ST. LOUIS — Bryan Garner was homeless and injecting as much fentanyl as he could get his hands on when he found the Missouri Network Outreach Center , a community center in an old brick rowhouse in St. Louis that connects people to addiction treatment.
Mr. Garner, 51, accepted the center's offer of assistance and has not used any illegal drugs since January.
"I really feel like, without this place, I wouldn't be here now," he said.
But how long the center will survive — and how long Mr. Garner will be able to get free treatment — is in question. The center exists thanks to $3.3 billion in opioid crisis grants , approved with strong bipartisan support, that the Trump administration and Congress have allotted to states since 2017, when a record 47,600 Americans died from overdoses involving opioids. The money for treatment, prevention and recovery is the administration's most tangible contribution to addressing the opioid epidemic , and a rare example of an initiative that has received almost full bipartisan support in Washington during President Trump's tenure.
But even as Mr. Trump has started to claim victory over the epidemic, citing "results that are unbelievable" at a drug abuse summit in April, neither he nor his administration's top health officials have talked publicly about extending the funding beyond next year, when it is scheduled to run out. Many in the addiction field fear that, with opioid overdose deaths finally beginning to level off, and other problems like high prescription drug costs emerging as campaign issues, the attention to treatment will dissipate.
"I've been in this field over 35 years, and I've never seen an investment like this," said Mark Stringer, the director of the Missouri Department of Mental Health. "Our plea would be for it to continue."
The Department of Health and Human Services referred questions about the future of the grants to the Substance Abuse and Mental Health Services Administration, which oversees them. Dr. Elinore McCance-Katz, that agency's director, was noncommittal. "If I could, I certainly would" continue the funding beyond next year, she said in an interview.
Preliminary data from the Centers for Disease Control and Prevention suggest that opioid overdose deaths dropped slightly in 2018, although deaths involving fentanyl, the powerful synthetic opioid that caused a sharp surge in deaths over the past few years, continued to climb. The final month of data for the year is expected to be released this week.
The grants have been especially crucial in Republican-led states that decided not to expand free Medicaid coverage to low-income adults under the Affordable Care Act, which guarantees addiction treatment as an "essential benefit." Many of these states have been hit hard by the opioid epidemic, and the grants are their main source of financing for treatment.
But Missouri is quickly exhausting its $65 million share, and other states that have not expanded Medicaid, including Kansas and North Carolina, are in a similar predicament. They have had to spend most of their grant money on medications and doctor appointments — expenses that expanded Medicaid has covered in other states — instead of on other important assistance like housing, recovery services or even naloxone, the overdose-reversal drug.
"When we first heard the money was coming, I remember thinking, 'Wow, that's a lot,'" said Nora Bock, who helps oversee addiction treatment programs for the Missouri Department of Mental Health. "Now it's like, 'Oh my God, it's nowhere near enough.'"
Some lawmakers in states that have been hit hard by the opioid crisis are starting to make noise about continuing the funding. Senator Rob Portman, Republican of Ohio, introduced legislation last month to continue the grants through 2024, at $500 million a year. Senator Jeanne Shaheen, Democrat of New Hampshire, has a bill that would increase the grants to $5.5 billion over five years, Both bills would let states use the money to help people addicted to methamphetamine and other drugs, not just opioids.
"My state is a little nervous that Congress is going to say, 'Gosh, we've solved this problem and we can move on,'" Mr. Portman said. "If you take away this foundation we've built, the edifice comes crumbling down."
To qualify for the money now, treatment programs must offer at least one of the three medications that have been approved to treat opioid addiction. Though it is backed by scientific evidence, that approach has nonetheless been rarely used in the past.
But the one-time nature of the grants — they were first authorized in 2016 by President Barack Obama, for two years — makes it hard for states to build out permanent treatment systems. The Bipartisan Policy Center noted that problem in a recent analysis , as did several witnesses at a House hearing on the federal opioid response last month.
In West Virginia, a state that expanded Medicaid but has been devastated by the epidemic, the grant money is "just a patch," Angela Gray, a public health nurse there, said at the hearing, adding that "without a long-term stable funding commitment and plan, my state will continue to bleed."
