A What-Works Approach to the Opioid Crisis

New federal funding will help, but states need to focus it on treatment backed by evidence.
July 6, 2017
A patient takes a dose of methadone at a drug treatment clinic.
A patient takes a dose of methadone, an opioid that reduces the symptoms of opioid withdrawal. (AP/Kevin D. Liles)
By Andrew Feldman  |  Contributor
Visiting Fellow at the Brookings Institution's Center for Children and Families
By Richard G. Frank  |  Contributor
Professor of health economics at the Harvard Medical School

States recently got important help to address the opioid epidemic: a billion dollars over two years from the 21st Century Cures Act, passed by Congress late last year. States are now deciding how to use that funding. A critical question -- a truly life and death issue -- is how states can save the most lives with it.

To put the opioid epidemic in perspective, about 34,000 Americans die in car accidents each year, and about the same number die from gun violence. Opioids, including prescription medications and heroin, kill almost as many: over 33,000 in 2015, more than any year on record. Moreover, in 2015 there were an estimated 2.7 million Americans who suffered from opioid dependence or addiction, with only about a quarter of them in treatment. Closing this treatment gap is a key goal of the Cures Act.

Simply increasing access to treatment, however, is not enough. If states focus only on increasing its availability without building in ways to learn which treatment and engagement strategies are most effective for this diverse population, it will be a huge missed opportunity that will cost lives down the road.

Why is this learning process so important? The field of opioid addiction treatment is still relatively new, with more questions facing us than solid answers. On the positive side, we know from dozens of clinical studies that medication-assisted treatment, or MAT, is effective. MAT involves combining one of several medications that can help people break their addiction with counseling and drug testing to monitor adherence with treatment plans.

What we still need to learn, however, is which treatments work best for whom, how to effectively implement treatments on a large scale, what type of outreach gets people into treatment, and how to keep people engaged in treatment over time. We also know little about how to integrate support services, such as employment and housing assistance, into treatment efforts to create "wrap around" services for people with particular needs, such as those returning from prison.

So how can states both act and learn? In distributing their Cures Act funding to local treatment providers, they might take a page from private-sector venture capital, where the more hard evidence applicants have behind their approaches the more funding they can receive. This differs from traditional public-sector grant making, where funding decisions are too often based on promises of effectiveness, not hard evidence of impact.

States, therefore, should launch "tiered-evidence" grant competitions. These would have three tiers to which treatment providers could apply: a development tier providing small grants for innovative but less-tested approaches; a validation tier providing medium-sized grants for approaches backed by moderate evidence; and a scale-up tier providing large grants for ap-proaches supported by strong evidence. The grants would come with funds and requirements for rigorous program evaluation, so that interventions that are found to be effective could move up tiers and qualify for expanded funding. This design would focus most of the Cures Act dollars on evidence-based approaches while also encouraging innovation.

The tiered-evidence approach is already being used by some innovative federal agencies. Over the last decade, five of them have launched tiered-evidence grant programs, also known as innovation funds. An example is the Education Innovation and Research Program at the Department of Education, designed to support and evaluate field-initiated innovations to improve achievement for high-needs students.

To encourage states to use a tiered-evidence approach with their Cures Act dollars, the U.S. Department of Health and Human Services could team up with a set of results-focused philanthropic foundations. Together, they could offer states bonus dollars -- in effect extra Cures Act funds -- if they use a tiered approach, since the evidence produced by doing so would benefit all states. They might also offer additional bonus dollars if states were willing to team up to test evidence-based approaches in several states at once, allowing evaluators to speed up learning about what works, where, and for whom.

Finally, HHS should make it clear to states that they and their grantees are allowed to use part of their Cures Act dollars for evaluation. Without this clarification, states may avoid a tiered-evidence approach, thinking they and their grantees lack the resources to implement it.

Seizing the opportunity the Cures Act provides will require governors, legislators, public-health leaders, service providers, federal officials and foundation executives who understand and champion the value of learning strategies. Using tiered-evidence grants to allocate funding to local providers would take more work on the front end but would pay big dividends over time. It would help us say not only "We want to help you overcome your opioid disorder" but also "We know how to help you do that."