringe services programs (SSPs) across Washington state found that the majority of participants were interested in reducing or stopping their substance use but face barriers in doing so. Participants were also interested in seeing either health care or mental health providers in addition to accessing services offered by the SSP. Assisting individuals in navigating the care continuum, in addition to other social services such as housing supports, emerged as a pressing priority for states as they support individuals through challenges posed by the rapidly changing drug supply. Programs include:
- A large majority of states have invested opioid settlement funding into harm reduction methods such as naloxone, fentanyl test strips, and syringe service programs, exploring unique models of distribution such as naloxone vending machines and partnering with local organizations to increase reach in the community.
- Oregon’s harm reduction clearinghouse works to provide no-cost harm reduction supplies such as naloxone, wound care kits, and infection prevention supplies to community based organizations, law enforcement, service providers, and other partners across the state. The clearinghouse received a state opioid settlement allocation of $13.7 million, which will help the organization continue resource distribution efforts and expand access to additional partners.
- Washington introduced legislation that calls for a pilot of health engagement hubs, which will offer medical, harm reduction, and social services all in one location. The program, which will be tested across one rural and one urban location, seeks to explore how to best decrease barriers to service offerings and increase utilization.
Moving Forward
Recent provisional data from the Centers for Disease Control and Prevention shows a promising downward trend in overdose deaths, though these levels still remain starkly greater than pre-pandemic rates. Trends and emerging threats related to substance use have and will continue to evolve. However, the core needs and issues to tackle remain the same, including supporting a “no wrong door” approach to connecting individuals to care, building and strengthening the continuum of treatment services, and holistically addressing both social service and human needs in conjunction with substance use services. States can continue to use opioid settlement dollars over the next several years, a unique opportunity to fund these areas and build internal capacity and infrastructure to sustain them.
