U.S. Department of Health and Human Services 
Office of Inspector General 
 
 
States Use of 
Grant Funding for 
a Targeted 
Response to the 
Opioid Crisis
OEI-BL-18-00460 
Suzanne Murrin 
March 2020 
Deputy Inspector General 
 
  for Evaluation and Inspections 
oig.hhs.gov  Report in Brief  U.S. Department of Health and Human Services 
March 2020 
Office  of Inspector General 
OEI-BL-18-00460 
 
 
States Use of Grant Funding for a Targeted 
Why OIG Did This 
Response to the Opioid Crisis  
Review 
To address the increased need 
What OIG Found  for treatment services, the 21st 
More than $300 millionalmost a third of the total  Century Cures Act established 
Key Takeaway 
nationwide grant funding for the State Targeted  the STR grant program.  
States have been slow to spend 
Response to the Opioid Crisis grant program (STR  Through this program, 
their awards under the State 
grant program)remained unspent after 2 years.   SAMHSA awarded almost 
Targeted Response to the 
Among individual States, 14 spent less than half of  Opioid Crisis grant program  $1 billion in grants to States 
their respective grant allocations.  In total, all but  (STR grant program).  With an  over a 2-year grant period 
six States requested no-cost extensions that will  average of 130 opioid-overdose  (May 2017 through April 2019).  
allow them up to an additional 12 months to spend  deaths per day, it is paramount  States were required to use 
their original STR funding.  States attributed  that SAMHSA and its State  these funds to: 
partners quickly and effectively 
spending delays primarily to challenges related to 
 expand access to 
use Federal grant dollars to 
State procurement processes.  Additionally, several 
evidence-based treatment 
expand access to treatment for 
States are in danger of exceeding the legislatively 
opioid use disorder (OUD).    for OUD, especially MAT;  
mandated 5-percent cap on administrative costs.   
States reported that the STR   reduce unmet treatment 
Across all States, 65 percent of spending was  expenditures they did make  needs; and  
devoted to improving access to treatment in  allowed them to expand access   reduce opioid overdose-
general for opioid use disorder (OUD), and as a  to treatment; however,  related deaths through 
result, States reported that the number of patients  SAMHSA did not collect data to  the provision of 
determine how many patients 
receiving any type of OUD treatment increased  prevention, treatment, 
received medication-assisted 
substantially during the grant period.  However,  and recovery support 
treatment, an evidence-based 
although the Substance Abuse and Mental Health  services.  
treatment for OUD. 
Services Administration (SAMHSA) required States 
How OIG Did This 
to use STR grant funds to implement or expand 
Review 
access specifically to evidence-based OUD treatmentparticularly, medication-
assisted treatment (MAT)the agency did not collect data on how many  For 56 States and territories 
patients specifically received MAT versus other types of treatment (i.e.,  that received STR grants, we 
detoxification or abstinence-based treatment).     examined how much of each 
States award remained 
Given the lack of data, it is unclear how successful the STR grant program was at 
unspent at the end of the first 
achieving its goal of expanded access to MAT.  Without such data, SAMHSA has limited 
and second years of the grant 
means to monitor whether the money spent through the STR grant program, or other 
period.  We also reviewed 
future grant programs, is helping patients obtain effective, evidence-based treatment for 
progress reports to determine 
OUD. 
how States used STR grant 
funds to expand access to 
What OIG Recommends  
OUD prevention, evidence-
We recommend that SAMHSA work closely with States and territories during the 
based treatment, and recovery 
no-cost extension period to address barriers to timely spending and to ensure that 
support services.  We also 
administrative cost caps are not exceeded.  Additionally, we recommend that SAMHSA 
reviewed the number of 
require States that receive grants for OUD treatment to specifically report how many 
patients who received OUD 
patients are receiving MAT.  SAMHSA concurred with our recommendations.  
treatment and recovery 
services through STR-funded 
activities. 
Full report: oig.hhs.gov/oei/reports/oei-BL-18-00460.asp  TABLE OF CONTENTS 
BACKGROUND  1 
Methodology  5 
   
FINDINGS   
Almost a third of total nationwide STR grant funding ($304 million) remained unspent after  7 
2 years 
States reported using STR funding to expand access to treatment, but the number of patients  8 
who specifically received MAT is unknown  
   
CONCLUSION AND RECOMMENDATIONS   
Work closely with States and territories during the no-cost extension period to address  12 
barriers to timely spending and to ensure that administrative cost caps are met 
Require States receiving OUD treatment grants to specifically report how many patients are  13 
receiving evidence-based treatment, including MAT 
   
AGENCY COMMENTS AND OIG RESPONSE  14 
   
APPENDICES   
A:  Percentages of STR Awards That Remained Unspent by April 30, 2019  15 
B:  Percentage of STR Award Expenditures by Category as of October 31, 2018  17 
C:  Agency Comments  19 
   
ACKNOWLEDGMENTS  21 
   
BACKGROUND 
Objective  
To review grantees use of funds under the State Targeted 
Response to the Opioid Crisis grant program. 
The rise in opioid addiction and overdose rates among Americans 
combined with inadequate access to quality, specialized treatment for 
substance abuse continues to fuel the opioid crisis.  More than 2 million 
people in the United States have an opioid use disorder (OUD) related to 
prescription pain relievers and/or heroin.1  Moreover, roughly two-thirds of 
the 70,000 drug overdose deaths in 2017 involved an opioid, with an 
average of 130 opioid-overdose deaths each day.2  Access to appropriate 
treatment is vital in addressing the escalating rates of addiction and 
mortality.  However, the Substance Abuse and Mental Health Services 
Administration (SAMHSA) estimates that only 29 percent of people with 
OUD received specialty treatment for illicit drug use in 2017.3   
To address the increased need for OUD treatment services, the 21st Century 
Cures Act established the State Targeted Response to the Opioid Crisis 
grant program, hereinafter referred to as the STR grant program.4 The STR 
grant program, administered by SAMHSA, provided $1 billion over a 2-year 
period to 57 States and U.S. territories.  According to SAMHSA, the purpose 
of the program is to expand access to evidence-based OUD treatment, 
particularly medication-assisted treatment (MAT); reduce unmet treatment 
needs; and reduce opioid overdose-related deaths through the provision of 
prevention, treatment, and recovery support services.5, 6   (Recovery support 
typically occurs after treatment begins and is an ongoing process in which 
patients rebuild their lives, relationships, and health.7) 
In this report, OIG examined how States and territories used STR grant 
funds disbursed in 2017 and 2018 to meet the above goals. 
Medication-Assisted  MAT is widely recognized as the primary evidence-based treatment for 
OUD.8, 9  It includes the use of medications approved by the Food and Drug 
Treatment 
Administration (FDA) in combination with behavioral interventions and 
recovery support services.10  Exhibit 1 provides an overview of the 
medications (i.e., methadone, buprenorphine, and naltrexone) used in MAT.  
Some in the treatment community adhere to an abstinence-only philosophy 
thatin contrast to MATavoids the use of medications, particularly those 
that activate opioid receptors.  However, abstinence-based treatmentthe 
use of behavioral therapy or counseling combined with complete 
abstinenceis not scientifically supported.  MAT has been found to be 
States Use of Grant Funding for a Targeted Response to the Opioid Crisis  1 
OEI-BL-18-00460   
more effective than abstinence-based treatment at keeping patients in 
treatment and reducing their use of opioids because MAT drugs are 
designed to reduce opioid cravings and withdrawal.11  Research has also 
shown that abstinence-based treatment is associated with a very high 
relapse rate, and significantly increases an individuals risk for opioid 
overdose and death if opioid use is resumed.12, 13   
Exhibit 1: Three FDA-Approved Drugs Are Used in Medication-Assisted Treatment. 
MAT is the use of medications coupled with effective behavioral therapies and recovery support services to 
treat OUD and prevent opioid overdose.  There are three FDA-approved drugs used in MAT, and each is 
subject to different restrictions. 
Methadone  Buprenorphine  Naltrexone 
  Schedule II controlled    Schedule III controlled    Not a controlled substance   
substance  substance      Can be prescribed by any 
  Dispensed only through    Dispensed through a  health care provider 
SAMHSA-certified Opioid  SAMHSA-certified OTP or a  licensed to prescribe 
Treatment Programs (OTPs)  Buprenorphine-Waivered  medications 
Office-Based Opioid 
Treatment practice 
 
