March 2020

Issue Focus by Alison Perencevich

The opioid epidemic remains a critical public health crisis that necessitates philanthropic attention. While opioids are at the forefront of our country’s drug policy discourse, they are not the only drug devastating communities, nor will they be the last without sustained, coordinated action. Philanthropy is uniquely suited to respond to immediate challenges while also supporting broader systems change. Tackling this crisis requires recognition of the social determinants and structural inequities that contribute to substance use and addiction. It also requires acknowledgment of the racial and ethnic inequalities in our nation’s response to past drug epidemics, disparities in access to treatment, and the disproportionate number of people of color and low-income individuals that end up in the criminal justice system.

Deaths from drugs, alcohol, and suicides—often called deaths of despair—are on the rise, with different states affected in different ways (The Commonwealth Fund 2019). The latest Centers for Disease Control and Prevention data indicate a promising yet modest decline in national drug overdose deaths from 2017 to 2018, yet the underlying data trends illuminate the evolution of the crisis and continued risks. For instance, the rate of drug overdose deaths involving synthetic opioids such as fentanyl increased by 10 percent between 2017 and 2018, while the rate of overdose deaths involving cocaine more than tripled and increased nearly five-fold for psychostimulants such as methamphetamine (Hedegaard et al 2020). Mental illness and substance use disorders affect every community. Behavioral health disparities are significant, however, especially in access to treatment for racial and ethnic minority populations, LGBTQ communities, low-income individuals, and those involved in the criminal justice or foster care systems. The treatment gap remains staggering—only about 13 percent of people with a substance use disorder receive treatment—and inequalities exist for American Indians/Alaskan Natives, African American, Latino, and Asian American populations (Substance Abuse and Mental Health Services Administration 2019).

The health, social, and economic costs of substance use disorders connect with the work of many funders. Recognizing these linkages offers a timely opportunity to think differently, forge new partnerships, and support community efforts that catalyze the cultural shift needed to reduce stigma and truly integrate behavioral health into all systems of care. There are many funding needs and potential strategies. The following article highlights different ways foundations have responded to the opioid and drug overdose crisis. While not an exhaustive list, the examples provide helpful insights, actionable guidance, and opportunities to engage.

Lead with Equity and Inclusion. The opioid and drug overdose epidemic is a health equity issue. The crisis is not only impacting white, rural populations. Native Americans have the highest opioid-related death rate of any other racial and ethnic group (Joshi 2018). Drug deaths among African Americans in urban counties have risen steeply, far outpacing any other racial or ethnic group, largely attributed to fentanyl often mixed with cocaine or other drugs (Lippold 2019). Though the opioid epidemic is widespread, it is also highly localized, and requires that funders support community-rooted equity strategies that are culturally appropriate, taking into consideration race, ethnicity, language, gender, gender identity, sexual orientation, disability, and economic and community conditions. Given that Native American children are placed in out-of-home care 300 percent more often than white children, Empire Health Foundation has prioritized efforts that support family preservation, including the Rising Strong program that allows families to stay together while recovering from addiction. The foundation also supports a Tribal Alliance of fourteen regional tribes that are developing a behavioral health treatment model that incorporates traditional, whole-person healing. The Substance Abuse and Mental Health Services Administration’s National Network to Eliminate Disparities in Behavioral Health supports information sharing, resources, training, and technical assistance to promote behavioral health equity efforts across the country. Philanthropy can be a leader in funding organizations led by those most impacted or historically disenfranchised, including individuals in recovery, families impacted by addiction, formerly incarcerated, LGBTQ, and communities of color. In the spirit of “nothing about us without us” funders should also be intentional and thoughtful about including those most impacted in planning processes, steering committees, advisory groups, and other decisionmaking structures, as well as appropriately compensating individuals for their time and knowledge. The Maine Health Access Foundation’s Community Responsive Grantmaking program funds projects that are community identified, led, and reviewed and recently awarded a grant to Healthy Acadia to support building a recovery residence for women and their children.

Prevent Overdose and Reduce Harm. Preventing overdose deaths and reducing harm associated with drug use is a critical first step in saving lives and connecting individuals with treatment. Philanthropy has long supported harm reduction efforts, but it remains an underfunded area. Naloxone (brand name Narcan) is a medication that rapidly reverses opioid overdose. Interact for Health has been a longtime funder of naloxone distribution and syringe access in the Cincinnati region, and recently shared lessons learned from over a decade of work on the opioid crisis. Currently, the foundation supports the NARCAN Distribution Collaborative and a pre-arrest diversion strategy involving Quick Response Teams of police, fire, emergency medical services, and treatment professionals that engage with individuals who overdose within 48 to 72 hours to provide resources, naloxone, and connections to treatment. In West Virginia, the Claude Worthington Benedum Foundation has supported regional harm reduction activities, as well as treatment and recovery programs. At the national level, Open Society Foundations and the Harm Reduction Coalition helped form the Opioid Crisis Response Fund, a start-up nonprofit fund that raises money to provide grants supporting naloxone distribution by organizations that directly serve the most at-risk populations.

