The Principles Quick Guide to Monitoring Opioid Settlement Spending

The Principles for the Use of Funds From the Opioid Litigation are nationally recognized guidance for states, counties, and cities receiving money from the lawsuits against entities that contributed to the opioid epidemic. These planning Principles, coordinated by faculty at the Johns Hopkins Bloomberg School of Public Health, can help jurisdictions create a foundation for effective spending of the monies to save lives from overdose.

The Principles for the Use of Funds From the Opioid Litigation encourage governments to use data to determine areas of need (Principle 5) and direct funding to programs supported by evidence (Principle 2). As discussed in a separate Quick Guide, counties can get started by conducting a needs assessment to inform initial funding decisions. From there, counties can establish a set of indicators to monitor if the funded programs, services, and interventions are producing the intended results.

What are indicators?

Indicators are the foundation of evaluation. The CDC describes indicators as measurable outputs that can be used to determine if a program is being implemented as intended and achieving its expected outcomes. In the context of opioid settlement spending, indicators are a tool that counties can use to count the outputs of their investments. For the purpose of this resource, outputs are defined as activities that have taken place, products that have been distributed, and services that have been delivered as a result of settlement expenditures.

How can counties use indicators?

Counties can use indicators to count the outputs of their opioid settlement investments. For example, imagine that County A conducted a needs assessment and found that access to naloxone (i.e., overdose reversal medication) is a top area of need. Based on this information, County A decides to purchase a bulk order of naloxone for distribution in the community. County A can then select one or more indicators to monitor how much of this naloxone has been distributed in the community (e.g., number of naloxone kits distributed at community events and/or number of naloxone kits dispensed by harm reduction vending machines).

Where does the data come from?

Much of the data involved in monitoring opioid settlement investments already exists. For example, county coroners or medical examiners can provide data on opioid-involved deaths, emergency medical services agencies can provide data on overdose-related calls for service, and county health departments can provide data on screenings for opioid use disorder. Counties may also request data from private health systems, correctional facilities, and schools, as appropriate.

In addition to existing data sources, counties can obtain new data through the information reported by funded entities. For example, counties can incorporate indicators into requests for proposals and require that grantees report on specified outputs.

Steps for Monitoring Opioid Settlement Spending

Step 1: Establish a Strategic Plan

Opioid settlement funds are the newest available funding source for county opioid response efforts. The addition of new funding has the potential to save additional lives from overdose but only if it supplements, rather than replaces, other available funding. Thus, counties should establish a strategic plan before spending opioid settlement funds.

A strategic plan builds upon information from the most recent needs assessment to define specific objectives and priority areas that a county will pursue over a defined timeframe.

Click here to view an example strategic plan from Fairfax County, Va.

Step 2: Match Priorities with Funding Opportunities

Counties can use the strategic plan to align available funding sources with each priority area. The strategic plan may define priority areas on different levels, such as:

• Intervention. Priority areas may include specific interventions or opioid abatement strategies (e.g., treatment with medications for opioid use disorder, naloxone to reverse overdose, public education campaigns).
• Continuum of care. Priority areas may include components of the continuum of care (i.e., prevention, treatment, harm reduction, and recovery).
• Setting. Priorities areas may include certain settings or environments (e.g., schools, hospitals, jails).

Priority areas can also be defined in many other ways. In the absence of a strategic plan, or if a county has not defined its priority areas as described above, a county can reflect on the following questions. These questions are intended to help counties identify the areas of potential investment of opioid settlement funds that are most important in their local context.

Questions:

• Are we improving the screening and early identification of opioid use disorder?
• Are we improving access to medications for opioid use disorder?
• Are we improving utilization of medications for opioid use disorder?
• Are we improving access to naloxone?
• Are we getting naloxone to people who are the most vulnerable to overdose?
• Are we improving access to harm reduction services?
• Are people staying engaged in treatment long enough for it to be effective?
• Are we applying a public health approach within our health and human services systems?
• Are we applying a public health approach within our criminal justice system?
• Are we improving our understanding of overdose risks in our communities to inform our
  response strategy?
• Are we preventing people from developing opioid use disorders?

A priority area may be funded by one source, multiple sources, or not yet funded. By considering how each priority area was funded prior to the availability of opioid settlement funds, counties can strategically invest opioid settlement funds to enhance existing services and/or add new services to the landscape.

Step 3: Select Activities to Fund

After aligning opioid settlement funds with the appropriate priority areas, counties can begin to fund specific activities within that priority area. Depending on how broadly the priority area is defined, there may be many promising or evidence-based interventions that fall under that priority area. For example, under the priority area of ‘expand access to naloxone,’ a county could:

• Fund community-based organizations to purchase and distribute the medication,
• Directly purchase naloxone for the health department to distribute, or
• Invest in a campaign to educate the public about the use and availability of the medication.

The national opioid settlement agreements provide an extensive, though not exhaustive, list of eligible expenditures of opioid settlement funds. For assistance with selecting activities to fund, counties may explore NACo’s Opioid Solutions Strategy Briefs, a series on high impact, eligible expenditures of opioid settlement funds, or this comprehensive report coordinated by researchers at Harvard Medical School.

Step 4: Monitor the Funded Activities for Success

After selecting one or more activities to fund, counties can select indicators that will help them to monitor the outputs of their investment(s). Counties may implement activities directly or by funding external entities. Whether internal or external, the entity leading implementation will likely also be responsible for reporting data to the county. Thus, it’s a best practice to communicate data collection and reporting requirements to implementation partners as early as possible. Counties can include this information in funding announcements and requests for proposals and specify the frequency at which
implementation partners must collect and report this data.

As stewards of opioid settlement funds, counties are encouraged to regularly review and share this data with the public. Timely review of activities, outputs, and outcomes of programs can highlight early or emerging successes as well as opportunities for adjustments to program implementation. The results may be released in a standalone report or in conjunction with a needs assessment report, advisory board recommendations report, or a report on the expenditure of opioid settlement funds.

Step 5: Repeat

Jurisdictions should regularly evaluate the needs of their communities and the outputs of funded programs. By monitoring opioid settlement spending, counties can measure progress in each priority area and adjust annual budgets as needed.

Ready to Get Started?

The Johns Hopkins Bloomberg School of Public Health, in partnership with Vital Strategies, has developed an interactive tool to assist counties with establishing indicators to monitor opioid settlement spending. The Opioid Settlement Principles Resource and Indicators (OSPRI) tool contains a list of potential indicators derived from the list of eligible expenditures contained in the national opioid settlement agreements. After guiding users through a short number of prompts, the tool displays a feasible number of potential indicators that the county can use to monitor its opioid settlement investments.

The tool begins by asking the user to select its priority area(s) based on the categories presented in Step 2. If the user is interested in specific interventions, parts of the continuum of care or settings, they can select one of the options presented under the corresponding dropdown menu. If the user has not defined its priorities in these ways, they can select the question that most closely aligns with their area of interest (e.g., Are we improving access to naloxone?).

After selecting their priorities, an initial set of indicators will appear.

The user can then apply various filters to narrow the results. Each indicator is provided alongside potential data source(s) and instructions on how to interpret the data. After refining the results to a workable number of indicators, the county can share the results with stakeholders for continued discussion or integrate them into requests for proposals or informational materials for potential partners. In this way, the indicators will act as a foundation for the county to report the outputs of their investments and set up for future evaluation of outcomes and impacts.

Access the tool