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Substance Abuse Disorder/Opioid Use Disorder (SUD/OUD): Traditional treatment versus harm reduction for grant writers

We’ve been writing Substance Use Disorder / Opioid Use Disorder (SUD/OUD) treatment grant proposals since 1993, so we’ve been at it for long enough to see waves of funder preferences around approaches come and go. SUD/OUD are hard problems, and made harder because of the misinformation and disinformation about Oxycodone and Oxycontin that Purdue Pharma and its subsidiaries spread for decades, in a way that’s likely worse than the way the cigarette companies once marketed their wares.

For the first 20 years or so in business, the SUD/OUD treatment grant proposals we wrote were usually based on the standard “Step-Down” paradigm, in which people with addiction receive treatment along a continuum of care from a high level of care and then “step down” to lower care levels in increments, leading to eventual recovery and self-care. Following engagement, referral, or self-presentation and development of an individual treatment plan (ITP), the step-down levels are more or less like this:

  • Detoxification/hospitalization
  • Inpatient treatment
  • Intensive outpatient treatment
  • Outpatient treatment, often including 12-Step peer support groups and, for those with OUD, medication assisted treatment (MAT)
  • Recovery and self-care

The levels can be further broken down, but the above is a common schema. As patients move down the treatment continuum, they usually receive case-managed wraparound supportive services—like legal assistance, workforce development, primary/dental care, affordable housing, etc.— at least until they are in recovery and have been “clean and sober” for six to twelve months. The “affordable housing” part has gotten much harder, though, because most cities use zoning laws to restrict the supply of housing, which causes prices to rise, which makes a given housing unit difficult for a grant-funded organization, or a person with drug addiction, to afford. Also, it’s an unfortunate reality that most people with SUD/OUD will relapse multiple times, sending them to the top of the treatment pyramid again. In this way, step-down treatment is something like the classic board game Chutes and Ladders I played as a kid. “Step down” was the main “treatment game” available for decades, although methadone was sometimes used for what we now call OUD.

About ten years ago, we began noticing a difference in SAMSHA, HRSA, and other RFPs for SUD/OUD: those agencies now want usually applicants to augment treatment to include “harm reduction.” As defined and described by SAMHSA, “Harm reduction is critical to keeping people who use drugs alive and as healthy as possible, and is a key pillar in the multi-faceted Health and Human Services’ Overdose Prevention Strategy.” Most of our clients resisted this shift but have gradually gotten on board the harm reduction train as pure harm reduction RFPs, like SAMHSA’s “FY ’22 Harm Reduction NOFO,” began to appear. The shift isn’t surprising, because in grant seeking it pays to follow the golden rule. No, not that golden rule, this one: “The people with the gold make the rules.”

Harm reduction projects usually involve a van-based outreach model in which Peer Support Workers (PSWs) go in teams to what are termed “hot spots” to engage people living with SUD/OUD. “Hot spots” include places like homeless encampments, shelters, parks, etc. The outreach effort can be either obvious (e.g., signage on the van and PSWs in logo t-shirts) or on the down low (e.g., plain white van and PSWs in street clothes), or a hybrid version using magnetic signs placed on the van, or removed from it, depending on the needs of a particular location on a given day. The PSWs distribute harm reduction supplies like clean syringes (with or without exchange), alcohol swabs, sterile water ampules, spoons, fentanyl test strips, sharps containers, and condoms, along with emergency food, clothing, hygiene items, and so forth. The outreach van is also used to provide some direct services in the field like wound care, rapid HIV tests, and naloxone administration.

The most extreme version of harm reduction are safe injection sites: while these are illegal in most of America because the drugs themselves are technically illegal, if widely available, three safe injection sites have recently and prominently opened, two in NYC and one in San Francisco. One key problem with a safe injection site initiative is that few businesses or residents want one near them, much like no one wants to be in proximity of a methadone clinic, so permitting is a real challenge. We’ve yet to write a safe injection site proposal but likely soon will.

A key difference between the standard treatment model and the harm reduction model is that clients are typically not tracked (when Joe or Mary shows up for supplies, their identity isn’t verified and they aren’t entered into a client database for tracking), and, most significantly, services aren’t case-managed. PSWs will offer “warm handoffs” for follow-up treatment like MAT and other center-based services, but there’s no automated follow-up from the harm reduction team.

We’re just grant writers, so we don’t have an immediate opinion as to whether step-down treatment or harm reduction is more efficacious, and most studies on the subject are somewhat questionable, although every treatment/harm reduction proposal we write claims the project design uses “evidence-based practices” (EBPs). When in doubt, claim both “evidence” and “innovation” for your program, leaving aside that those two are often mutually exclusive. If your agency provides SUD/OUD treatment, consider adding a harm reduction component, as this is clearly where the feds are going with grant funds. A cynic might conclude that the feds are pushing harm reduction because it’s much cheaper than providing longitudinal case-managed treatment, but we’ll leave that conclusion to others.