Source: SAMHSA, Medication-Assisted Treatment, April 26, 2019.  Accessed at https://www.samhsa.gov/medication-assisted-treatment on 
September 3, 2019.  
Note:   Schedule II drugs have a high potential for abuse, with use potentially leading to severe psychological or physical dependence.  
Schedule III drugs have a moderate to low potential for physical and psychological dependence. 
Despite the well-documented effectiveness of MAT, individuals often 
encounter barriers to accessing this type of treatment.14, 15  Because of the 
historic emphasis on abstinence in substance abuse treatment, MAT has 
sometimes been stigmatized and dismissed as substituting one addiction 
for another.16  Many patients seeking OUD treatment experience difficulties 
in finding providers who prescribe MAT,17 as approximately 90 percent of 
conventional drug treatment facilities do not offer it.18  Additionally, prior 
OIG work and other research have demonstrated that there are geographic 
disparities in the availability of MAT services.19, 20   
To address these barriers, the U.S. Department of Health and Human 
Services (HHS) developed a Five-Point Strategy to Combat the Opioid Crisis, 
which prioritizes improving access to MAT and strengthening data 
collection and reporting on patients receiving MAT.21  The STR grant 
program represents one of HHSs primary efforts to meet these stated 
goals.22  However, in a 2017 review, the Government Accountability Office  
found that HHS had not established performance measures that would 
allow HHS to determine whether its various programs, including the STR 
grant program, were successful in expanding access to MAT.23 
 
States Use of Grant Funding for a Targeted Response to the Opioid Crisis  2 
OEI-BL-18-00460   
State Targeted  The STR grant program was SAMHSAs first opioid-specific grant program 
that provided nationwide funding to expand access to OUD prevention, 
Response to the 
treatment, and recovery support services.  The agency awarded $970 million 
Opioid Crisis Grants 
in STR funding across all 50 States, the District of Columbia, 4 U.S. 
territories, and the free-associated States of Palau and Micronesia 
(collectively referred to hereafter as States).24, 25  SAMHSA allocated this 
funding using a formula based on drug-related deaths and unmet 
treatment needs in each State.26  Funds were split over a 2-year period, with 
$485 million awarded for the first grant year (May 1, 2017, to April 30, 2018) 
and the remaining $485 million awarded for the second grant year (May 1, 
2018, to April 30, 2019).27, 28  SAMHSA also divided an additional $1 million in 
supplemental STR funding among three StatesMassachusetts, New 
Hampshire, and West Virginiathat have been particularly affected by the 
opioid crisis.29 
Required Activities 
States were required to develop a strategic plan identifying and addressing 
gaps in OUD prevention, treatment, and recovery support services.30  Within 
this broad mandate, States were given flexibility to determine how to best 
use funds to meet the needs of their respective communities.  SAMHSA 
reviewed and approved each States strategic plan. 
Although States had flexibility to use STR funding for a variety of activities, 
SAMHSA required all strategic plans to address the following: 
  designing and implementing primary and secondary prevention 
methods; 
  implementing or expanding access to clinically appropriate 
evidence-based treatmentparticularly, the use of MAT; 
  assisting patients with treatment costs; 
  providing treatment coverage for patients transitioning from 
criminal justice or other rehabilitative settings; and 
  enhancing recovery support services. 
States were also permitted to use funds to train practitioners; support 
telehealth in rural and underserved areas; purchase the overdose-reversal 
drug naloxone for distribution; enhance their respective State Prescription 
Drug Monitoring Programs; and conduct other nondirect allowable activities 
specified by SAMHSA.31, 32 
Funding Requirements 
States were required to spend funds in accordance with SAMHSAs funding 
requirements, which included provisions that:33   
  funds may supplement, but not supplant, existing OUD prevention, 
treatment, and recovery support services within the State; 
States Use of Grant Funding for a Targeted Response to the Opioid Crisis  3 
OEI-BL-18-00460   
  providers that receive funding must not deny a patient access to 
MAT or consider a patient not in recovery based solely on the 
patients use of MAT; and 
  no more than 5 percent of the total 2-year grant award can be used 
for administrative and infrastructure development costs. 
States were permitted to carry over unobligated funds to the second year of 
the STR grant program if the amount did not exceed 10 percent of the 
States approved annual budget.34, 35  To carry over unobligated funds 
exceeding this amount, prior approval from SAMHSA was required.  
Although the 2-year STR grant period ended on April 30, 2019, States could 
apply to SAMHSA for a one-time no-cost extension.  This extended the final 
budget period for up to 12 months to give States additional time to obligate 
and spend their STR grant funds beyond the original end date for the 
project. 
Reporting Requirements 
States were required to submit both financial and progress reports twice 
a year (every November and May).  Progress reports included information 
on how States allocated their STR funding across the different areas (i.e., 
prevention, treatment, recovery, and administrative costs) as well as 
information on the number of people receiving treatment and recovery 
support services through STR grant funding.36 
STR Grant Program Reauthorization 
The SUPPORT for Patients and Communities Act of 2018 reauthorized the 
STR grant program through FY 2021.37  However, Congress did not allocate 
new funds to STR in FY 2019.  Instead, Congress provided funding through a 
new effortthe State Opioid Response (SOR) grant program.38 
State Opioid  As described above, Congress established the SOR grant program to build 
upon the STR grant program.  The requirements for the SOR grant program 
Response Grants 
are similar to those for STR grants but are more explicitly focused on 
increasing access to MAT using the three FDA-approved medications for 
the treatment of opioid use disorder.39 
SAMHSA awarded the first SOR grant 17 months after it awarded the first 
STR grant.40  Therefore, States received both STR and SOR funding during 
the second year of the STR grant period, as depicted in Exhibit 2 (see next 
page).  The SOR funding was distributed using a formula similar to the STR 
grant formula, but it included an additional 15-percent set-aside for the 
10 States hardest hit by the crisis.41  SAMHSA first announced awarding $930 
million in SOR grants on September 19, 2018, and announced an additional 
$487 million in supplementary funding on March 20, 2019.42, 43  Another 
$932 million was announced in September 2019 for second-year SOR 
grants.44 
States Use of Grant Funding for a Targeted Response to the Opioid Crisis  4 
OEI-BL-18-00460   
Exhibit 2.  States Received Both STR and SOR Grant Funding During 
the Second Year of the STR Grant Program. 
   
