TREATMENT INITIATIVES

How states are using StateTargeted Response (STR) andState Opioid Response (SOR)funds to make a difference

In April of 2019, the National Association of State Alcoholand Drug Abuse Directors (NASADAD) sent an inquiry to theSingle State Agencies for alcohol and other drug servicesrequesting information on how they were using the StateTargeted Response (STR) and State Opioid Response (SOR)grants to address the opioid crisis in their states. The resultsof the inquiry were summarized into state-specific profileshighlighting prevention, treatment, overdose reversal, andrecovery support efforts. State profiles generally covered areporting timeframe between May 2017 - April 2019. A totalof 50 state responses were received. Washington D.C. andU.S. Territories did not respond to the inquiry. Below is abrief analysis of the most common ways states have usedSTR/SOR funds to restructure and improve access totreatment services, as well as select examples of innovativetreatment initiatives.

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March 2020

STATES’ MOST COMMONTREATMENT INITIATIVES WITHSTR/SOR FUNDS

Medication-assistedTreatment (MAT) ServiceExpansion

88% (44)

60% (27)

Telehealth

Pregnant & PostpartumTreatment Services 48% (24)

Persons with OUD

Justice-involved populationswith OUD

Pregnant and parenting womenwith OUD

Service Delivery Modelsacross the Spectrum ofCare

Services Provided/Developed

Populations and Partners Served

Correctional & ReentryServices

Professional & PeerWorkforce Development

Healthcare professionals,addiction and mentalhealth clinicians, recoverycoaches and peer supportspecialists

Patients with OUD

64% (32)

50% (25)

66% (33)Persons with OUD

Percentage of StateRespondents (n=50)

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March 2020National Association of State Alcohol and Drug Abuse Directors

TREATMENT INITIATIVES

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Of the 50 state responses, the majority oftreatment initiatives funded with STR/SORincreased capacity and access to MAT forindividuals with opioid use disorders (OUD).This expansion included establishing orenhancing Opioid Treatment Programs (OTPs)and office-based opioid treatment programs(OBOTs), providing services in federallyqualified health centers (FQHCs), and openingmedication units within substance usedisorder and mental health agencies. Toincrease office-based MAT, funds were usedto increase the number of Drug AddictionTreatment Act (DATA) waiver trainings offeredthroughout the country. Additionally,treatment service systems have expandedaccess to at least two of the three Food andDrug Administration-approved medications(methadone, buprenorphine, naltrexone) andhave reduced or eliminated treatment costsfor uninsured and underinsured patients. Other state efforts included theimplementation of service delivery modelsacross the spectrum of care, such as hospital-based models that incorporate screening, briefintervention and referral to treatment (SBIRT)to identify individuals with OUD; provide MATconsultation or initiation; and offer peersupport and direct linkage to community-based substance use disorders (SUD)treatment. Many delivery models identifiedthroughout states largely followed the huband spoke approach to improve treatmentaccessibility by extending contracts oragreements with SUD treatment programs,primary care, and other human servicesprograms in more rural and underserved stateregions. Primarily, opioid treatment hubs orOTPs/clinics serve a defined geographicalarea that support spokes. Spokes facilities(e.g., OBOTs, FQHCs), provide ongoing SUDtreatment, primary healthcare services, andwrap around recovery services. Hub andspoke systems and other service delivery

models have utilized funding to provide a fullarray of comprehensive psychosocial services,including but not limited to: toxicologyscreening, rapid assessment and evaluation,counseling, case management, transportationassistance, supportive housing, vocationalassistance, and other recovery supportservices. State grantees have allocated funds toimprove reentry services for opiate-dependent criminal justice populationsworking with jails, prisons, and drug courts.Funds have largely provided coverage forMAT in criminal justice settings and enhancedin-house services and treatment transition.Services consist of screening, assessment,MAT maintenance and induction, treatmentand recovery planning, peer support services,and post-release linkage to community-basedtreatment providers. STR/SOR funds have supported workforcedevelopment to provide on-site technicalassistance and trainings on OUD (e.g., OUDcare for specialty populations, DATA waivertrainings, integration of SBIRT), as well as tomentor a number of multi-disciplinaryprofessionals such as primary care physicians,psychiatrists, physician assistants, andsubstance use and mental health clinicians.Further, other community MAT educationinitiatives span across first responder, lawenforcement, criminal justice, and academicsettings. Funding has also allowed states to expandaccess to MAT by utilizing telehealthtechnology. State telehealth efforts includeimplementing the Project ECHO (Extensionsfor Community Healthcare Outcomes) modelacross several university medical centersand community providers in SUD care. Thiscollaborative model of medical education andcare management has enhanced the delivery

March 2020National Association of State Alcohol and Drug Abuse Directors

SELECTED EXAMPLESOF STATE TREATMENTINITIATIVES

of evidence-based OUD care by linkingmulti-disciplinary team of specialists withhealthcare professionals in the substanceuse disorders field. Such joint efforts havegiven clinicians in rural and underservedcommunities the tools to provide specialtycare to OUD and chronic pain patients in-house. Other telehealth efforts haveinvolved providing ongoing clinicalcheckups and consultations via technology. States have also increased their capacity toserve pregnant and postpartum womenwith OUD. To reduce the incidence ofneonatal abstinence syndrome (NAS),states have integrated obstetric andsubstance use treatment. Through direct

With SOR funding, the WashingtonState Division of Behavioral Health andRecovery (DBHR) has expandedaccessibility to OUD treatment byestablishing delivery systems throughOpioid Treatment Networks (OTNs) with17 contracted organizations (eightemergency departments, five jails, twosyringe support programs, one shelter,and one fire department). Funds havesupported the OTN infrastructure,staffing, coverage of MAT medications,and linkage procedures to community-based providers. In addition, DBHR usedSTR and SOR funding to develop sixhub and spoke models statewide toincrease access to MAT, SUD treatmentand/or primary healthcare services,wrap around services, and referralsystems. As of April 2019, 1,752individuals have received MAT throughthe OTNs, and an additional 5,943individuals have received MAT throughthe Hub & Spokes.

