Editor’s Note: The opioid epidemic represents a clear and present danger to the nation’s public health, with drug overdoses now claiming more lives each year than car crashes and gun violence combined. With no national strategy or significant funding for confronting the crisis, local leaders are stepping up to implement programs that address the prevalence and impact of untreated substance use disorders (SUDs) and serious mental illness (SMI). In a new post for the Health Affairs Blog, summarized below, Manatt Health shares insights into the local initiatives that cities and counties are establishing to alleviate the human and economic devastation of the opioid epidemic in their communities. To read the full post, click here.

The post highlights findings from a new Manatt Health report, supported by the Robert Wood Johnson Foundation, “Communities in Crisis: Local Responses to Behavioral Health Challenges.” Drawing from extensive research and interviews with local program leaders, the report provides detailed profiles of 13 local initiatives, as well as a comprehensive taxonomy categorizing program elements and features. Click here to download the report and taxonomy.

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A staggering 20 million adults in the United States have an SUD, yet 88% do not receive treatment for their conditions. Local communities are experiencing the human and economic costs of the opioid epidemic firsthand, especially rural communities, where the opioid-related death rate is 45% higher than in metro areas. Untreated SUDs contribute to rising rates of incarceration, homelessness and use of emergency services.

Despite heightened federal attention to the opioid crisis—most recently, President Trump’s declaration of a public health emergency to address the drug epidemic and new federal Medicaid guidance—we still lack both a clear national strategy and adequate dedicated funding. Unable to wait for federal action, cities and counties are designing, funding and launching innovative local programs—almost all built and operated on a shoestring budget. The following is a sample of innovative initiatives that communities are supporting to confront the opioid epidemic and SMI:

  • More than 2,600 communities have created police crisis intervention teams to train officers in tactics to safely de-escalate individuals experiencing behavioral health crises;
  • Cities and counties have developed “diversion programs” with first responders, who divert individuals in crisis away from hospital emergency departments (EDs), jails and courts toward more appropriate therapeutic settings where they can receive treatment, recovery and social support services;
  • Localities are establishing jail-based treatment programs, providing medication-assisted therapies and care transition programs to support coordinated, ongoing care upon re-entry into the community; and
  • Local agencies are adopting housing first and harm reduction programs that incorporate sustainable housing and safer or managed substance use as a means to support long-term recovery.

There are literally thousands of local programs that have been launched to address the opioid crisis. The most successful efforts share a set of common factors that together create client-centric systems of care aligning law enforcement, criminal justice, public health and community resources to coordinate, improve access to and deliver a broad spectrum of treatment, recovery, health and social services.

Clear and Consistent Themes

Our research into local initiatives to combat the opioid crisis reveals some clear and consistent themes across the country:

  • It takes a village—and village leadership. Public agencies need to collaborate and align with community-based health and social service providers. Strong leadership from mayors’ offices, county sheriffs, judges and others has been used to galvanize community and public support.
  • Access to health and social services benefits is critical. There is a profound need to ensure that people afflicted with behavioral health disorders gain access to a broad set of treatment and social support services. Local programs have incorporated supportive mechanisms to help clients obtain access to Social Security benefits, healthcare coverage (most notably Medicaid) and other benefits that can help pay for clinical services and provide a source of income and other benefits that help clients recover.
  • Care coordination and management demand a major effort. Accessing and coordinating the delivery of a broad spectrum of services require substantial effort. Local programs are deploying case workers and counselors to help clients navigate labyrinthine criminal justice systems and agencies; coordinate and support access to services; and work with partners in the community to provide therapeutic treatment, housing, education, employment and other social services.
  • Funding is scarce. Most cities and counties are hampered by limited funding for behavioral health programs. Agencies are weaving together a patchwork of funding streams, including state and local general funds, targeted assessments often coupled with contributions from local health system community benefit programs, local and national philanthropic organizations, and federal programs. These funding streams are often time-limited and subject to legislative appropriations, restricting their scale and making their future uncertain.

Most surprising is the limited use of Medicaid funding to support local programs. While many low-income adults affected by the opioid crisis are eligible for Medicaid—especially in states that have expanded their Medicaid programs—the vast majority of local programs have not fully leveraged Medicaid funding to sustain and grow their initiatives. The failure to fully leverage Medicaid funding suggests a breakdown in coordination across state, county and city agencies, and a lack of understanding about how Medicaid programs can be an invaluable resource for local efforts.

Evaluating and Spreading Interventions

There is a significant need for thorough evaluation and widespread dissemination of successful local approaches. More evidence will allow city and county leaders with state and federal partners to make more informed decisions about investing in the programs that are having broader and longer-term impacts on the well-being of individuals and communities.

What’s Next

The opioid crisis continues unabated as every level of government struggles to identify, fund and organize an effective response. The challenge and opportunity is to weave together the knowledge and capabilities of local leaders with federal and state resources to mount a more comprehensive attack on the opioid epidemic.