Source: OIG review of SAMHSA grant award announcements 
Methodology  Scope 
This study included 56 of the 57 States and territories that received STR 
awards during the 2-year grant period (May 2017 through April 2019).  We 
excluded one territorythe U.S. Virgin Islandsfrom our analysis because 
a hurricane had destroyed its communications infrastructure, rendering it 
unable to implement its STR grant program.  This study examined only 
funds disbursed under the STR grant program.  We did not include any 
other SAMHSA grant programs, such as SOR grants, in this review. 
Data Sources 
We obtained drawdown data from the HHS Payment Management System 
for both years of the STR grant program (May 2017 through April 2019).  
Drawdown data reflects records of grantee withdrawals of STR funds.   
From SAMHSA, we obtained a list of the States that requested to carry over 
first-year STR grant funds into the second year of the grant program; the 
amounts they requested to carry over; and the States rationales for the 
unspent funds.  We also obtained a list of the States that requested a no-
cost extension to allow for up to 12 additional months to spend their grant 
funds beyond the original end date for the project. 
We also obtained from SAMHSA the three 6-month STR grant progress 
reports that each State submitted for the first 18 months of the program 
(May 2017 through October 2018).  The progress reports for the final 
6 months of the 2-year STR grant program (November 2018 through 
April 2019) were not available at the time of our review.  The STR progress 
reports included data on (1) how States allocated funding among the 
various priorities, (2) the OUD service providers that received grant funding, 
and (3) the number of patients receiving treatment and recovery support 
services through STR grants. 
States Use of Grant Funding for a Targeted Response to the Opioid Crisis  5 
OEI-BL-18-00460   
Data Analysis 
We analyzed STR grant drawdown data to determine how much of each 
States award remained unspent after each year of the 2-year grant period.  
We examined the States carryover requests to determine how many States 
requested to carry over more than 10 percent of their funding and why their 
grant awards had remained unspent.  We also examined how many States 
requested no-cost extensions for additional time to spend their grant funds 
beyond the original end date for the project. 
We reviewed the three progress reports that each State submitted at 
6-month intervals to determine (1) the amount of funding devoted to 
prevention, treatment, recovery support, and administrative costs after 18 
months of STR grant funding; (2) how States reported using STR funds to 
expand access to MAT; and (3) the number of patients who received 
treatment and recovery support services during each 6-month period.  
Limitations 
This report relied on States self-reported data on how the STR grant 
funding was spentthe priority areas on which they focused; the type of 
providers that received subrecipient funding; and the number of patients 
who received services.  OIG did not independently assess the validity of 
these data. 
Although SAMHSA maintained its own financial records about the overall 
amount drawn down and carried over by each State, it relied on States 
progress reports for more detailed information about how STR funding was 
spent (e.g., the proportions dedicated to prevention, treatment, recovery 
support, and administrative costs).  Although these data were self-reported 
by each State, they were the best available information about how States 
were using their STR awards.  
Standards  We conducted this study in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General on 
Integrity and Efficiency.   
States Use of Grant Funding for a Targeted Response to the Opioid Crisis  6 
OEI-BL-18-00460   
FINDINGS 
Almost a third of  States have been slow to spend their STR awards, with $304 million 
remaining unspent after 2 years  
the total nationwide 
During the first grant year, most States experienced delays in implementing 
STR grant funding 
their respective STR grant programs.  In total, $295 million (61 percent) of 
($304 million) 
the $485 million award allocated in the first year remained unspent after 
remained unspent  12 months.  As a result, all but 2 States carried over first-year funding into 
the second yearincluding 17 that requested to carry over more than half 
after 2 years 
of their annual funding. 
Although expenditures increased during year two of the grant, 
$304 million31 percent of the total 2-year $970 million awardstill 
remained unspent after 24 months.  This included nine States and five 
territories that spent less than half of their respective grant allocations.  (See 
Exhibit 3.)  Six of the nine States had drug overdose death rates that were 
higher than the national rate, so their inability to expend STR funding is 
particularly concerning.45  (Data on overdose death rates in U.S. territories 
were not available.)  For example, West Virginias drug overdose death rate 
was more than double the national rate, yet it still had nearly two-thirds of 
its STR award remaining at the end of the second year.  Appendix A shows 
the percentage of each STR grant award that was spent by April 30, 2019.  In 
total, all but six States requested a no-cost extension that will allow them to 
spend their STR funding for up to 12 months beyond the original end date 
for the project.46   
Exhibit 3: Fourteen States Spent Less Than Half of Their Respective 
STR Grant Awards by the End of the 2-Year STR Grant Period.  
Total Spent Remaining Balance
Micronesia 22.6% 77.4%
Northern Marianas 23.2% 76.8%
Puerto Rico 31.2% 68.8%
West Virginia 34.1% 65.9%
Vermont 36.4% 63.6%
Delaware 36.8% 63.2%
Arkansas 39.1% 60.9%
Nebraska 43.6% 56.4%
Palau 44.0% 56.0%
Montana 45.2% 54.8%
Louisiana 45.8% 54.2%
Indiana 46.9% 53.1%
American Samoa 47.5% 52.5%
Arizona 49.4% 50.6%
  
