How To Invest Opioid Settlement And Federal Funding To Prevent Substance Use And Promote Youth Mental Health | Health Affairs Forefront

How To Invest Opioid Settlement And Federal Funding To Prevent Substance Use And Promote Youth Mental Health | Health Affairs Forefront

Two national crises, the opioid epidemic and the COVID-19 pandemic, have accelerated recognition of the need for improvements in how we address the national emergency of youth mental health problems. Each has prompted new funding streams for substance use prevention and mental health promotion, both for direct and shorter-term improvements in existing interventions as well as for the more structural or systemic changes needed for a sustainable impact on the health and well-being of our nation’s youth. The two crises, moreover, have played out against the backdrop of deep-rooted structural racism in the U.S., shining a spotlight on profound inequities. Black, Latino, and Indigenous communities and other communities of color in the U.S. are disproportionately exposed to risk factors for substance use and mental disorders and face significant barriers to accessing quality services. An effective national strategy to reduce and prevent youth substance use and mental disorders must prioritize health equity.

Smart use of new federal funding for youth mental health initiatives in the wake of the pandemic, as well effective allocation of state opioid settlement funds toward prevention, can and should be used to shore up the infrastructure needed for a comprehensive approach to preventing youth substance use and mental health problems. The following are practical, sustainable, and research-informed actions that can accomplish this important goal.

Spend Newly Allocated Funds On Substance Use Prevention And Mental Health Promotion

States should spend a significant portion of the opioid litigation funds on comprehensive approaches to preventing the use of all harmful substances, not just opioids, and should ensure that those efforts incorporate mental health promotion strategies. Likewise, a significant portion of the federal youth mental health funds should include substance use prevention initiatives.

Initially, to address the current acute phases of the opioid and youth mental health crises, states should invest a significant portion of funds in treatment, harm reduction, and recovery support services. Then, as the investment in these services helps to abate these crises – and as the acute phase of the COVID-19 pandemic subsides – states should increase the percentage of funds spent on prevention until it is equal to or exceeds the spending on treatment, harm reduction, and recovery supports. If substance use prevention/mental health promotion dollars are spent on effective, evidence-informed efforts and satisfy the key components of successful implementation, future crises will be averted, and the funds needed for treatment, harm reduction, and recovery support will stabilize or continue to decline over time.

In utilizing the funds, states should not supplant existing Substance Abuse and Mental Health Services Association (SAMHSA) block grant funds, which account for the majority of substance use prevention spending in most states. The existing and new funding amounts allocated toward substance use prevention and mental health promotion should be made not only publicly available in a technical sense, but readily accessible to the public so that advocates and stakeholders can obtain those numbers for monitoring and accountability purposes. To determine the amount that will be spent and what indicators will be used to decide when that allocation should increase, each community or locality receiving the funds should conduct a thorough needs assessment. Transparent, stakeholder-guided funding allocation decisions should ensure that the selected strategies and initiatives are:

  • Delivered across childhood and adolescence in a coordinated fashion. Prevention/mental health promotion efforts should start in the earliest stages of a child’s life and continue throughout development, rather than being initiated in adolescence when many of the risk factors for addiction and mental health problems have already taken root.
  • Aimed at promoting positive youth development and preventing risk factors for both substance use and mental health problems. Addressing malleable risk and protective factors related to positive youth development helps not only to prevent youth substance use and mental disorders but also enhances healthy social, emotional, behavioral, and academic growth more broadly.
  • Implemented in settings that serve youth, including schools and a range of youth-serving organizations. These settings directly and significantly impact youth and also help to shape the attitudes and behaviors of families and surrounding communities, two critical contexts that influence a child’s substance use and mental health. 
  • Delivered in a tiered fashion whenever possible. Tiered programming provides broad-based skills and supports to all youth (e.g., all students in a grade or a school) with more intensive resources for youth with risk factors or early signs and symptoms of substance use or mental health problems.
  • Inclusive of parents and other caregivers. Parents and other caregivers play one of the most critical roles in preventing children’s substance use and promoting their mental health. Interventions should explicitly include education, tools, and supportive resources for parents and other caregivers.
  • Implemented in a way that is trauma informed, culturally sensitive, and equitable. Interventions should be tailored to address trauma exposure, a known risk for substance use and mental health problems, which is more prevalent in marginalized and low-income communities. Effectively taking into account individual, community, and generational trauma in the context of prevention/health promotion efforts requires specialized training for those implementing interventions with youth. States and localities should ensure that funding is allocated in a way that does not inadvertently create or exacerbate inequities for historically marginalized communities or families.