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Funders sometimes force grantees to provide services they don’t want to: FQHCs and Medication Assisted Treatment (MAT)

We often remind clients that those with the gold make the rules. Accepting a government grant means the applicant must sign a grant agreement, in which the applicant agrees not only to provide wherever services were specified in the proposal, but also abide by a myriad of regulations and laws. While many applicants will tussle with a funder over the budget, there’s rarely any point in trying to modify the boiler plate agreement—just like one can’t modify Apple or Facebook’s Terms of Service.

In addition to the specific terms of the grant agreement, grantees quickly become subject to other influences from the funder—when the Godfather makes you an offer you can’t refuse, you know that eventually you’ll be told to do something you’d otherwise not much want to do. While a federal agency is unlikely to place a horse’s head in a nonprofit Executive Director’s bed, the grantee might end up having to provide an unpalatable service.

A case in point is HRSA’s relatively recent (and divisive) endorsement of Medication Assisted Treatment (MAT) for treating opioid use disorder (OUD). Since HRSA is the primary FQHC funder, it is essentially their Godfather and has great influence over FQHCs. In the past few years, HRSA has strongly encouraged FQHCs to provide MAT. The CEOs of our FQHC clients have told us about HRSA pressure to start offering MAT. It seems that, even after several years of cajoling, only about half of our FQHC clients provide MAT, and, for many of these, MAT is only nominally offered. Other clients see offering MAT as a moral imperative, and we’ll sometimes get off the phone with one client who hates MAT and then on the phone with another client who sees not providing MAT as cruel.

“MAT” generically refers to the use of medications, usually in combination with counseling and behavioral therapies, for the treatment of substance use disorders (SUD). For OUD, this usually means prescribing and monitoring a medication like Suboxone, in which the active ingredients are buprenorphine and naloxone. While Suboxone typically reduces the cravings of people with OUD for prescribed and street opioids (e.g., oxycontin, heroin, etc.), it is itself a synthetic opioid. While MAT replaces a “bad opioid” with a “good opioid,” the patient remains addicted. Many FQHC managers and clinicians object to offering MAT for OUD, for a variety of medical, ethical, and practical reasons:

  • Like its older cousin methadone, as an opioid, Suboxone can produce euphoria and induce dependency, although its effects are milder. Still, it’s possible to overdose on Suboxone, particularly when combined with alcohol and street drugs. So it can still be deadly.
  • While MAT is supposed to be combined with some form of talking or other therapy, few FQHCs have the resources to actually provide extensive individual or group therapy, so the reality is that FQHC MAT patients will likely need Suboxone prescribed over the long term, leaving them effectively addicted. We’re aware that there’s often a wide gap here between the real world and the proposal world.
  • Unless it’s combined with some kind talking therapy that proves effective, MAT is not a short-term approach, meaning that, once an FQHC physician starts a patient on Suboxone, the patient is likely to need the prescription over a very long time—perhaps for the rest of their life. This makes the patient not only dependent on Suboxone, but also dependent on the prescriber and the FQHC, since few other local providers are likely to accept the patient and have clinicians who have obtained the necessary waiver to prescribe it. Suboxone users must be regularly monitored and seen by their prescriber, making for frequent health center visits.
  • As noted above, prescribed Suboxone can, and is often, re-sold by patients on the street.
  • Lastly, but perhaps most importantly, most FQHC health centers prefer to look like a standard group practice facility with a single waiting room/reception area. Unlike a specialized methadone or other addiction clinic, FQHC patients of all kinds are jumbled together. That means a mom bringing her five-year old in for a school physical could end up sitting between a couple of MAT users, who may look a little wild-eyed and ragged, making her and her kid uncomfortable. Since FQHCs usually lack the resources for anything beyond minor paint-up/fix up repairs, there is simply no way around this potential conflict.

Given the above, many FQHC CEOs remain resistant to adding the challenges of MAT to the many struggles they already face. Still, the ongoing pressure from HRSA means that most FQHCs will eventually be forced to provide at least a nominal MAT program to keep their HRSA Program Officer at bay. The tension between a typical mom and her five-year old against a full-fledged behavioral and mental health program is likely to remain, however. Before you leave scorching comments, however, remember that we’re trying to describe some of the real-world trade-offs here, not prescribe a course of action. What people really want in the physical space they occupy and what they say they want in the abstract are often quite different. You can see this in the relentless noise around issues like homeless service centers; everyone is in favor of them in someone else’s neighborhood and against them in their own neighborhood. Always pay attention to what a person actually does over a person’s rhetoric.