Source: OIG analysis of the Payment Management Systems Grant Drawdown Report, May 2, 2019. 
States Use of Grant Funding for a Targeted Response to the Opioid Crisis  7 
OEI-BL-18-00460   
Challenges with State procurement processes were a primary driver 
for spending delays 
SAMHSA staff reported that the most common explanation for States not 
drawing down significant portions of their respective STR awards was 
challenges related to State procurement processes.  Procurement 
challenges included State legislative timelines that did not align with Federal 
appropriation cycles; State staffing shortages, sometimes as a result of 
hiring freezes; reluctance from contract bidders because the grants had a 
short duration (i.e., 2 years);47 and delays that resulted from contract 
negotiations.  In addition to States encountering procurement challenges, 
some States also expressed to SAMHSA that they had not drawn down their 
awards because of workforce challenges and stigma related to MAT. 
Although SAMHSA cannot assist with State-specific procurement processes, 
it stated that it works with States to accelerate program implementation in 
other ways.  For example, SAMHSA awarded an STR technical assistance 
contract to the American Academy of Addiction Psychiatry, which partnered 
with 27 other national professional organizations to form the Opioid 
Response Network.  This network provides training and technical assistance 
focusing on applying evidence-based practices in prevention, treatment, 
and recovery support to meet locally identified needs.  SAMHSA also 
reported that it works with States via regular conference calls and prioritized 
site visits.  These technical assistance activities are intended to support 
States in effectively expending their STR awards by helping States overcome 
obstacles to expanding OUD prevention, treatment, and recovery support 
services in their respective local communities.  
States reported  Across all States, 65 percent of STR funding was devoted to 
expanding access to treatment 
using STR funding 
According to SAMHSA, funding under the STR grant program was intended 
to expand access 
to expand access to evidence-based OUD treatment, especially MAT; 
to treatment, but  reduce unmet treatment needs; and reduce opioid overdose-related deaths 
the number of  through the provision of prevention, treatment, and recovery support 
services.  States had flexibility in determining how to prioritize these goals 
patients who 
when spending their STR awards. 
specifically 
During the first 18 months of the 2-year grant program, 65 percent of the 
received MAT is 
total STR funding spent nationwide was devoted to treatment, 17 percent to 
unknown 
prevention, 13 percent to recovery support, and the remaining 4 percent to 
  administrative costs.  (See Exhibit 4.)  However, there was wide variation 
among States in how they allocated funding in accordance with their 
assessment of local needs.  For example, 46 States reported that more than 
half of their expenditures went to treatment services.  Among these 
46 States were 2 StatesDelaware and Floridathat dedicated more than 
90 percent of their expenditures to treatment.  In contrast, one State
Massachusettsreported that it spent more than half of its expenditures on 
recovery support services.  Two StatesSouth Dakota and Nebraska
States Use of Grant Funding for a Targeted Response to the Opioid Crisis  8 
OEI-BL-18-00460   
reported that they spent more than half on prevention.  Appendix B shows 
the percentage of each States STR grant award expenditures by category. 
Exhibit 4: Nearly Two-Thirds of STR Grant Funding Spent During the 
First 18 Months Was Devoted to Treatment. 
65%
17%
13%
4%
Treatment Prevention Recovery Support Administration
 
Source: OIG analysis of SAMHSA STR Grant data, 2019. 
Although 4 percent of funding was spent nationwide on administrative 
costs, more than a third of States (22 of 56) were exceeding the 5-percent 
administrative spending cap at the 18-month mark of the 2-year grant 
period.  (See Appendix B.)  This included eight States that had spent 
10 percent or more in this area.  SAMHSA staff noted that administrative 
expenses are often higher during the initial implementation of a grant and 
that agency staff work closely with grantees to ensure that administrative 
caps are not exceeded by the time all funds have been disbursed.  However, 
at least according to the 18-month data reported to SAMHSA, two States 
(i.e., Georgia and Minnesota) will exceed the 5-percent threshold even if they 
do not spend another dollar on administrative costs during the remainder of 
the grant. 
STR grant funding increased the number of patients receiving some 
form of OUD treatment, but SAMHSA did not track whether these 
patients received MAT 
SAMHSA required States to use STR grant funds to implement or expand 
access to evidence-based treatment for OUD, particularly MAT.  However, 
SAMHSA required States to provide data only on the number of patients 
who received any type of OUD treatment (i.e., detoxification, 
abstinence-based approaches, or MAT).  SAMHSA did not collect data on 
the precise numbers of patients who received MAT services through 
STR funding, but rather on the broad numerical ranges of such patients
States Use of Grant Funding for a Targeted Response to the Opioid Crisis  9 
OEI-BL-18-00460   
e.g., 25 to 49, 100 to 249, 1000 or more.  As a result, an exact count of 
patients receiving STR-funded MAT cannot be calculated. 
As shown in Exhibit 5, the number of patients receiving any OUD treatment 
(not exclusively MAT) under STR grants nationwide increased steadily from 
about 37,000 patients during the first half of the first grant year to 
approximately 118,000 during the first half of the second year.  Similarly, the 
number of patients receiving recovery support services also increased over 
time, from 13,000 in the first 6 months of the grant to nearly 54,000 patients 
1 year later.   
Exhibit 5: The Number of Patients Receiving Treatment and Recovery 
Support Services Increased Substantially After Initial Delays in 
Implementation of the STR Program. 
Treatment Recovery Support
140,000
118,271
120,000
100,000
84,640
80,000
53,749
60,000
37,141
40,000
20,629
12,973
20,000
0
May 2017Oct. 2017 Nov. 2017Apr. 2018 May 2018Oct. 2018
 
