"States Don't Have Good Capacity to Leverage All the Money That's Coming": A Qualitative Study of Federal and State Agencies' Funding Experiences for Opioid Use Disorder Services Among Justice-Involved Populations

Justice-involved populations are among the most vulnerable to opioid-related harms. Despite nearly 85% of justice-involved persons being diagnosed with a substance use disorder, only around 5% receive any medication treatment while incarcerated, and those without treatment experience a 10-40x higher risk of overdose within two weeks of release. In 2019, nine federal agencies allocated $485 million via 520 grants to states to address opioid use among justice-involved populations. Relative to need, half of states received more generous funding, while the other half were underfunded. Supported by NIDA’s Justice Community Opioid Innovation Network, this qualitative interview study characterizes the perspectives and experiences of federal-level workers who allocate funding and state-level workers who receive funding

The study’s first phase mapped where 2019 federal funding for OUD/CJ was allocated by state and city, the federal agencies providing grants, the organizations receiving funding, and funding amounts. Based on these data, we ranked states by need and funding status and developed three categories according to high and low quartiles: high need/high funding, high need/low funding, and low need/high funding. This typology revealed 11 states distributed across each category, which were selected for this study. Our sample included staff among key federal agencies distributing funding for OUD/CJ, and staff receiving grants in 2019 among these 11 states. Recruitment also included outreach to knowledgeable state-level staff through snowball sampling. Salient literature and mapping data informed semi-structured interview guides, which covered: participant and organizational background, organizational priorities, and participant perspectives on and experiences with funding needs, grant types, and collaboration across funders and grantees. Interviews (30-60 minutes) were recorded, transcribed, de-identified, and analyzed via a grounded theory approach in Dedoose. Our codebook included deductive codes from interview guides and inductive codes generated via transcript review. Authors tested the codebook with three federal and state interviews, respectively. Upon codebook refinement, one author coded remaining transcripts, and authors reviewed analytic memos at bi-weekly team meetings.

Most respondents confirmed that federal funding is not adequately matched to OUD/CJ need. Both federal and state respondents described pre- and post-award pipeline challenges. Organizations, including police departments, drug courts, and community-based organizations, experienced uneven access to technical assistance to identify and secure funding. Though federal funds were often allocated quickly, some organizations stated that limited monitoring and evaluation infrastructure impeded implementation. For some organizations, grant periods (≤ four years) provided insufficient runway to launch programs and implement sustainability plans, particularly in shifting political contexts. Collaboration quality varied across respondents, with some describing federal-level workers’ limited subject matter expertise to support grantees effectively.

States’ uneven technical assistance access cultivates a funding pipeline marked by and reproducing inequity. Creaming of organizations with pre-existing technical assistance connections leaves less-connected organizations, often addressing greater need, with fewer resources. Longer grant periods with reliable paths to no-cost extensions and funding for personnel and treatment infrastructure may increase program sustainability and continuity of care. Findings will inform federal and state policymaking to improve OUD funding allocations and infrastructure for justice-involved populations.