O'Neill Institute  |  June 6, 2023

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STATES AND LOCAL GOVERNMENTS ARE GRAPPLING with escalating rates of overdose and ongoing challenges with addiction, exacerbated by the COVID-19 pandemic and an unpredictable and volatile drug supply. The multiple, disconnected systems that address substance use disorder (SUD) create a longstanding challenge to the state and local response to addiction. These systems include not only prevention, treatment, harm reduction and recovery, but also mental health, healthcare, hospitals, emergency medical services, courts, corrections, child welfare, schools, shelters, housing supports, vocational training, economic development, public assistance, and more. Individuals with SUD must often engage with these multiple, disjointed systems through various government agencies in order to access needed services and supports.

Money, Ego and Turf (collectively “MET”) perpetuate structural barriers to addressing SUD, including an onerous regulatory structure and disjointed funding, impede access to quality treatment and non-clinical community-based supports, and lead to challenges with linkage, engagement, and achieving long-term recovery. Societal barriers, including stigma, discrimination, and longstanding racial inequality, also prevent people from accessing needed care, services, and supports.

Further, a lack of coordinated infrastructure that helps to facilitate shared goals, evidence-based practices, and data consistency across these systems creates silos and inefficiencies that prevent a comprehensive strategy necessary to address addiction in the United States. For providers and government program administrators, these disconnected systems create disorganization, fragmentation, and duplication within the larger landscape of care. For many individuals and families, the current structure is, at best, ineffective, and at worst, contributes to the skyrocketing number of drug-related deaths. This system architecture has also led to initiative fatigue, duplicative and onerous reporting and regulatory structures, and a lack of trust among providers.

A recent infusion of significant federal dollars, opioid litigation proceeds, and other funding sources, such as philanthropy and cannabis tax revenue, as well as innovation and research, has created an opportunity for governments to re-imagine traditional approaches to SUD. With the opportunity to direct local, state, and federal funds, governments can implement a new, cohesive system to promote access to evidence-based, individualized, low-barrier care.

This brief proposes guiding principles and concrete recommendations for governments to leverage this momentum and transform government budgets to incentivize investment in a coordinated, targeted, and outcomes-driven approach to SUD. The principles presented were developed through research on best and promising practices in the SUD space and other health and social justice areas, as well as focus group and individual interviews across the spectrum of government, public health, law enforcement and criminal justice, health and behavioral health systems. These interviews and focus groups included persons with lived experience with substance use disorders, as well as representatives from innovative programs that have used incentives and funding structures to drive positive outcomes.

This brief is not exhaustive and is intended to be the beginning of a roadmap to re-imagine how we address addiction in this country. It builds on a body of work that includes recommendations for federal reforms to restructure how SUD is financed and measured in the United States.

Read the report here.

The authors specifically acknowledge Regina (Regi) Huerter for use of the term “Money, Ego, Turf.”

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