Source: OIG analysis of SAMHSA STR grant data, 2019. 
The information above suggests that the STR grant program was likely 
successful in expanding access to general OUD treatment and recovery 
support services, given that Congress required States to use allocated funds 
to supplement, not supplant, existing treatment and recovery support 
services.  However, it is unclear how successful the program was at 
achieving its goal of expanding access to MAT, because SAMHSA did not 
collect specific data on how many patients received this service. 
Although we were unable to determine how many patients received MAT, 
SAMHSA did ask States to indicate whether they were using STR grant 
funding to expand access to MAT in different clinical and institutional 
settings.  During the most recent reporting period (May through 
October 2018), 50 of the 56 States and territories responded that they were 
using STR grant funds to expand access to at least one of the three types of 
MAT.  As shown in Exhibit 6, 71 percent of States reported using STR 
funding to expand access to MAT in Opioid Treatment Programs 
(commonly known as methadone clinics), 62 percent to MAT in doctors 
offices, and 52 percent to MAT in other settings.  Additionally, nearly 
States Use of Grant Funding for a Targeted Response to the Opioid Crisis  10 
OEI-BL-18-00460   
two-thirds of States reported offering MAT services to patients transitioning 
from criminal justice facilities or residential settings for substance-abuse 
treatment.  During the same period (May through October 2018), States 
indicated that they allocated funds to a total of 641 MAT-providing entities.   
Exhibit 6: Most States Reported Using STR Grant Funds To Expand 
Access to MAT. 
States Using STR 
Grant Funds for This 
Select STR Grant Priority Areas  Service 
Expanding the number of patients served with: 
Methadone, buprenorphine, or naltrexone in  40 (71%) 
Opioid Treatment Programs  
Buprenorphine-Waivered Office-Based Opioid  35 (62%) 
Treatment practice settings 
Naltrexone in other settings  29 (52%) 
Expanding the number of MAT patients admitted from:  
Hospital emergency departments or hospital  32 (57%) 
inpatient treatment units 
Detoxification services  26 (46%) 
Residential services for substance-abuse  37 (66%) 
treatment 
Correctional or detention facilities  34 (61%) 
Source: OIG analysis of SAMHSA May to October 2018 STR Grant Report, 2019.  N = 56 States and 
territories.    
States Use of Grant Funding for a Targeted Response to the Opioid Crisis  11 
OEI-BL-18-00460   
CONCLUSION AND RECOMMENDATIONS 
With an average of 130 opioid-overdose deaths per day,48 it is paramount 
that SAMHSA and its State partners quickly and effectively use Federal grant 
dollars to expand access to OUD treatment.  The STR grant program 
represented SAMHSAs first nationwide effort to assist States in addressing 
the opioid crisis through improved access to evidence-based OUD 
treatment services.  In this review, OIG found that most States were slow to 
spend their STR awards, with $304 millionalmost a third of total funding
remaining unspent after 2 years.  These delays raise serious concerns given 
the urgency of the opioid crisis as well as the billions in additional opioid 
funding allocated through other grant programs, such as the SOR grant 
program.  The fact that many States found it difficult to spend STR awards in 
a timely fashion leads to questions about their capacity to meet the urgent 
treatment needs of Americans suffering from OUD.  If States are slow or 
stalled in spending Federal grants, local communities may not have the 
resources needed to fight the overdose epidemic and to continue their 
efforts to reverse the OUD crisis. 
In addition, several States were also in danger of exceeding the legislatively 
mandated 5-percent cap on administrative costs.  According to data 
provided to SAMHSA, two of these States may have already exceeded this 
threshold. 
Nonetheless, States reported using STR grant funding to expand access to 
treatment services.  Across all 56 States and territories included in our 
review, 65 percent of spending over the first 18 months was devoted to 
increasing access to some form of OUD treatment, with most States 
reporting that at least a portion of their respective STR awards went towards 
MAT-related services.  However, SAMHSA did not collect data on how many 
patients specifically received MATthe primary evidence-based OUD 
treatmentversus other types of treatment (abstinence or detoxification).  
Without such information, it is unclear how successful the program was at 
achieving its goal of expanding access to evidence-based OUD treatment. 
We recommend that SAMHSA do the following: 
Work closely with States and territories during the no-cost 
extension period to address barriers to timely spending and to 
ensure that administrative cost caps are not exceeded 
Fifty-one States and territories requested no-cost extensions that will allow 
them to spend their STR funding for up to 12 months beyond the original 
end date for the project.  During this additional time, SAMHSA should 
proactively monitor Statesparticularly, the 14 that have spent less than 
half of their respective grant allocationsto ensure they efficiently and 
effectively spend their awards to meet STR program goals.  If States are 
States Use of Grant Funding for a Targeted Response to the Opioid Crisis  12 
OEI-BL-18-00460   
experiencing barriers to expanding OUD treatment capacity through the 
STR program, these same barriers could likewise limit their ability to 
effectively administer similar grant programs, such as the SOR grants.  
SAMHSA could take any lessons learned from assisting States with barriers 
to OUD treatment expansion and apply them to future grant programs with 
similar goals.  Likewise, SAMHSA should apply any tools and lessons learned 
from its monitoring of the STR grant expenditures (including oversight of 
States administrative spending) to be better prepared for oversight of other 
opioid treatment grant programs, like SOR.    
Additionally, SAMHSA staff should carefully review the administrative costs 
reported by States since our review, with particular attention to the 
22 States at risk of exceeding the 5-percent cap on such costs.  SAMHSA 
should impose additional award conditions, such as requiring additional 
project monitoring and more detailed financial reports, for those States that 
have exceeded the administrative cost cap.49 
Require States that receive grants for OUD treatment to 
specifically report how many patients are receiving MAT  
A key strategy of HHSs Five-Point Strategy to Combat the Opioid Crisis is to 
strengthen public health data reporting and collection to improve the 
timeliness and specificity of data.  A primary goal associated with this 
strategy is to collect better data on outcomes, including better data on the 
number of patients receiving MAT.  Also, in an October 2017 report, GAO 
found that HHS lacked specific performance measures to evaluate whether 
its efforts had expanded access to MAT, and recommended that HHS 
establish performance measures with targets related to expanding access 
to MAT.50 
SAMHSA is one of the primary Federal agencies charged with providing 
funding to States to address the opioid crisis and plays a significant role in 
HHSs efforts to collect more timely and specific data in this area.51  As 
SAMHSA continues to administer grant programs intended to increase 
access to OUD treatment, it should develop specific metrics to track and 
monitor whether the patients served through these programs are receiving 
MAT, the primary evidence-based treatment for OUD.  Without such data, 
SAMHSA has limited means to monitor whether the money spent through 
STR grants, SOR grants, and other future grant programs is helping patients 
obtain effective, evidence-based treatment for OUD. 
   
States Use of Grant Funding for a Targeted Response to the Opioid Crisis  13 
OEI-BL-18-00460   
AGENCY COMMENTS AND OIG RESPONSE 
SAMHSA concurred with both of our recommendations. 
In response to our first recommendation, SAMHSA noted that it permitted 
no-cost extensions so that States had additional time to complete grant 
activities that might have been delayed because of procurement processes 
or other challenges.  SAMHSA also stated that its Government Project 
Officers communicate regularly with States to discuss barriers to 
implementation, provide guidance, and direct grantees to appropriate 
technical assistance.  OIG believes that as part of this process, SAMHSA 
should work proactively with the 14 States and territories identified in this 
report that had spent less than half of their grant allocations, as these States 
may be encountering significant challenges.  Additionally, OIG urges 
SAMHSA to monitor the 22 States and territories at risk of exceeding the 
5-percent administrative cost cap and impose additional award conditions 
on those that exceed it. 
In response to the second recommendation, SAMHSA indicated that its 
newer opioid-related grant program, the SOR grant program, requires the 
reporting of more detailed information, including the exact number of 
clients receiving MAT services.  OIG believes that SAMHSAs efforts to 
collect more precise data under the SOR grant program will improve HHSs 
ability to evaluate whether its efforts have expanded access to effective, 
evidence-based treatment for OUD. 
Finally, SAMHSA took issue with how OIGs findings presented data related 
to MAT reporting.  SAMHSA stated that it tracked whether STR grant 
funding was used to provide MAT, but that it did not collect data on the 
exact number of patients receiving MAT.  OIG acknowledges this in the 
report and makes the point that collecting data on numerical ranges of 
patients who were provided MAT does not allow OIG or SAMHSA to 
calculate the total number of patients receiving MAT through STR funding.    
For the full text of SAMHSAs comments, see Appendix C.  
 
