Tribal Leaders Call for Extended Grant Cycles, Equitable Grant Opportunities and More During Tribal Opioid Response Consultation

On November 9, 2023, the Substance Abuse and Mental Health Services Administration (SAMHSA) hosted a Consultation on the Tribal Opioid Response (TOR) grant funding methodology. Since the program’s inception in fiscal year (FY) 2018, SAMHSA has utilized user population estimates from the Indian Health Service (IHS) as the basis for determining grant award amounts for the TOR grant program. During the Consultation, SAMSHA was specifically seeking feedback and recommendations for the funding methodology of the grant program for FY 2024.

After reviewing the previous methodologies, five questions were posed to Tribal leaders:

Should SAMHSA award each TOR grant recipient the same amount, similar to other SAMHSA discretionary Tribal grant programs?
What other methodologies should be considered instead of or in addition to the above?
Should SAMHSA continue to utilize IHS user population estimates as the basis for determining TOR grant award amounts? If so, what tiers of funding should be established?
Given the requirement in the 2023 Consolidated Appropriations Act that the TOR formula methodology “gives preferences to Tribes and Tribal Organizations serving populations with demonstrated need with respect to opioid misuse and use disorder or drug overdose deaths,” how can Tribes demonstrate this need?
TOR has traditionally been administered as a 2-year program. There is an opportunity to extend this timeframe up to 3 or 5 years. How long should the TOR grant cycle be?

As to the first question, attendees voiced concerns with awarding each TOR recipient the same amount and everyone agreed that a tiered system is more equitable than equal distributions. Others suggested that funding should be based on user population or overall enrollment, or possibly a mix between demonstrated need and population. Another suggestion focused on the disparities that exist in remote locations, where the cost of creating and operating TOR-type programs require much more funding than non-remote locations. Staffing needs create funding issues in remote locations as well, as most qualified staff need increased financial incentives to live and work in remote areas.

As to the second question, some suggested that SAMHSA revise how it gathers data, to look at broader trends to identify opioid hotspots, and then to focus resources in those areas. Others explained that Tribal communities know their own specific needs and have a better understanding of their user populations, so external agencies should not determine scope of need or who is to be included in a user population. They suggested that receiving funds via contracting or compacting could address the concern. Another suggestion was that SAMHSA could award a base amount of grant funding, with additional dollars being provided for programs that have consistently shown success.

As to the third question, attendees pointed out that IHS user population estimates do not capture the fact that every AI/AN has the potential to be impacted by substance use; therefore, the actual need within a Tribal community cannot be accurately quantified, and that more funding for prevention is needed. Others explained that many Tribes that are in rural areas have members who reside in urban communities, and those in the urban areas may not be accurately counted. Some pointed to the inherent challenges that using the IHS user metric creates. For example, IHS uses the Purchased and Referred Care Delivery Area (PRCDA) to determine when and where it will acknowledge a patient as an opioid user. If an AI/AN patient resides outside the PRCDA, those patients do not count toward the IHS user total, thereby giving the appearance of a lack of need.

As to the fourth question, some were concerned that requirements involving the demonstration of need could harm grant recipients who run successful and long-standing programs, with those programs demonstrating a decreased need for grant funding because of their success. Another concern addressed the issue of misidentifying the cause-of-death for those who die from an overdose. For example, someone who likely died of an overdose may be determined to have died from respiratory or heart failure because autopsies or forensic evaluations are expensive for more rural counties. Others suggested that SAMHSA should provide suggestions on how to measure or demonstrate the need on the grant application itself. Geographical concerns, and the financial challenges that arise in addressing those concerns, were addressed by several attendees and it was suggested that SAMHSA should take note of geographic challenges in considering how need can be demonstrated.

As to the fifth question, some explained that more frequent grant opportunities would benefit Tribes that were not able to apply within the application window. Everyone seemed to agree that prevention, treatment, and creating programs with longevity require extending the funding cycles to 5 years. Many were concerned that programs that cannot count on longer funding cycles are much more likely to fail, as staff and clients all count on longevity to operate an effective program. Others explained that shorter-term funding cycles prevent institutional knowledge from being learned and handed down and they prevent long-term program planning. Another attendee explained that SAMHSA could adopt a three-year grant for new applicants and a 5-year grant for returning applicants.

What is TOR?

TOR’s purpose is to assist in addressing the overdose crisis in Tribal communities by increasing access to treatment of opioid use disorder, and supporting the continuum of prevention, harm reduction, treatment, and recovery support services for opioid use disorder and concurring substance use disorders. TOR also encourages the use of traditional practices. According to SAMHSA representatives, TOR has provided 11,142 individuals with opioid use disorder treatment and since April of 2022, TOR recipients have trained more than 39,000 community members on the use of naloxone, which has resulted in the reversal of 1,452 opioid overdoses.

What Next?

SAMHSA will accept written comments from Tribes until 5:00 PM ET on November 23, 2023. Comments can be emailed to [email protected]. SAMHSA will report on the outcomes of the Consultation within 90 calendar days of the final Consultation. The report will be provided by February 20, 2024.