Since 2017, the federal government has awarded $2 billion to states specifically for opioid prevention, treatment, and recovery. But a new spending package passed last month allows states to use federal funds to address the growing use of stimulants, including cocaine and methamphetamine, that are emerging as the newest wave of drugs fueling the overdose crisis in many states.

The addition of stimulants to federal funding presents both challenges and opportunities for states. They will need to develop initiatives that also address stimulant use, though currently there are few evidence-based treatment guidelines for this. On the plus side, the new funding flexibility allows states to address the social factors that contribute to all substance use disorders (SUD), instead of focusing on a single class of drugs.

Background

To date, federal funding to address the opioid epidemic  has flowed from the Substance Abuse and Mental Health Services Administration (SAMHSA) through State Targeted Response (STR) and State Opioid Response (SOR) grants. The latest spending package includes a seemingly minor language addition that poses a potentially major shift in how states use the funding.

What is the fourth wave of the overdose crisis?

Stimulants, including methamphetamine and cocaine, are increasingly prevalent and play a role in overdoses in certain states, mostly west of the Mississippi River.

Prevalence is growing, however, in eastern and Appalachian states already hit hard by opioids as well.

The federal decision to broaden substance categories is a direct response to the quickly-developing threat of stimulants like cocaine and methamphetamine reported in provisional federal overdose data for drug deaths though July 2019. Distinct regional patterns show that stimulants are increasingly prevalent in overdoses primarily west of the Mississippi River, but are growing in eastern and Appalachian states hit hard by opioids. While opioids remain the most frequent killer of Americans who die of drug overdose, the increasing presence of stimulants in this data suggests an emerging “fourth wave” of a drug overdose epidemic that began with prescription opioids and quickly escalated, propelled by heroin and then fentanyl.

Previous iterations of STR and SOR grant funding have given states the opportunity to target funds toward the factors that fueled those waves of opioids. This included prevention initiatives around reducing unnecessary prescribing and diversion of opioids and clinical engagement that was focused on medication-assisted treatment (MAT) for opioid use disorder (OUD). Funds were used to support the development of waivered providers to prescribe buprenorphine, or training for peers with lived opioid experience. The opioid focus was unequivocal.

How States Can Address Stimulant Use

The addition of stimulants to the federal language poses a new set of challenges and welcome opportunities for states. The most pressing issue for both policymakers and clinicians will be treatment – while treatment for OUD can include MAT, often in conjunction with psycho-social supports, treatment for stimulant use currently has no evidence-based medical options, limiting opportunities for clinical intervention to just behavioral mediation.

There is some evidence, however, to suggest that in addition to cognitive-behavioral therapy, contingency management approaches in which individuals are provided with small, tangible rewards for negative urine drug screens can be effective treatment for stimulant use.

Notwithstanding these differences in treatment protocols, states can leverage previous opioid work in their response:

• Care models: Integrated care models emphasizing and reimbursing for team-based care can be adapted to these treatment approaches.
• Reimbursement: States can use 1115 Demonstration waivers to support financing these models and address the Medicaid Institutions for Mental Diseases (IMD) exclusion to expand inpatient opportunities. (The IMD exclusion prohibits use of Medicaid funds for mental health care provided in residential treatment facilities larger than 16 beds.)
• Workforce: States can invest in training and continuing education focusing on stimulant treatment modes for licensed behavioral health providers and non-licensed workforce.

Another major opportunity with this change is that states can explicitly tailor efforts to poly-substance use. Even as opioid overdose deaths have dominated in data reports, media attention, and policy activity in recent years, the majority of opioid overdose deaths reviewed in one recent report from the Centers for Disease Control and Prevention involved at least one other drug. Poly-substance use has been self-reported as near universal by individuals entering treatment specifically for OUD.

States Can Now Address What Fosters All SUD

This federal funding change allows states to use federal grant funds to address the factors that foster SUD, instead of focusing on the effects of a specific substance. For example, given the well-documented link between childhood trauma and SUD, states can invest in prevention efforts that protect children and support resiliency, like reimbursement policies and programs that allow parents with SUD to stay with their children in residential treatment or utilizing models of family-centered treatment. Being mindful of the 2015 study that linked deaths of despair (including those from drug overdose) to economic struggle, states can continue investing in strategies that addressing social determinants of health, including recovery housing, job training, and recovery workplaces.

One of the major challenges of developing state SUD policies is that SUD is not itself substance-specific. This language change aligns federal resources to help states address that discrepancy. Specific state guidance from SAMHSA on this change has not been released, but state policymakers will be able to build on their foundational initiatives developed with the support of earlier federal grants and establish new pathways to innovation.