   
States Use of Grant Funding for a Targeted Response to the Opioid Crisis  14 
OEI-BL-18-00460   
APPENDIX A:  Percentages of STR Awards 
That Remained Unspent After 2 Years 
State  2-Year Grant Award  Total Spent  Remaining Balance 
Alabama  15,935,746  91.9%  8.1% 
Alaska  4,000,000  51.2%  48.8% 
American Samoa  500,000  47.5%  52.5% 
Arizona  24,343,036  49.4%  50.6% 
Arkansas  7,802,590  39.1%  60.9% 
California  89,499,542  50.2%  49.8% 
Colorado  15,739,302  78.3%  21.7% 
Connecticut  11,000,314  88.4%  11.6% 
Delaware  4,000,000  36.8%  63.2% 
District of Columbia  4,000,000  52.1%  47.9% 
Florida  54,300,806  88.6%  11.4% 
Georgia  23,565,420  72.2%  27.8% 
Hawaii  4,000,000  59.6%  40.4% 
Idaho  4,000,000  94.2%  5.8% 
Illinois  32,657,166  71.6%  28.4% 
Indiana  21,851,984  46.9%  53.1% 
Iowa  5,456,154  75.4%  24.6% 
Kansas  6,228,804  93.3%  6.7% 
Kentucky  21,056,186  62.9%  37.1% 
Louisiana  16,335,942  45.8%  54.2% 
Maine  4,078,058  71.5%  28.5% 
Maryland  20,073,627  58.9%  41.1% 
Massachusetts  23,818,848  80.9%  19.1% 
Michigan  32,745,360  56.0%  44.0% 
Micronesia  500,000  22.6%  77.4% 
Minnesota  10,758,698  73.3%  26.7% 
Mississippi  7,169,354  71.6%  28.4% 
Missouri  20,031,796  97.3%  2.7% 
Montana  4,000,000  45.2%  54.8% 
Nebraska  4,000,000  43.6%  56.4% 
Nevada  11,326,656  67.1%  32.9% 
New Hampshire  6,589,732  55.3%  44.7% 
New Jersey  25,991,241  55.5%  44.5% 
New Mexico  9,585,102  87.3%  12.7% 
New York  50,521,352  74.4%  25.6% 
North Carolina  31,173,448  90.9%  9.1% 
North Dakota  4,000,000  89.6%  10.4% 
Northern Marianas  500,000  23.2%  76.8% 
States Use of Grant Funding for a Targeted Response to the Opioid Crisis  15 
OEI-BL-18-00460   
State  2-Year Grant Award  Total Spent  Remaining Balance 
Ohio  52,121,004  77.0%  23.0% 
Oklahoma  14,566,458  84.7%  15.3% 
Oregon  13,128,850  55.2%  44.8% 
Palau  500,000  44.0%  56.0% 
Pennsylvania  53,015,118  73.4%  26.6% 
Puerto Rico  9,623,924  31.2%  68.8% 
Rhode Island  4,334,014  71.4%  28.6% 
South Carolina  13,151,246  94.6%  5.4% 
South Dakota  3,999,994  53.6%  46.4% 
Tennessee  27,630,264  90.2%  9.8% 
Texas  54,724,714  52.1%  47.9% 
Utah  11,074,916  85.5%  14.5% 
Vermont  4,000,000  36.4%  63.6% 
Virginia  19,524,664  95.4%  4.6% 
Washington  23,580,512  70.0%  30.0% 
West Virginia  12,096,966  34.1%  65.9% 
Wisconsin  15,273,876  60.0%  40.0% 
Wyoming  4,000,000  82.3%  17.7% 
Total  969,482,784  68.7%  31.3% 
 
   
States Use of Grant Funding for a Targeted Response to the Opioid Crisis  16 
OEI-BL-18-00460   
APPENDIX B:  Percentage of STR Award 
Expenditures by Category After 18 Months 
State  Prevention  Treatment  Recovery Support  Administration 
Alabama  8.9%  85.6%  2.9%  2.6% 
Alaska  31.4%  33.3%  35.2%  0.0% 
American Samoa  12.5%  84.5%  0.0%  3.0% 
Arizona  24.0%  73.0%  0.0%  2.9% 
Arkansas  23.1%  46.6%  14.7%  15.6% 
California  34.7%  63.6%  0.0%  1.6% 
Colorado  20.3%  76.3%  3.2%  0.3% 
Connecticut  29.7%  44.9%  23.8%  1.6% 
Delaware  0.2%  91.9%  0.0%  7.9% 
District of Columbia  9.9%  87.2%  0.5%  2.3% 
Florida  1.5%  91.7%  3.5%  3.3% 
Georgia  20.2%  52.1%  14.3%  13.3% 
Hawaii  9.9%  80.1%  10.0%  0.0% 
Idaho  6.1%  65.8%  26.1%  2.0% 
Illinois  14.6%  81.1%  1.2%  3.1% 
Indiana  29.2%  60.5%  0.0%  10.3% 
Iowa  22.2%  72.7%  0.0%  5.1% 
Kansas  12.9%  81.4%  4.6%  1.2% 
Kentucky  24.2%  55.5%  14.4%  5.9% 
Louisiana  16.7%  62.7%  8.7%  11.9% 
Maine  22.9%  74.9%  2.0%  0.2% 
Maryland  28.6%  69.2%  1.4%  0.8% 
Massachusetts  12.7%  8.5%  74.1%  4.7% 
Michigan  32.2%  53.0%  7.8%  7.0% 
Micronesia  8.4%  77.5%  6.4%  7.7% 
Minnesota  23.8%  53.5%  13.2%  9.5% 
Mississippi  9.5%  86.0%  1.0%  3.5% 
Missouri  4.9%  83.3%  7.8%  3.9% 
Montana  21.5%  54.7%  12.3%  11.5% 
Nebraska  54.5%  37.0%  0.0%  8.5% 
Nevada  13.2%  81.7%  0.0%  5.1% 
New Hampshire  39.1%  54.5%  6.4%  0.0% 
New Jersey  3.5%  43.1%  48.8%  4.6% 
New Mexico  22.2%  63.1%  10.5%  4.2% 
New York  18.6%  46.6%  31.6%  3.3% 
North Carolina  12.8%  80.3%  6.2%  0.7% 
North Dakota  24.8%  59.3%  10.4%  5.5% 
Northern Marianas  0.0%  86.2%  0.0%  13.8% 
Ohio  21.1%  76.2%  0.0%  2.7% 
Oklahoma  32.6%  54.9%  5.0%  7.5% 
States Use of Grant Funding for a Targeted Response to the Opioid Crisis  17 
OEI-BL-18-00460   
State  Prevention  Treatment  Recovery Support  Administration 
Oregon  26.1%  63.5%  8.0%  2.4% 
Palau  7.0%  81.7%  8.3%  3.0% 
Pennsylvania  15.7%  65.4%  14.6%  4.3% 
Puerto Rico  27.1%  63.1%  0.7%  9.1% 
Rhode Island  22.7%  35.4%  35.4%  6.4% 
South Carolina  17.4%  62.0%  16.6%  4.0% 
South Dakota  79.3%  7.5%  2.7%  10.5% 
Tennessee  18.3%  71.8%  7.0%  2.9% 
Texas  9.5%  52.3%  30.3%  7.9% 
Utah  11.6%  73.7%  10.0%  4.6% 
Vermont  25.8%  24.1%  37.2%  12.8% 
Virginia  24.9%  53.8%  17.7%  3.6% 
Washington  15.1%  71.8%  8.2%  5.0% 
West Virginia  18.4%  70.7%  8.9%  1.9% 
Wisconsin  11.8%  63.6%  18.4%  6.1% 
Wyoming  8.9%  84.1%  6.7%  0.4% 
Total Expenditures  17.2%  65.4%  13.2%  4.2% 
Nationwide 
 
   
States Use of Grant Funding for a Targeted Response to the Opioid Crisis  18 
OEI-BL-18-00460   
APPENDIX C:  Agency Comments 
   
States Use of Grant Funding for a Targeted Response to the Opioid Crisis  19 
OEI-BL-18-00460   
 
States Use of Grant Funding for a Targeted Response to the Opioid Crisis  20 
OEI-BL-18-00460   
ACKNOWLEDGMENTS 
Heather Barton served as the team leader for this study, and Louis Day 
served as the lead analyst.  Others in the Office of Evaluation and 
Inspections who conducted the study include Louise Schoggen and Jeremy 
Siegel.  Office of Evaluation and Inspections staff who provided support 
include Adam Freeman and Christine Moritz.  
We would also like to acknowledge the contributions of other Office of 
Inspector General staff, including Jennifer Wagner. 
This report was prepared under the direction of David Tawes, Regional 
Inspector General for Evaluation and Inspections in the Baltimore regional 
office, and Heather Barton, Deputy Regional Inspector General.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
To obtain additional information concerning this report or to obtain copies, 
contact the Office of Public Affairs at Public.Affairs@oig.hhs.gov.  
 