The opioid crisis is increasingly intertwined with HIV and hepatitis C outbreaks. Infected needles result in over 3,000 new cases of HIV and approximately 10,000 new cases of hepatitis C each year in the United States (AIDS United). Syringe access programs are a proven and cost-effective prevention and harm reduction tool. The Health Foundation of Greater Indianapolis, which has a long history of supporting efforts to prevent and treat HIV/AIDS, has supported syringe service programs and harm reduction supplies to help address opioid-related outbreaks. In addition, Open Society Foundations, AIDS United, and others have supported the Syringe Access Fund, a national grantmaking collaborative that supports service providers and policy projects that reduce use of shared syringes and ensure their safe disposal.

Overdose prevention sites, also called safe injections sites or supervised consumption sites, are another public health approach to overdose prevention that have been implemented in several other countries. These sites are medically supervised and provide on-site initiation of Medication Assisted Treatment (MAT), wound care, and referrals to primary care, social services, and housing services. Safehouse in Philadelphia is poised to be the United States’ first lawful supervised consumption site and has received philanthropic support from Scattergood Foundation, Curaterra Foundation, AIDS United, and Proteus Fund.

Improve the Continuum of Care and System Capacity. For too long substance use disorders have been treated as a criminal justice problem instead of a public health issue. Investments are needed across the continuum of prevention, early intervention, treatment, and recovery services, and across health, social services, employment, housing, and corrections systems. Foundation investments are helping to change drug policies and practices, though more support is needed. Law Enforcement Assisted Diversion (LEAD) is a successful alternative to incarceration program that diverts low-level offenders from the criminal justice system into treatment and social services. LEAD was developed in Seattle with support from the Open Society Foundations, Ford Foundation and others, and is now being replicated in other jurisdictions across the country with support from additional funders like New York State Health Foundation. Relatedly, Arnold Ventures, formerly the Laura and John Arnold Foundation, is working to build bridges between correctional facilities and community-based treatment to reduce overdose deaths, reduce recidivism, and increase engagement in evidence-based opioid use disorder treatment. In partnership with the U.S. Department of Justice – Bureau of Justice Assistance, Arnold Ventures is supporting selected communities in developing partnerships and plans for initiating or expanding a MAT continuum of care model from jail to community post-release. Recognizing the impact of addiction on children and families, the Michigan Health Endowment Fund has supported efforts to implement an integrated intervention model to address substance use disorders among parents of children in the welfare system; the goal of this initiative is to improve outcomes for families by focusing on stable recovery from addiction and reunification or prevention of out-of-home placement. Lastly, addressing substance use disorders in pregnant women and preventing neonatal abstinence syndrome is another vital area of work. The Montana Healthcare Foundation’s Meadowlark Initiative supports efforts to integrate prenatal and behavioral health care to improve maternal and neonatal outcomes, including reducing newborn drug exposure, neonatal abstinence syndrome, and perinatal complication. The initiative provides funding and technical assistance to prenatal and postpartum care providers to implement a coordinated, team-based system of care that improves outcomes for women with substance use disorders and helps keep families together and children out of foster care.

Research shows that chronic disease management with MAT and behavioral supports are the most effective way to treat substance use disorders, yet lack of access to quality integrated treatment, workforce capacity, gaps in insurance coverage, payment policies, and other barriers to care persist. The Pew Charitable Trust’s Substance Use Prevention and Treatment Initiative works with states to reduce the inappropriate use of prescription opioids and expand access to effective treatment including MAT and behavioral health therapies. Pew also partnered with CDC Foundation, Bloomberg Philanthropies, Vital Strategies, and Johns Hopkins University to support ten states over three years to implement solutions to strengthen prevention and treatment efforts, including improving collaboration between public health and law enforcement. Similarly, California Health Care Foundation helped establish the California Opioid Safety Network, a community of local coalitions sharing strategies and best practices to reduce opioid addiction and deaths. Local opioid safety coalitions bring together community stakeholders to develop strategies to increase access to treatment, decrease opioid overuse, and reduce overdose deaths. To help address workforce and access challenges, the Nicholson Foundation supported Project ECHO for Pain Management and Opioid Addiction using telecommunications technology to foster mentoring partnerships between primary care providers and specialists in pain management and addiction treatment with the goal of reducing the overprescribing of prescription opiates and expanding access to buprenorphine. With the goal of helping to improve pain management education and change physician prescribing patterns, Bethesda Inc.’s grantmaking initiative bi3 supported a randomized, controlled study examining the effectiveness of the PainPack System, a non-opioid pain management alternative. Effectively addressing chronic pain remains an important part of the opioid response, including research, implementation, and scaling of promising nonpharmacological approaches to pain and alternatives to opioids. The John A. Hartford Foundation has helped elevate the need for better pain management for older adults with chronic pain, especially those in rural communities. In addition, Grantmakers In Aging, with support from Empire Health Foundation, developed a report highlighting issues and opportunities to support older people in rural communities dealing with the opioid crisis.

