The Principles Quick Guide to Removing Policy Barriers

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 consider both empirical evidence (Principle 2) and public testimony (Principle 5) when allocating funds from the opioid settlements. After decades of research into effective interventions for opioid use disorder, there are now many evidence-based solutions to the prevention, treatment, recovery, and reduction of harms associated with opioid use. For an evidence-based program to produce the intended results, it may first be necessary to remove laws and regulations that interfere with proper implementation of the program. By conducting a policy review, county leaders can proactively identify and amend policies that may otherwise limit the impact of opioid settlement investments.

What is a policy barrier?

A policy barrier is a law or regulation that impedes the implementation of evidence-based interventions. By conducting a policy review, counties can ensure they are aware of any policies that may go against the scientific evidence or have an adverse effect on certain demographic groups. For example, a policy passed decades ago may need to be amended to reflect new findings or lessons learned that have emerged since then.

What is a policy review?

A policy review examines policies concerning substance use and determines whether these policies are blocking the implementation of evidence-based interventions. These reviews should be done periodically and are often completed by participatory boards or committees (e.g., a citizens advisory board) or departments (e.g., health department) within the county.

A policy review can assess either state and/or county policies, as both can play a role in promoting or obstructing the use of evidence-based programs. A policy review can also be done in collaboration with a needs assessment. Findings from the review will identify any instances of inaccurate or counterproductive policy language and equip county officials to resolve these issues through the amendment process.

Who should conduct a policy review?

Counties may select an external organization to conduct the policy review or assemble a team of stakeholders. For example, if a county has established a multidisciplinary committee to oversee the expenditure of opioid settlement funds, this entity may have the requisite skills and capacity to conduct the review. A research team from a local university may also be well equipped to conduct the review. 

Policymakers, including county legislators, executives and agency leaders, should be engaged throughout the process. Their expertise and authority is fundamental to drafting and enacting
the necessary policy changes. 

Steps for conducting a policy review

An effective policy review involves both governmental and non-governmental participation. The county government is responsible for initiating the policy review and identifying the review team. The review team is responsible for data collection, data analysis and developing recommendations. Ideally, the review team and county leadership will meet once the review is completed to discuss its findings and strategize on next steps. 

The team conducting the review should:

1. Generate a list of initial policies to review

The entity conducting the review should develop a list of policies under county authority that concern the provision of substance use-related services. If possible, the review should include comparative policy examples from nearby jurisdictions. For example, the review team may assess whether differences in zoning requirements for substance use treatment facilities are associated with different levels of service utilization.

What types of policies to examine?

As the rate of fatal drug overdose has reached record levels in recent years, the policy review should focus on policies that involve the delivery of services to populations most at risk of drug overdose.

At a minimum, a policy review should consider:

• Policies that prohibit or restrict the distribution of sterile syringes, such as one-for-one exchange policies.
  • If current policy allows for the operation of syringe service programs, policies that require participants to turn in syringes in order to receive new ones may limit the effectiveness of the programs.
• Policies that prohibit or restrict the distribution of drug checking supplies like fentanyl or xylazine test strips.
• Policies that prohibit or restrict the distribution of safer use equipment for other modes of substance use (e.g., snorting, smoking.
• Policies that prohibit or restrict the possession of syringes, drug checking supplies or other forms of safer use equipment.
• Policies that concern the delivery of substance use treatment services, including prohibitions on the use of methadone and buprenorphine.

2. Meet with affected groups

The review team should gather information from people with living experience of opioid use disorder and their providers through direct conversations. These conversations can identify factors that prevent clients from receiving care and/or prevent providers from following evidence-based guidelines. Conversations should include people with lived or living experience of opioid use disorder, first responders (e.g., law enforcement, EMS) and practitioners who provide direct services, both at county clinics and community-based organizations.

3. Request public comment

In addition to meeting with individual stakeholders, the review team should solicit public comment. County leaders can support this process by hosting public hearings, disseminating a survey or establishing an open docket.

4. Engage with county officials

The review team should present its findings to county elected officials and relevant agency leaders. Officials should provide feedback and strategize with the review team and other experts on how to implement the needed policy changes. This may mean amending or repealing existing policies. It may also mean creating a strategy to advocate for policy change at the state level.

5. Finalize and release policy review

The final results of the policy review should be publicly released to promote accountability. 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. The policy review should be revisited periodically, ideally every three years, to identify any new recommendations and report on amendments to date.

After the policy review has been completed, the county is responsible for addressing its findings. This process should be led by members of the executive and legislative branches who participated or were consulted in the policy review, such as the health committee of a county commission. If the policy report has identified any policy barriers at the state level, county policymakers can advocate for policy reform at the state-level on behalf of their jurisdiction. The county’s state association of counties, as well as NACo, can help amplify these advocacy efforts.

County Examples

Allegany County, New York

In 2016, the Allegany County Board of Legislators established an ad-hoc legislative committee to oversee the county’s response to the opioid epidemic. Charged with developing a strategic plan, the committee began by contracting with a local research organization to produce a community health needs assessment and policy review. The policy review was published in a 2016 report containing a comprehensive summary of county legislation, resolutions and other policies regarding heroin and opioid use. The results of the policy review serve as a living document that continues to inform the county’s opioid response efforts, including a strategic plan updated every three years. LEARN MORE.

Baltimore County, Maryland

In May 2019, Baltimore County Executive Johnny Olszewski established an expert working group to gather information and develop recommendations for the County’s overdose response strategy. Through an extensive public engagement and policy review process, the working group developed a set of 11 recommendations, including a recommendation to assess the impact of zoning policy on the availability of certified recovery housing. In 2019, Baltimore County had the second highest overdose death rate in the state, but no certified recovery houses. The results of the policy review have created a common ground from which county officials, local practitioners and community members can develop a policy solution. LEARN MORE.

Milwaukee County, Wisconsin

In 2021, fentanyl test strips – small strips of paper that detect the presence of fentanyl in various substances – were considered illegal drug paraphernalia under state law. That same year, Milwaukee County lost 560 lives to drug overdose, with fentanyl involved in the vast majority (79%) of deaths. After identifying this policy barrier, Milwaukee County Supervisor Sylvia Ortiz-Velez worked with Senator Lena Taylor to co-author a resolution to decriminalize fentanyl test strips. The resolution resulted in a bipartisan bill that was passed by the Wisconsin State Senate and Assembly in January 2022 and signed into law in March 2022. Within weeks, Milwaukee County began distributing fentanyl test strips through its division of Behavioral Health Services. LEARN MORE.