States Use of Grant Funding for a Targeted Response to the Opioid Crisis  21 
OEI-BL-18-00460   
ABOUT THE OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public 
Law 95-452, as amended, is to protect the integrity of the Department of 
Health and Human Services (HHS) programs, as well as the health and 
welfare of beneficiaries served by those programs.  This statutory mission is 
carried out through a nationwide network of audits, investigations, and 
inspections conducted by the following operating components: 
Office of Audit  The Office of Audit Services (OAS) provides auditing services for HHS, either 
by conducting audits with its own audit resources or by overseeing audit 
Services 
work done by others.  Audits examine the performance of HHS programs 
and/or its grantees and contractors in carrying out their respective 
responsibilities and are intended to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, 
abuse, and mismanagement and promote economy and efficiency 
throughout HHS. 
Office of Evaluation  The Office of Evaluation and Inspections (OEI) conducts national evaluations 
to provide HHS, Congress, and the public with timely, useful, and reliable 
and Inspections 
information on significant issues.  These evaluations focus on preventing 
fraud, waste, or abuse and promoting economy, efficiency, and 
effectiveness of departmental programs.  To promote impact, OEI reports 
also present practical recommendations for improving program operations.   
Office of  The Office of Investigations (OI) conducts criminal, civil, and administrative 
investigations of fraud and misconduct related to HHS programs, 
Investigations 
operations, and beneficiaries.  With investigators working in all 50 States 
and the District of Columbia, OI utilizes its resources by actively 
coordinating with the Department of Justice and other Federal, State, and 
local law enforcement authorities.  The investigative efforts of OI often lead 
to criminal convictions, administrative sanctions, and/or civil monetary 
penalties. 
Office of Counsel to  The Office of Counsel to the Inspector General (OCIG) provides general 
legal services to OIG, rendering advice and opinions on HHS programs and 
the Inspector 
operations and providing all legal support for OIGs internal operations.  
General 
OCIG represents OIG in all civil and administrative fraud and abuse cases 
involving HHS programs, including False Claims Act, program exclusion, and 
civil monetary penalty cases.  In connection with these cases, OCIG also 
negotiates and monitors corporate integrity agreements.  OCIG renders 
advisory opinions, issues compliance program guidance, publishes fraud 
alerts, and provides other guidance to the health care industry concerning 
the anti-kickback statute and other OIG enforcement authorities.
States Use of Grant Funding for a Targeted Response to the Opioid Crisis  22 
OEI-BL-18-00460   
ENDNOTES 
 
1 Substance Abuse and Mental Health Administration (SAMHSA), Key Substance Use and Mental Health Indicators in the United States: 
Results from the 2018 National Survey on Drug Use and Health, August 2019. 
2 Centers for Disease Control and Prevention (CDC), Understanding the Epidemic, December 2018.  Accessed at 
https://www.cdc.gov/drugoverdose/epidemic/index.html  on July 23, 2019.   
3 SAMHSA, Results from the 2017 National Survey on Drug Use and Health: Detailed Tables, September 2018. 
4 21st Century Cures Act, P.L. No. 114-255, 1003. 
5 SAMHSA, State Targeted Response to the Opioid Crisis Grants: Funding Opportunity Announcement (FOA) No. TI-17-014. 
6 SAMHSA defines recovery as a voluntary, self-directed, ongoing process where patients access formal and informal resources; manage 
their care and their addiction; and rebuild their lives, relationships, and health to lead full meaningful lives.  The delivery of recovery 
support services typically occurs after the acute stage of treatment.  SAMHSA, Federal Opioid Treatment Standards, January 2015. 
7 SAMHSA, Federal Opioid Treatment Standards, January 2015. 
8 U.S. Department of Health and Human Services (HHS), Facing Addiction in America: The Surgeon Generals Spotlight on Opioids, 
September 2018.   
9 World Health Organization, Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence, 2009.  
Accessed at http://www.who.int/substance_abuse/activities/treatment_opioid_dependence/en/. 
10 HHS, Facing Addiction in America: The Surgeon Generals Spotlight on Opioids, September 2018.   
11 National Institute on Drug Abuse, Effective Treatments for Opioid Addiction, November 2017.  Accessed at 
https://www.drugabuse.gov/publications/effective-treatments-opioid-addiction/effective-treatments-opioid-addiction on September 10, 
2019. 
12 Bart, G., Maintenance medication for opiate addiction: The foundation of recovery.  J Addict Dis. 2012; 31(3): 207-225. 
13 HHS, Facing Addiction in America: The Surgeon Generals Spotlight on Opioids, September 2018.   
14 United States Government Accountability Office (GAO), Laws, Regulations, and Other Factors Can Affect Medication-Assisted Treatment 
Access, September 2016. 
15 Jones, Christopher M., et al., National and State Treatment Need and Capacity for Opioid Agonist Medication-Assisted Treatment. 
American Journal of Public Health 105.8 (August 2015): 55-64.   
16 White, W., Long-term strategies to reduce the stigma attached to addiction, treatment, and recovery within the City of Philadelphia (with 
particular reference to medication-assisted treatment/recovery).  Philadelphia: Department of Behavioral Health and Mental Retardation 
Services, 2009. 
17 GAO, Laws, Regulations, and Other Factors Can Affect Medication-Assisted Treatment Access, September 2016. 
18 The White House, The presidents commission on combating drug addiction and the opioid crisis. Washington, DC, U.S. Government 
Publishing Office, November 1, 2017. 
19 OIG, Geographic Disparities Affect Access to Buprenorphine Services for Opioid Use Disorder, OEI-12-17-00240, January 2020. 
20 Congressional Research Service, Location of Medication-Assisted Treatment for Opioid Addiction: In Brief, June 2019.  Accessed at 
https://www.everycrsreport.com/reports/R45782.html on September 19, 2019. 
21 HHS, Strategy to Combat Opioid Abuse, Misuse, and Overdose.  A Framework Based on the Five Point Strategy, April 2017. 
22 GAO, Opioid Use Disorders: HHS Needs Measures to Assess the Effectiveness of Efforts to Expand Access to Medication-Assisted 
Treatment, October 2017. 
23 Ibid. 
24 HHS Press Release, Trump Administration awards grants to states to combat opioid crisis, April 2017.  Accessed at 
https://www.hhs.gov/about/news/2017/04/19/trump-administration-awards-grants-states-combat-opioid-crisis.html on August 29, 2018. 
The four territories were American Samoa, the Northern Mariana Islands, Puerto Rico, and the Virgin Islands. 
25 HHS Press Release, HHS provides states second installment of grant awards to combat opioid crisis, April 2018.  Accessed at 
https://www.hhs.gov/about/news/2018/04/18/hhs-provides-states-second-installment-grant-awards-combat-opioid-crisis.html on 
July 25, 2019. 
26 SAMHSA, State Targeted Response to the Opioid Crisis Grants: Funding Opportunity Announcement (FOA) No. TI-17-014. 
27 HHS Press Release, Trump Administration awards grants to states to combat opioid crisis, April 2017.  Accessed at 
https://www.hhs.gov/about/news/2017/04/19/trump-administration-awards-grants-states-combat-opioid-crisis.html on July 23, 2019. 
28 HHS Press Release, HHS provides states second installment of grant awards to combat opioid crisis, April 2018.  Accessed at 
https://www.hhs.gov/about/news/2018/04/18/hhs-provides-states-second-installment-grant-awards-combat-opioid-crisis.html on 
July 25, 2019. 
29 SAMHSA, SAMHSA directing supplemental funding to three states hit hard by opioid crisis, March 2018.  Accessed at 
https://www.samhsa.gov/newsroom/press-announcements/201803200300 on July 23, 2019. 
 