In general, investments in long-term recovery services and supports has been very limited. Recovery schools, houses, and organizations can be found in some communities, but are not widespread. The Peter and Elizabeth Tower Foundation helped create Team Fourteen, a family-based recovery counseling program that includes the participation of parents/caregivers in youth recovery counseling. Episcopal Health Foundation has funded projects to expand a peer-based recovery coach model that provides long-term support services for people with substance use disorders and mental health issues. Lastly, the Sandgaard Foundation, a relatively new national foundation, plans to support long-term recovery and recovery awareness, which may include funding for recovery houses, recovery community organizations, sober living centers, recovery concerts and events, and peer recovery specialists.

Ultimately prevention is one of the most important tools to stem current and future drug crises. Given that many substance use disorders develop in adolescence, a focus on young people is particularly vital. The Conrad N. Hilton Foundation has been one of the main national funders focused on adolescent substance use prevention—primarily though efforts to expand Screening, Brief Intervention, and Referral to Treatment—however the foundation will be transitioning out of the field in 2021. Over the years, the Hilton Foundation has partnered with several foundations on youth prevention and early intervention efforts including the New Hampshire Charitable Foundation and Montana Healthcare Foundation. In addition, the Richard M. Fairbanks Foundation launched Prevention Matters, a four-year $12 million initiative to help schools implement evidence-based substance use prevention programs. Relatedly, the Foundation for Appalachian Ohio is supporting youth-led prevention efforts with grants to local organizations, schools, and communities to initiate programs or ground existing efforts in an evidence-based substance use prevention approach.

Address Stigma and Promote Recovery. Stigma remains a significant barrier at all levels of intervention. Public awareness campaigns, provider trainings, and other anti-stigma efforts can help change the narrative and promote recovery. Funders in the Greater Cincinnati region formed the Funders’ Response to the Heroin Epidemic to provide financial resources and strategic support to community partners. Reducing stigma related to opioid use and addiction is a key focus area for the group, which is supporting a solutions-oriented public education campaign. Also, GE Foundation, RIZE Massachusetts, and Shatterproof partnered to address provider stigma associated with opioid use disorders and released report findings highlighting opportunities to increase screening and treatment of opioid use disorders among health care professionals. Language and communication also matter, especially when it comes to reducing stigma and changing the narrative of substance use. The Conrad N. Hilton Foundation supported the development of a communications playbook for adolescent substance use prevention that researched evidence-based framing strategies and offers effective communication recommendations. In addition, Paso del Norte Health Foundation has developed a strategic plan for their Think.Change Initiative aimed at utilizing a collective impact model and researched-informed constructs to reduce stigma associated with mental illness. Finally, the nation’s response to the HIV/AIDS epidemic provides important historical perspectives and lessons for addressing stigma. Funder colleagues in the HIV/AIDS philanthropic field can be key thought partners and allies in addressing issues of stigma, equity, and recovery.

Cultivate Coalitions and Advance Policy Change. No funder can tackle this crisis alone and many funders have harnessed their convening power to support collaboration and build coalitions. Building capacity and supporting existing regional infrastructure is critical to helping align multi-sector partners for system and policy change efforts. Palm Health Foundation utilized a 100-day challenge model to bring together diverse community stakeholders to spur urgent systems change in response to the opioid overdose crisis in their region. Relatedly, the Richard M. Fairbanks Foundation helped launch the Indiana Funders Collaborative: Focusing on Substance Use Disorders, a group of private and public sector funders who meet regularly and share information on new initiatives and funding opportunities. In 2018, philanthropic organizations and government representatives in U.S. Department of Health and Human Services Region 5 hosted an Opioid Funders Summit in Chicago to promote dialogue on regional approaches to the crisis. As previously mentioned, funders in the Greater Cincinnati region formed Funders’ Response to the Heroin Epidemic to jointly invest in efforts to end the region’s opioid and heroin epidemic. Lastly, a newly organized group of funders have been convening as the Substance Use Disorders Funders Collaborative with the goal to decrease duplicative efforts, identify gaps and fund innovation, work in areas where there is little funding, and improve visibility of issues such as prevention and harm reduction.