Here in St. Louis, which has one of the highest overdose death rates of any large city, the need is extreme. Even now, only a fraction of the opioid-addicted population is benefiting from the money: about 5,650 people over the last two years, most of whom were prescribed buprenorphine.
The $230,000 that the MO Network community center that helped Mr. Garner received through the federal grant program this year is paying its rent and funding salaries for three full-time and six part-time employees. The center uses funds from another source to buy and distribute clean needles to people who inject fentanyl and other drugs, which the federal government is prohibited from paying for.
The center's staff members persuade many people who come for needles or group activities to try treatment — 82 in May. They link them to Assisted Recovery Centers of America, a Missouri company that is the main treatment provider under the state's grant program.
"People come for needle exchange in the morning, get put in an Uber to a treatment site, get buprenorphine that same day and get put in housing that night," said Rachel P. Winograd, an associate research professor at the University of Missouri-St. Louis, who has helped the state plan how to use its allocation. "But boy, does that soak up money fast."
Missouri decided not to use any of its grant funds for residential care or group therapy, opting instead for a "medication first" approach that does not require lengthy initial assessments, counseling, participation in groups or drug-free urine samples as conditions for obtaining medication. The lack of barriers has led to better retention in treatment, Ms. Winograd said.
Assisted Recovery Centers, or ARCA, is using grant money to treat about 1,200 patients for opioid addiction in St. Louis and, through telemedicine, in several dozen rural locations throughout Missouri. That is about 40 percent fewer than last year, as the company had to slow admissions to avoid running out of money. It is also providing temporary housing for about 82 of those patients; the state imposed a 45-day limit after it realized how quickly the grant funds were disappearing.
"With the volume we are asked to serve, we will be out of treatment dollars again by the middle of August," said Suneal Menzies, ARCA's executive director.
Nor is Missouri the only state that is struggling to keep up with the need. In North Carolina, where one million people remain uninsured, grant money that was supposed to last until May ran out in February. The state is spending $2 million a month through the program and hopes to have just enough to keep treatment for thousands of uninsured patients going through September.
"We're digging ourselves out of a meteor-sized hole with a teaspoon," said Kody Kinsley, a deputy secretary at the North Carolina Department of Health and Human Services.
Kansas, too, has struggled. Its grantees ran out of their second year of opioid grant money last fall, months ahead of time.
Shane Hudson, president and chief executive of CKF Addiction Treatment, a treatment center based in Salina that has received more than $2 million in grant funds, said that with Medicaid expansion, "these opioid grant dollars could go much further, and we could afford more skilled staff to provide more of these services."
The center is already preparing patients for the likelihood that they will have to take on the cost of their treatment eventually, Mr. Hudson added.
While the money has undoubtedly saved lives, many who have benefited from free treatment remain fragile.
One recent morning at ARCA's clinic on Chippewa Street in St. Louis, Brandi Russell, 37, said she had been receiving buprenorphine through the grant program since January. But she had relapsed on her birthday, in April, after seven weeks of sobriety.
"Fentanyl is everywhere in this area — you have no clue," she said as she waited to see her doctor. "Dealers will come up to you at the gas station, say, 'Here's some samples, let me put my number in your phone.'"
The MO Network recently retrofitted an old ambulance to hand out naloxone and tell opioid users on the streets about free treatment options, including at ARCA. It takes the vehicle out into the community several times a week.
Driving the vehicle past an empty warehouse near the Mississippi River one evening, Aaron Laxton, a social worker, stopped to talk to Albin Martin, 36. Mr. Martin said he had been kicked out of a recovery home 10 days earlier for using fentanyl. He had gone on to overdose twice in the last week, he said, but other homeless individuals had revived him with Narcan.
"They said I was completely cold and blue," he told Mr. Laxton and Chad Sabora, who helped found the group in 2012. Back then, Mr. Sabora said, St. Louis had a five-month wait for any kind of drug treatment.
Mr. Sabora gave Mr. Martin a card with the MO Network's phone number. The center gives clients more chances than most other recovery housing options, letting them stay even after they have relapsed several times.
"Don't use alone, O.K.?" he told Mr. Martin as he climbed back into the mobile unit.
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