This Roadmap provides Governors with 17 specific, actionable recommendations to prevent overdose across five pillars of the Substance Use Disorder Continuum of Care: foundations, prevention, harm reduction, treatment, and recovery.
Implementing Best Practices Across the Continuum of Care to Prevent Overdose: A Roadmap for Governors contains recommendations that represent evidence-based and promising actions states and territories can consider as they work to strengthen the Continuum of Care for people at risk for overdose, including those with Substance Use Disorder (SUD). This Roadmap is a product of guidance and information from more than 30 subject matter experts, including more than 20 states and territories, the O’Neill Institute at Georgetown University Law Center, as well as extensive literature on this topic. These recommendations are oriented from a public health perspective and exclusively focused on overdose prevention. They reflect the current landscape of overdose and risk, which has shifted significantly since the 2016 NGA publication, Finding Solutions to the Prescription Opioid and Heroin Crisis: A Roadmap for States, and is now primarily driven by illicitly manufactured fentanyl rather than prescription opioids.
Recommendations
Foundations
Establish a state government coordinating body to set a statewide vision for overdose prevention.
- Coordinate an all-government approach to addressing overdose by directing cross-agency strategic planning and financial mapping.
Invest in state infrastructure to maximize resources.
- Streamline and create efficient procurement and grant-making processes to ensure funding allocated to overdose prevention has the greatest impact possible.
Seek and include the perspectives and leadership of people with a variety of lived experiences.
- Partner with and solicit input from people with lived and living experience in state planning.
- Streamline and create more efficient procurement and grant-making processes to provide funding and collaboration opportunities for community-based organizations that represent disproportionately impacted populations and that are led by and employ people with lived and living experience.
- Review and revise government hiring policies and practices to enhance employment opportunities for people with lived experience.
Invest in evaluation and test new ideas.
- Continuously monitor population-level data and leverage actionable insights to inform interventions and pivot resource allocation.
- Leverage federal funds to pilot and evaluate community-driven, culturally responsive, and innovative programs, investing in and scaling up those with demonstrated success.
- Invest time and resources into a long-term data strategy to collect accurate, complete, and timely outcome measures from relevant agencies and partners, and continuously evaluate state-funded programs.
Nurture and grow a mental health and substance use workforce that reflects the populations served.
- Leverage recruitment, scholarship, prospective education payments, and loan forgiveness programs to support students enrolled in mental health and substance use-related degrees, particularly those representing disproportionately impacted populations and communities.
- Invest in community-based organization initiatives that expand training capacity for mental health and substance use-related workers.
- Create more opportunities for entry-level mental health and substance use-related roles by establishing training and certification programs.
- Facilitate partnerships between employers and institutions of higher education to provide training and skills-building opportunities for mental health and substance use-related employees to advance their careers.
- Serve as a model for valuing state-employed peers by ensuring equitable pay and acknowledging their contributions.
Prevention
Champion and invest in initiatives that support family cohesion and well-being.
- Ensure that policies do not criminalize prenatal substance use nor deter pregnant and parenting people from accessing health care services.
- Revisit policies and procedures to ensure coordination and collaboration between all relevant agencies in delivering plans of safe care.
- Invest in initiatives that keep families together and healthy by addressing social drivers of health and enhancing employment opportunities, economic health, education, stable housing, and physical and mental health care.
- Leverage the Family First Prevention Services Act to keep families together and prevent foster care placement through access to substance use prevention and treatment, mental health services for parents and children, and parent skill-based programs.
Promote evidence-based requirements for funded prevention initiatives.
- Promote evidence-based primary prevention programming by developing and implementing processes and standards for state-funded substance use and overdose prevention programming.
- Invest in community-driven and culturally responsive interventions and create opportunities to evaluate and scale them.
Harm Reduction
Maximize federal resources and braid funding to promote health and reduce harm for people who use drugs.
- Utilize federal funds available for overdose response to support allowable wrap-around and engagement services at Syringe Services Programs for people who use drugs.