Require Community Inclusion In Programming And Funding Allocation Decisions

Recipients of the funding should be required to include a broad and diverse range of community perspectives when identifying or developing programming and determining how to allocate funds. Each jurisdiction that receives funding should create and support a Community Advisory Board, which should include community leaders, families, school personnel, health professionals, and youth to guide the approach. Cultivating community support will increase the likelihood that community needs are addressed, facilitate implementation, and create political pressure for sustained funding of effective programming. The Board, with assistance from experts in local universities or research organizations, should prioritize the following goals.

Conduct A Community Needs Assessment

Such assessments can allow boards to determine the strengths and needs of specific communities, utilizing evidence-based models when possible, such as Communities that Care. Needs assessment findings should be used to develop a clear roadmap for how to implement interventions and programming across a child’s development. The Board should share the draft roadmap with the broader community to obtain input for refining and finalizing the plan. The final plan should be made publicly available (e.g., through public posting on a website) to facilitate ongoing community awareness and buy-in.

Develop Data Infrastructure

With improved data infrastructure, boards will be better equipped to track the adoption and implementation of interventions and maintain an annual monitoring system to track changes in youth substance use, mental health problems, and relevant risk and protective factors. Data infrastructure might involve linking data across youth-serving sectors and systems (e.g., data from school records, health care, child welfare, juvenile justice data) to track key outcomes using valid and reliable measurement and assessment protocols. Organizations or consultants with expertise in cross-sector data sharing can be engaged to support this effort.

Ensure Sustainability By Requiring Investment In A Solid Prevention Infrastructure  

Too often, programs and interventions are not sustained on a long-term basis because of resource limitations and a lack of infrastructure. To ensure sustainability, recipients of funds should use established evidence-informed programs whenever possible and appropriate, as designated by reputable lists such as Blueprints for Healthy Youth Development, SAMHSA’s Evidence-Based Practices Resource Center and the Program Directory Search at At the same time the Community Advisory Board may also identify promising programs that are not included on such established lists and should ensure they meet pre-determined parameters of quality and fidelity with substance use prevention and mental health promotion science. In making this determination, the Board can seek expert guidance through partnerships with universities or other research organizations. This approach can encourage innovation and the continued development of an evidence base for future prevention and mental health promotion interventions.

Sustainability will also require investments in a strong infrastructure, using as a model SAMHSA’s Strategic Prevention Framework. Such infrastructure would include a sufficient number of prevention specialists and qualified mental health counselors to deliver programming. And just as necessary: regular training in culturally sensitive, equitable, and trauma-informed interventions for school mental health counselors, community health professionals, and substance use prevention specialists.


Years of research have shown that effective prevention strategies influence the factors that contribute to or protect against negative outcomes such as substance use, mental health problems, school drop-out, and involvement with the juvenile justice system. Current strategies are necessary, but not sufficient. They primarily target the individual child, rather than parents, families, and communities. They typically begin in late middle school or high school, rather than in early childhood when the seeds of risk and resilience are planted. They focus mostly on risk reduction, rather than on promoting health and resilience. They address only a small portion of individual factors associated with substance use and mental health problems, rather than the broader social determinants of health that are essential for achieving significant, equitable, and sustainable outcomes.

To meet this unprecedented moment of risk for our nation’s youth, we must capitalize on the new funding streams available to bolster their health and well-being. We must not squander this opportunity by re-using piecemeal strategies that have proven incapable of addressing the national opioid and COVID crises. We need to better integrate and coordinate our efforts across domains of influence in a child’s life and launch research-based initiatives that address not only substance use and mental illness but health and resilience more broadly. For the sake of our nation’s health, we must create and implement broad-based, sustainable, and equitable solutions for protecting youth from the current and future drug and health crises.

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