In some locations, people addicted to opioids are starting to get treatment for the first time. In others, bureaucratic hurdles prevent innovation, driving home the point that gaining ground on the epidemic will be difficult. There's one constant: It takes time for government grants to trickle down to real people.
At a congressional hearing Wednesday in Washington, Republicans and Democrats shared frustration as they questioned top administration officials about federal spending to fight the deadliest drug crisis in U.S. history.
"I don't understand why more resources aren't flowing to help out a rural state like West Virginia," said West Virginia Republican Rep. David McKinley. Rep. Ben Ray Lujan, a New Mexico Democrat, echoed: "People at home don't feel like they're getting help."
President Donald Trump is set to make a major speech on the opioid epidemic Thursday but it's unclear whether any new money will back up his expected declaration of a national emergency.
The $1 billion for states is part of last year's 21st Century Cures Act, which also addressed cancer research and medical innovation. The bipartisan bill was signed by President Barack Obama in December.
"It is a great opportunity, but it comes with a lot of angst," said Tom Hill of the nonprofit National Council for Behavioral Health, which advocates for addiction treatment providers. States have analyzed data, chosen contractors and are "just getting programs up and running right now."
— Alabama used some of its share to recruit 23 treatment providers to start more than 5,300 new patients on medications that block cravings.
— Ohio plans to train enough new doctors to treat at least 25,000 new patients with one of the addiction treatment drugs.
— Michigan is hiring 97 peer recovery coaches, many with histories of addiction themselves.
— Illinois has selected a contractor to run a 24-hour opioid crisis phone line.
But in other places innovation is stalled.
Washington state wants to buy and equip four mobile methadone vans to reach patients in underserved areas. Utah wants to use video to connect rural patients with a Provo-based doctor trained to prescribe buprenorphine, a medication used to treat opioid addiction.
Both efforts are on hold, lacking crucial regulations from the federal Drug Enforcement Administration. DEA spokesman Rusty Payne said agency officials "are well aware of the concerns on both issues and are currently developing rules to address them."
"The clock is ticking," said Richard Nance, director of Utah County Department of Drug and Alcohol Prevention and Treatment. "We have an opportunity to do a lot of good quickly."
States got half of their Cures Act grants in April and will get the rest next year. They must spend 80 percent on opioid addiction treatment. That's an incentive for some states to expand access to methadone, the oldest of the treatment drugs.
Florida, Idaho, Illinois, Kansas and Louisiana are among states with plans to do just that. In California, Aegis Treatment Centers, a for-profit company that is the state's largest methadone provider, will get up to $28.6 million over two years to expand into underserved regions. Of that, $1 million will go toward bus tokens or taxi vouchers for patients to get to the company's existing clinics.
Places like Fellowship House in Birmingham, Alabama, are using drugs like Suboxone, a combination of buprenorphine and naloxone, with patients for the first time.
"When I took Suboxone, it was like a miracle," said one Fellowship House patient, 43-year-old John Montesano, a former long-haul truck driver with a 20-year pill addiction, chronic pain and no health insurance. "I'd be dead now" without it, he said. "Or worse, not dead" and still using.
Montesano recently marked six months without a relapse. He attends daily recovery meetings, works at a sandwich shop and plans to reunite with his wife. As long as the money goes for treatment "the way Fellowship House does it," he said, Congress "should release all the money they can spare."
The Cures Act money is being doled out according to a formula favoring states with more overdose deaths and treatment needs. California received nearly $45 million. Texas got $27.3 million. Florida got $27.1 million. A dozen states, including Wyoming and Nebraska, received $2 million each.
Many state officials worry about funds drying up when the two-year grant ends.
"It's one thing to push out a great deal of money with a short time frame to spend it," said Larry Scott, who is coordinating Michigan's spending of its $16.3 million this year. "You have to come up with a plan for sustainability and that's what we need to do. This epidemic is not going away."