- Review and consider revisions to state laws, regulations, and policies to allow the use of state general funds for harm reduction tools and activities that are part of comprehensive harm reduction services but are without other funding sources.
- Braid state and federal funds to invest in community-based harm reduction programs.
Implement targeted and low-barrier distribution strategies for overdose reversal agents (ORAs) such as naloxone.
- Review and revise internal policies and processes that impede distribution and access.
- Implement universal overdose education and ORA distribution to individuals leaving correctional facilities and those under community supervision.
- Leverage partnerships with community-based organizations, including those led by people with lived and living experience, to reach those most likely to experience or respond to an overdose.
- Champion policies that:
- — Promote overdose education and ORA distribution through entities serving people most likely to experience an overdose.
- — Prioritize ORA distribution to disproportionately impacted populations and people who use drugs.
- — Prohibit life and health insurance discrimination related to ORAs.Require health insurers to cover ORAs, including non-prescription ORAs.
- — Expand Good Samaritan protections for people who experience or respond to an overdose.
Champion changes that allow for the distribution of harm reduction tools.
- Consider levers to establish Syringe Services Programs and protect staff, volunteers, and program recipients from charges related to possession of program supplies
- Consider policy changes to allow possession of harm reduction tools such as drug test strips to detect fentanyl and xylazine, and other risk reduction and participant engagement tools that may be considered paraphernalia under state law.
Treatment
Implement and invest in policies and programs that expand Medication for Opioid Use Disorder access beyond the office setting.
- Implement initiatives that incentivize and/or support emergency departments to provide Medication for Opioid Use Disorder (MOUD) and link individuals to community-based care providers.
- Leverage telemedicine for SUD treatment and invest in efforts to co-locate MOUD via telehealth in community-based settings, including harm reduction and outreach programs.
- Implement and invest in mobile MOUD programs that serve rural areas.
- Expand the scope of practice through collaborative practice agreements to allow pharmacists to initiate MOUD and link patients to community-based providers for maintenance.
- Work with regional DEA offices to ensure that federal rules around MOUD access are applied consistently.
- Implement policies and initiatives to offer SUD treatment, including all MOUD medications, in criminal legal system settings.
Implement and invest in evidence-based treatment and access models.
- Implement a Medication First treatment model and prioritize state and federal resources to programs that align with this model.
- Partner with public safety to implement deflection and diversion programs. Make all MOUD treatment forms available to those involved in the criminal legal system.
- Invest in peer-led post-overdose outreach programs.
- Communicate changes in federal rules to the clinical community and community partners, ensuring they can take advantage of opportunities to expand access.
Maximize federal funding resources for treatment.
- Leverage the telehealth flexibilities given to states to allow for Medicaid coverage of low-barrier MOUD via telehealth; remove state-level requirements for in-person visits associated with telehealth SUD treatment.
- Braid in state funding to optimally implement initiatives not sufficiently covered by federal funding due to limits.
- Take advantage of opportunities to make MOUD and other pre-release services available to incarcerated individuals with SUD through the Medicaid 1115 waiver.
Assess state-level policies that restrict access.
- Support state-level requirements for MOUD that are equivalent to federal requirements after the removal of the DATA 2000 waiver in 2022.
- Remove same-day billing restrictions and prior authorization requirements for MOUD medications from state Medicaid programs.
- Enforce laws ensuring parity in insurance coverage for SUD services.
Recovery
Foster communities that support recovery.
- Incentivize businesses that employ and support staff in recovery.
- Implement certification programs for “recovery ready” workplaces and communities.
Champion changes to policies to establish recovery residence standards.
- Champion changes to policies in order to require that state recovery residences meet national standards.
- Use state funds to support recovery residences that meet national standards.
Invest in small businesses and community-based organizations led by and employing people with lived experience who represent the communities they serve.
- Review and revise state-level processes and provide technical assistance to increase equity in procurement and grant-making for small businesses and community-based organizations.
- Support capacity-building for small businesses and community-based organizations led by people with lived experience who represent the communities they serve.
- Create funding opportunities for and invest in peer recovery organizations.