Medicaid is the largest source of coverage and funding for substance use disorder services in the United States, therefore efforts to expand or reduce Medicaid have major implications for fighting the epidemic. Funders can help states take advantage of Medicaid expansion to build stronger substance use systems of care and protect against cuts that would hurt access to services. Montana Health Care Foundation funded the development of a report that identified gaps in their state’s substance use system, role of Medicaid in the delivery system, and specific policy fixes that the state is now implementing. Similarly, Arnold Ventures supported the development of a toolkit for state Medicaid leaders on “Using Medicaid to Advance Evidence-Based Treatment of Substance Use Disorders.” As part of its portfolio of work on substance use disorders, New Hampshire Charitable Foundation has invested in public policy and advocacy, including the establishment of New Futures, a nonpartisan nonprofit organization that advocates for expanded health insurance coverage for treatment and other policies to prevent substance use. Additionally, ensuring health plans and insurers offer substance use disorder and mental health benefits at parity remains an ongoing challenge. Scattergood Foundation and Peg’s Foundation have supported a number of policy tools including: Parity Track, a repository of federal and state parity reports and resources; a policy paper series on timely behavioral health issues; and Health in Mind: A Philanthropic Guide for Mental Health and Addiction developed by the University of Pennsylvania’s Center for High Impact Philanthropy. Finally, Well Being Trust recently launched Healing the Nation: Advancing Mental Health and Addiction Policy, a policy action guide for policymakers and advocates.

Lastly, current opioid-related litigation has the potential for creating new sources of funding for prevention and treatment efforts but many unknowns remain. Funders can learn lessons from the previous tobacco settlement funds to ensure current litigation efforts help those most impacted. Litigation and other pressures on businesses associated with opioid manufacturing and distribution are also changing the philanthropic funding landscape. McKesson Corporation contributed $100 million to help establish the Foundation for Opioid Response Efforts, a new national foundation focused on provider education, payer strategies, policy initiatives, and public awareness.

 

Learn More and Get Involved

Despite these selected efforts and others, there is still more work to be done. There are many entry points and ways for funders to engage, regardless of foundation size or assets. Peer-to-peer learning is critical to advancing this work and sharing bright spots, challenges, and lessons learned. GIH encourages Funding Partners to share their efforts and connect with fellow funders via the Behavioral Health Funder Network E-forum. Send a note to bh@gih.org to keep the field informed of your work, share updates, or seek guidance from your peers. Over the last several years, GIH has partnered with Funders Concerned About AIDS and the Substance Use Disorders Funders Collaborative on learning opportunities related to drug policy, harm reduction, and the opioid crisis. Future educational programming is underway and participation is welcome.

The science is clear that substance use disorders are a chronic, treatable disease that require a comprehensive system of care like any other manageable chronic condition. Philanthropy has a vital role in helping to reform drug policies, scale prevention efforts, and address barriers to treatment and recovery. Health funders have an opportunity to respond to this health equity crisis and lead the way in catalyzing a movement to prevent drug overdose deaths and strengthen our nation’s behavioral health system.

 


References

The Commonwealth Fund. 2019 Scorecard on State Health System Performance. Access online February 2020.

Hedegaard H, Miniño AM, Warner M. Drug overdose deaths in the United States, 1999–2018. NCHS Data Brief, no 356. Hyattsville, MD: National Center for Health Statistics. 2020.

Substance Abuse and Mental Health Services Administration. Behavioral Health Barometer: United States, Volume 5: Indicators as measured through the 2017 National Survey on Drug Use and Health and the National Survey of Substance Abuse Treatment Services. HHS Publication No. SMA–19–Baro-17-US. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2019.

Joshi S, Weiser T, Warren-Mears V. Drug, Opioid-Involved, and Heroin-Involved Overdose Deaths Among American Indians and Alaska Natives — Washington, 1999–2015. MMWR Morb Mortal Wkly Rep 2018;67:1384–1387. DOI: http://dx.doi.org/10.15585/mmwr.mm6750a2external icon.

Lippold KM, Jones CM, Olsen EO, Giroir BP. Racial/Ethnic and Age Group Differences in Opioid and Synthetic Opioid–Involved Overdose Deaths Among Adults Aged ≥18 Years in Metropolitan Areas — United States, 2015–2017. MMWR Morb Mortal Wkly Rep 2019;68:967–973. DOI: http://dx.doi.org/10.15585/mmwr.mm6843a3

AIDS United. Syringe Access Fund. Access online February 2020.

 

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