Service Delivery Models:

MAT Expansion:In North Carolina, the Department ofHealth and Human Services (DHHS) hasutilized over two-thirds of STR and SORfunding to expand access to MAT touninsured individuals within the state. Priorto STR funding, North Carolina operated 53OTPs—the majority of which were privatepay programs. As of April 2019, there are77 OTPs in operation statewide providingall three FDA-approved medications whichmore than half of (40) have contracts withmanaged care organizations (MCOs) foruninsured individuals. This has led to20,000 individuals obtaining services daily.Additionally, several MCOs have extendedcontracts to OBOTs to better serve ruralcommunities.

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March 2020National Association of State Alcohol and Drug Abuse Directors

provider-to-provider collaboration andcase management, substance use,mental health, and obstetric care arebeing coordinated, as is peripartum andpostpartum pain management. Manystates have provided recovery and wrap-around support services for womenduring the postpartum period, as well asdevelopmental screenings for infantswith neonatal exposure to opioids.Additionally, states have implementedcommunity outreach efforts to makeOB/GYNs aware of these specialtyservices for pregnant and postpartumpatients.

The Maryland Department of Health,Behavioral Health Administration(MDH/BHA) has used SOR funds topartner with the University of MarylandSchool of Medicine to implement theMaryland Addiction Consultation Service(MACS). Services include free technicalassistance to prescribers with clinicalquestions, referral information,professional resources, and trainingopportunities related to SUDs and chronicpain management. By providing acomprehensive curriculum on keyaspects of prescribing (e.g., overview ofOUD and MAT, medication induction,specifics of dosing, MAT and co-occurring disorders, MAT with specialpopulations, etc.), and psychosocialsupports, Maryland providers are betterable to start or expand MAT for OUD. Asof April 2019, 366 prescribers have signedup for MACS, 10,476 prescribers havereceived overdose response training andnaloxone, and 192 calls have beenreceived through the referral line.

Professional &Peer WorkforceDevelopment:

Correctional & ReentryServices:The New York Office of Alcoholism andSubstance Abuse Services (OASAS) hasused SOR funds to support MAT forindividuals reentering communities from20 local correctional facilities and threestate facilities. Through a collaborationbetween OASAS and the New YorkState Department of Correction andCommunity Supervision (NYSDOCCS),DOCCS facilities have partnered withOASAS certified SUD treatmentproviders to facilitate the provision ofSUD treatment. Eligible returningindividuals receive SUD counseling, theoption to begin MAT during detainment,education and resources on MAT, and aperson-centered discharge plan forlinkage to community-based treatment.As of April 2019, 1,958 individuals in localcorrectional facilities have received SUDcounseling and educational resourceson MAT. Of these, more than half (1,356)have received a person-centered planfor linkage to community-basedtreatment upon correctional releasewith 49% (667) admitted to treatmentpost-release. An additional 631individuals in state correctional facilitiesreceived SUD counseling andeducational resources on MAT and atotal of 145 of these individuals receiveda naltrexone injection as well as aperson-centered care plan.

SELECTED EXAMPLESOF STATE TREATMENTINITIATIVES

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National Association of State Alcohol and Drug Abuse Directors March 2020

The Illinois Department of HumanServices Division of Substance UsePrevention and Recovery (IDHS/SUPR)has used SOR funds to pilot a new serviceenhancement program for pregnant andpostpartum women with OUD (PPW-OUD). With an emphasis on family-basedservices to PPW with a diagnosis of OUD,this innovative program trains andcertifies staff on various evidence-basedpractices such as: CommunityReinforcement and Family Training(CRAFT), Motivational Interviewing,Seeking Safety, Real Life Parenting, andIndividual Placement and Support (IPS).Additional service enhancement effortsprovide each family with a Doula CertifiedPeer Recovery Specialist—an individual inactive recovery who has obtained dualcertification as a birth and a postpartumdoula to aid recovering mothers throughall phases of obstetrics and addictionrecovery. The Doula Certified PeerRecovery Specialist provides up to 12months of recovery support services tomothers post-birth. Thus far, PPW-OUDpilot programs have been initiated at allfive provider sites, selected through acompetitive bidding process. ThroughApril 2019, 16 women have received theseenhanced services.

As a collaborative effort, the CaliforniaDepartment of Health Care Services(DHCS) has used SOR funds to partner withAmerican Indian and Alaska Nativecommunity stakeholders to implement aTribal MAT Project. Under this project,which addresses the culturally uniqueneeds of AI/AN populations, TeleWellBehavioral Medicine has used telehealthtechnology to provide psychiatric andaddiction medicine services at tribal andurban Indian health programs. This initiativefacilitates the provision of MAT to AI/ANpatients with OUD and includes clinicalassessment, drug screening, induction,prescribing, evaluation and management,psychosocial, and co-occurring psychiatrictreatment services. Additionally, TeleWelloffers monthly office hours fortelemedicine support and clinicalconsultation regarding MAT care delivery.Through March 2019, tele-MAT serviceshave been implemented in 15 new IndianHealth Providers (IHP).

Pregnant & PostpartumTreatment Services: Telehealth:

SELECTED EXAMPLESOF STATE TREATMENTINITIATIVES

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National Association of State Alcohol and Drug Abuse Directors March 2020