Opioid Block Grants

Beginning in the late 1990s, the United States experienced a significant increase in opioid-related drug overdose deaths, which rose from 8,050 in 1999 to 68,630 in 2020. To address the rising rates of opioid use and overdose deaths, Congress created new opioid-specific block grant programs that provide funding to increase access to substance use disorder (SUD) treatment such as medication-assisted treatment (MAT) for opioid-use disorder.

State Targeted Response (STR) Grants

In 2016, Congress enacted the 21^st Century Cures Act (the Cures Act; P.L. 114-255). Section 1003 of the Cures Act established the "Account for the State Response to the Opioid Abuse Crisis" in the Treasury, to which $500 million was transferred and deposited for each of FY2017 and FY2018. (Actual program funding was subject to appropriations.) The resulting grant—the State Targeted Response (STR) to the Opioid Crisis grant program—supplemented state activities related to the opioid crisis. The purpose of the grant program was to increase access to treatment, decrease unmet treatment need, and reduce overdose deaths through prevention, treatment, and recovery activities. Administered by the Substance Abuse and Mental Health Services Administration (SAMHSA), the STR grant was distributed to Single State Agencies with flexibilities to provide sub-awards and contracts to substance use treatment and prevention providers, opioid treatment programs (OTPs), and peer recovery networks, among others.

In FY2017 and FY2018, SAMHSA awarded grants to all 50 states, the District of Columbia, and several territories according to a formula. Formula variables were specified in statute, but the formula itself was determined by SAMHSA. Grantees received the same funding amount for both years.

Figure 1. Opioid Block Grant Distribution

Source: Congressional Research Service.

In 2018, the STR grant program was reauthorized by Section 7181 of the SUPPORT for Patients and Communities Act (P.L. 115-271). The provision authorized $500 million to be appropriated for each of FY2019 through FY2021; however, the STR grant program did not receive funding after FY2018, when it was effectively replaced by the State Opioid Response grant program.

State Opioid Response (SOR) Grants

Record-level drug overdose deaths continued through the 2010s, after which Congress provided $1 billion to SAMHSA in FY2018 through a new State Opioid Response (SOR) grant program. The appropriation, located in the annual Department of Health and Human Services appropriations act, included a $50 million set-aside for Indian tribes and an additional 15% set-aside for states with the highest opioid-related mortality rates. Program goals were similar to the STR grants with an emphasis on expanding access to MAT. The SOR funding was distributed using a formula similar to the STR grant formula but determined entirely by SAMHSA (with a requirement that the formula be submitted to the House and Senate Appropriations Committees).

When the STR grant authorization expired in FY2018, Congress increased the SOR grant appropriation by $500 million—the same amount as the STR grants—for a total of $1.5 billion for FY2019. The SOR grants received $1.5 billion in each of FY2020 and FY2021. In FY2022, Congress increased the SOR grant appropriation by $25 million, for a total of $1.525 billion. Congress increased the SOR grant appropriation by $25 million in FY2022 for a total of $1.525 billion, and then by another $50 million in FY2023 for a total of $1.575 billion.

The SOR grant program requirements and structure were similar to those for STR grants but were more explicitly focused on increasing access to MAT using the three FDA-approved medications for the treatment of opioid use disorder (methadone, buprenorphine, and naltrexone). Grants were distributed to states via the Single State Agency with state discretion for use or further distribution. The FY2020 appropriation language added "stimulants" to the grant purpose, allowing SOR funds to support activities related to methamphetamine and cocaine—substances increasingly involved in drug-related overdose deaths.

To safeguard funding for states with declining drug-related mortality rates—including those that no longer qualified for the additional set-aside funding—report language accompanying FY2021 appropriations directed SAMHSA to award $3 million in supplemental grants to states whose year-over-year funding declined by more than 40%. Report language in subsequent years directed the agency to avoid funding cliffs among states and between fiscal years.

The Restoring Hope for Mental Health and Well-Being Act (Division FF, Title I of P.L. 117-328, the Consolidated Appropriations Act, 2023) amended Section 1003 of the Cures Act by replacing the STR grant authorization with an authorization for the SOR program. This new SOR statutory authorization codified minimum allocation amounts for grantees and formula preferences—including an avoidance of funding cliffs between states. The authorization specified use of grant funds and state reporting requirements. It also included a set-aside of up to 15% for states with the highest drug overdose death rates. The provision authorized to be appropriated $1.575 billion for each of FY2023 through FY2027.

Tribal Opioid Response (TOR) Grants

From FY2018 to FY2021, the SOR grant appropriation included a $50 million set-aside for Indian tribes and tribal organizations—known as the TOR grants. TOR grants were not distributed by a formula. Instead, tribes and tribal organizations apply individually, as a consortia, or in partnership with an urban Indian organization. Funds were distributed noncompetitively based on tribal population. Tribes were instructed to use a needs assessment or strategic plan to identify gaps from which to build substance use disorder prevention, treatment, and recovery services. Other grant requirements are similar to the SOR grant program. For each of FY2022 and FY2023, Congress specified a TOR set-aside of $55 million. Authorization for the TOR grants was included in the P.L. 117-328 provision that codified the SOR program.

Figure 2. Opioid Block Grant Timeline Authorizing Legislation and Appropriations Levels over Time for the STR, SOR, and TOR Grants.

Source: Congressional Research Service. Notes: For more information about SAMHSA-administered grant programs, see https://www.samhsa.gov/grants and CRS Report R46426, Substance Abuse and Mental Health Services Administration (SAMHSA): Overview of the Agency and Major Programs.