Why is it so hard to use opiate settlement funds in rural communities?

The Virginia General Assembly created the opioid abatement authority to manage and allocate 55% of the commonwealth’s settlement funds from opioid litigation. These funds must be used for addiction-related programs. 

Grant funding for opioid treatment programs is available to cities and counties and state agencies across the state through grant applications that are reviewed and awarded by the Virginia Opioid Abatement Authority.  

But there are various ways that funding is awarded.

Direct funding, competitive funding and the ‘gold standard incentive’

Virginia’s abatement authority is somewhat unique because it directs a large portion of the funding straight to cities and counties, giving localities significant control, said Katie Greene, a director at the National Academy for State Health Policy. Some other states, such as Minnesota and North Carolina, have adopted similar approaches.  

“The benefit of having strong local control is that they are very familiar with their community and what they need. I think some of the drawbacks are that cities and counties might not have the resources or capacity or expertise to be funding substance use initiatives,” Greene said. 

There is a “gold standard incentive” in Virginia, which encourages localities to use opioid settlement funds strictly for remediation purposes. Local governments can receive a 25% increase in funding eligibility if they voluntarily adhere to the same stringent guidelines that apply to the authority’s own distributions. 

In Buchanan County, $186,704 was available this year through non-competitive grants, but according to a state summary of opioid funds from the authority, none of those funds were applied for.  

The county has some of the highest rates of babies born with drugs in their system, according to 2022 state data. It’s also home to Miracle Hawkinberry, who struggled with addiction for more than a decade and through multiple pregnancies before she got the help she needed. Her story is featured in an earlier installment of this series. 

Buchanan County has about $55,000 available through the gold standard incentive, but the county has not been awarded any of these funds yet. 

The financial director for Buchanan County did not respond to multiple queries made via email and phone call regarding how the county has used its directly disbursed funds. 

In Roanoke, $200,446 was available in competitive grants and $590,172 was directly allocated to the city. Money from the direct allocation can be used as matching funds for a project proposal, and about $202,294 was awarded or used as matching funds this year.

Grant applications must align with specific goals that are outlined in the settlement litigation. Even money used from direct distributions must be carefully tracked and reported back to the state authority, said the authority’s executive director Tony McDowell. 

The grant application cycle for abatement funds falls between from Oct. 1 to April 1 of each year. In the months leading up to the opening day of the cycle, the state authority holds multiple virtual training sessions to help applicants build a grant proposal and offers pre-deadline reviews of the application before it’s submitted. 

State legislation identifies broad priority areas, which were created through a combination of the settlement agreement, state law and a statewide memorandum of understanding, McDowell said. 

Mixed priorities?

In Virginia, priority is given to initiatives that partner with existing organizations that have a track record of success in addressing opioid use disorder. Priority is also given to programs that focus on communities with high rates of opioid-related issues, targeting historically economically disadvantaged areas. 

Applications that include matching local funds are also given priority.

Many economically disadvantaged areas, however, are unlikely to have the resources, infrastructure or established programs necessary to demonstrate this level of success, potentially disadvantaging them in the competitive application process. 

Programs for pregnant and parenting women are not identified as a priority area in the state code, but according to McDowell, authority representatives work to inform localities that funds can be used for these types of programs through webinars and outreach.

According to Greene, Virginia is a leader in terms of how it’s prioritizing evidence-based programs, like inpatient residential treatment facilities. But smaller localities, like in Southwest Virginia, may struggle to pull together the partnerships that would give them a competitive edge for grant money. On top of that, applying for grants is a big undertaking, and smaller governments may not have resources to create effective grant applications.

Before reaching the grant portal on the Virginia Opioid Abatement Authority website, users see at least 47 links to user guides, registration training resources, rules and requirements and sample applications. Navigating further leads to a glossary of terms, policies on timeframe, lists of performance measures and numerous training videos, each about an hour long. 

The process is complex, and there’s a lot to learn about accessing funds effectively and then reporting back to the state authority that funding was used appropriately. For small local governments with limited staff, it’s likely overwhelming.

Simcox had the luxury of working with grant writers and pulled on other treatment organizations to create programs like the one at The Grove, which is a collaboration between Carilion Clinic, Restoration Housing and Anderson Treatment.

“You need somebody who knows the problem, can write and research the proposal, so it’s not going to deter us from trying to see our patients,” Simcox said. “With our boots on the ground experience we have a lot of ideas, but it takes a lot of time and resources to apply.” 

With limited resources, rural community service boards at a disadvantage to get competitive funds

The employees at the Cumberland Mountain Community Service Board, where Miracle Hawkinberry finally found the support she needed to enter recovery after entering drug court and detoxing in jail, have seen additional barriers play out for other rural boards, said Kristie Jones, the director of adult behavioral health services at the Cumberland board. 

Community service boards are publicly funded organizations that offer mental and behavioral health services throughout Virginia. The Cumberland board has one of the most robust resource networks in the region. It opened in 1972 to serve Buchanan, Tazewell and Russell counties and has expanded over the decades, opening a detox and recovery center, now known as Laurels Recovery Center, focused on alcoholism, which later evolved to treat other forms of substance abuse. It also offers support for mental health crises. 

Many of the boards across the state — there are 40 in Virginia — don’t provide inpatient services. While the Cumberland board does offer some inpatient services, it does not have accommodations for women to bring their children with them during treatment, which limits accessibility for mothers in need of care. 

Other boards have struggled to recruit and retain employees, and may not have the resources needed to apply for specialized grant funding, Jones added.

The priorities listed in the state code for abatement funds are focused on generally reducing overall negative effects of drug use on public health and safety, like providing inpatient services for all men and women rather than creating programs that target interventions for a specific demographic, McDowell said.

“If our grant application process seems complicated that probably is because of the amount of due diligence necessary to ensure these funds reach the people who need it, and that we are complying with the various court orders and applicable state law,” McDowell said. 

Even with the resource-rich Carilion Clinic backing her, Simcox said the grant committee turned down her team’s opioid abatement grant application, which would have funded a care coordinator role for a program that supports pregnant women with substance use disorder.