States Use of Grant Funding for a Targeted Response to the Opioid Crisis  23 
OEI-BL-18-00460   
 
30 SAMHSA, State Targeted Response to the Opioid Crisis Grants: FOA No. TI-17-014. 
31 Naloxone is an opioid antagonist that can quickly restore normal respiration to a person whose breathing has slowed or stopped 
because of an opioid overdose.  It is a nonscheduled (i.e., nonaddictive) prescription medication and works only if individuals have 
opioids in their systems; the medication has no effect if opioids are absent.  National Institute on Drug Abuse, Medication-Assisted 
Treatment: Naloxone.  Accessed at https://www.drugabuse.gov/publications/drugfacts/naloxone on June 10, 2019.   
32 A prescription drug monitoring program is an electronic database that tracks controlled substance prescriptions in a State.  CDC, 
What States Need to Know about PDMPs, October 2017.  Accessed at https://www.cdc.gov/drugoverdose/pdmp/states.html on 
November 25, 2019.   
33 SAMHSA, State Targeted Response to the Opioid Crisis Grants: FOA No. TI-17-014. 
34 SAMHSA, Fiscal Year 2017 - Award Standard Terms.  Accessed at https://www.samhsa.gov/sites/default/files/grants/fy-2017-standard-
terms-conditions.pdf on November 25, 2019. 
35 Obligated balances are balances for which there has been legally binding action (for example, contracts signed) and for which 
payment has not yet been made but will be required to be made in the future.  Unobligated balances are balances that have not yet 
been committed by contract or other legally binding action by the Government.  U.S. Government Publishing Office (GPO), Balances of 
the Budget Authority, Budget for Fiscal Year 2020.  Accessed at https://www.govinfo.gov/content/pkg/BUDGET-2020-
BALANCES/pdf/BUDGET-2020-BALANCES.pdf on July 22, 2019. 
36 SAMHSA, State Targeted Response to the Opioid Crisis Grants: Funding Opportunity Announcement (FOA) No. TI-17-014. 
37 SUPPORT for Patients and Communities Act, P.L. No. 115-271, tit. VII,  7181(h). 
38 Consolidated Appropriations Act, 2018, P.L. No. 115141. 
39 SAMHSA, State Opioid Response Grants: FOA No. TI-18-015. 
40 HHS Press Release, HHS Awards Over $1 Billion to Combat the Opioid Crisis, September 2018.  Accessed at 
https://www.hhs.gov/about/news/2018/09/19/hhs-awards-over-1-billion-combat-opioid-crisis.html on July 23, 2019. 
41 These 10 States were allocated a total of $142.5 million in additional SOR grant funding.  The 10 States with the highest mortality rates 
related to drug poisoning deaths were West Virginia, Ohio, New Hampshire, the District of Columbia, Pennsylvania, Kentucky, Maryland, 
Massachusetts, Delaware, and Rhode Island.   SAMHSA, State Opioid Response Grants: FOA No. TI-18-015. 
42 HHS Press Release, HHS Awards Over $1 Billion to Combat the Opioid Crisis, September 18, 2018.  Accessed at 
https://www.hhs.gov/about/news/2018/09/19/hhs-awards-over-1-billion-combat-opioid-crisis.html on June 3, 2019.  
43 HHS Press Release, HHS releases additional $487 million to states, territories to expand access to effective opioid treatment; 2019 SOR 
grants will total $1.4 billion, March 20, 2019.  Accessed at https://www.hhs.gov/about/news/2019/03/20/hhs-releases-additional-487-
million-to-states-territories-to-expand-access-to-effective-opioid-treatment.html on June 3, 2019. 
44 HHS Press Release, Trump Administration Announces $1.8 Billion in Funding to States to Continue Combating Opioid Crisis, 
September 4, 2019.  Accessed at https://www.hhs.gov/about/news/2019/09/04/trump-administration-announces-1-8-billion-funding-
states-combating-opioid.html on September 4, 2019. 
45 CDC, 2017 Drug Overdose Death Rates.  Accessed at https://www.cdc.gov/drugoverdose/data/statedeaths/drug-overdose-death-
2017.html on December 12, 2019. 
46 HHS, HHS Grants Policy Statement, January 1, 2007.  A grant recipient may submit a one-time post-award amendment to request a 
no-cost extension of up to 12 months on its project to ensure completion of the originally approved project, or to permit an orderly 
phase-out of a project that will not receive continuation support.  As of July 25, 2019, 48 State requests for no-cost extensions had been 
approved by SAMHSA and 3 State requests were pending review. 
47 Pradhan, R. and Ehley, B., Hundreds of millions in state opioid cash left unspent, Politico, March 3, 2019.  Accessed at 
https://www.politico.com/story/2018/03/19/opioid-crisis-funding-unspent-468658 on October 2, 2019. 
48 Centers for Disease Control and Prevention (CDC), Understanding the Epidemic, December 2018.  Accessed at 
https://www.cdc.gov/drugoverdose/epidemic/index.html  on July 23, 2019.   
49 45 CFR  75.207, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS AwardsSpecific award 
conditions. 
50 GAO, Opioid Use Disorders: HHS Needs Measures to Assess the Effectiveness of Efforts to Expand Access to Medication-Assisted 
Treatment, October 2017. 
51 Ibid. 
States Use of Grant Funding for a Targeted Response to the Opioid Crisis  24 
OEI-BL-18-00460