SOR & STR Funding – A high-speed entrance ramp to a one lane road with an uncertain destination

It is common knowledge that are substance use care system infrastructure is in disrepair. This is particularly true on the public funded side, were funding, including our federal Substance Abuse Prevention and Treatment (SAPT) Block Grant has historically been dwarfed by the magnitude of the service need.

It has lost even more ground in recent years.

As background, the SAPT Block Grant is distributed to all States and Territories. It is the cornerstone of States’ substance abuse prevention, treatment, and recovery efforts. The SAPT Block Grant is administered by the Substance Abuse and Mental Health Services Administration (SAMHSA), within the Department of Health and Human Services (HHS). Over the past decade, SAPT Block Grant funding has not kept up with health care inflation, resulting in a staggering 24% decrease in the real value of funding by FY 2019.

As many our aware, beyond this block grant there has been an influx of money to address the opioid epidemic.  As the Bipartisan Policy Center  noted in their March  2019 report, Tracking Federal Funding to Combat the Opioid Crisis, Between FY2017 and FY2018, funding specifically targeted to opioid use disorder treatment and recovery increased by $1.5 billion (from $599 million to $2.12 billion).

A number of very good, innovative short-term projects focused on opioids are being funded through these STR and SOR dollars. There has even been recognition in recent weeks that the opioid epidemic is part of a larger addiction problem and the federal government is allowing states to use these funds for other drug addiction needs, such as methamphetamine care. However, we need to also consider our long-term service strategies and how we will meet our care system needs as these dollars are time limited.

In looking through what various effective programs that states are doing with the money, large portions of the STR and SOR dollars are being spent on facets of care like purchasing overdose reversal kits or medication for an MAT or access to care through hospital warm handoffs, but relatively few dollars are going to the actual care system infrastructure. This is like a high-speed entrance ramp to a one lane road. I have been talking to providers and advocates across the nation, and there are broad concerns that despite the innovative nature by these many of initiatives, we are not using these monies to support our woefully inadequate long-term care service system infrastructure.  These monies and the projects they support have an uncertain future.

For the record, I don’t blame the states for this. As I said earlier in the post, there are some very innovative (and life preserving) things that are being done with these dollars.  As they are short term dollars, the focus on their spending is short term. I recently made the analogy of bridge building. If you know you need a bridge and it will take several years to build it, you don’t start building a bridge that you can’t fund to completion. You fill potholes or widen the entrance ramp instead.

We are in deep trouble over the long term if we don’t build the bridge to what care needs to look like. Incidentally, I don’t blame federal legislative efforts either as short-term funding was probably what was perceived as politically feasible at the time that these funding initiatives passed through Congress and in the Executive Branch, we just need to take it to the next level.

We cannot forget that short term, narrowly focused funding initiatives are not the answer to our larger SUD system infrastructure needs. What is being done is not sustainable in current form. The report referenced above by the Bipartisan Policy Center noted in their recommendations that “given the considerable federal investment in opioid funding, it is unlikely that a state will be able to replace this funding without a new dedicated state funding source or continued federal funding.” We should evaluate what is working best, consider how what is being done and ensure that long term recovery is our ultimate goal for all persons with a substance use condition.

We need to establish a more permanent source of federal funding that addresses states needs in a sustainable manner. If we do not do this the best worst case scenario is that a large portion of these short term projects would die on the vine.  The worst, worst case scenario is the pitting of interest groups against each other for access to remaining funds once the STR and SOR funds dry up. In this scenario, those with the most lobbyists usually win. This may not bode well for the overall health or efficacy of our SUD care system.

We may end up cannibalizing our care system to provide even smaller slices of the pie to more groups as funds dry up. We cannot allow this to happen. As I noted in my opinion piece in Statnews, “Addiction treatment is broken, here’s what it should look like,” we need to focus our efforts on long term treatment and recovery support services for at least five years that help sustain recovery in ways that support people getting into and staying in recovery. We must have sustainable funding in proportion to care needs.

If we are not mindful, we might actually head backwards and further degrade our care system as SOR and STR funds dry up or even continue year to year with no long-term strategic direction. We cannot allow this to happen. We should be having vigorous dialogue about what we want care to look like in America.