Form Tables A-E Tables A-E Tables A-E

Attachment A

Table A

State Targeted Response to the Opioid Crisis
(Opioid STR)
Obligation and Expenditure Report
FY 2017 Opioid STR
Obligation

FY 2017 Opioid STR
Expenditure

State Identifier:
Expenditure Category

1.

Opioid Use Disorder Prevention Activities

2.

Opioid Use Disorder Treatment Services

3.

Opioid Use Disorder Recovery Support Services

5.

Administration (excluding program / provider level)

6.

Total

Table A

State Targeted Response to the Opioid Crisis
(Opioid STR)
Obligation and Expenditure Report
FY 2018 Opioid STR
Obligation

State Identifier:
Expenditure Category

2.

Opioid Use Disorder Prevention Activities

2.

Opioid Use Disorder Treatment Services

4.

Opioid Use Disorder Recovery Support Services

5.

Administration (excluding program / provider level)

6.

Total

FY 2018 Opioid STR
Expenditure

Attachment B
Opioid STR Table B1
Report Period- From:
State Identifier:

To::

Number of Persons Served (Unduplicated Count) for Opioid Use Disorder Treatment Services by Age, Sex and Race/Ethnicity
Sex and Race/Ethnicity
A. Total
B. White
E.
Asian
H. Unknown
C. Black or
D. Native
F. American
G. More
I. Not
African
Hawaiian/
Indian/Alaska Than One
Hispanic or
American
Other Pacific
n Native
Race
Latino
Islander
Reported

Age

M

F

M

F

M

F

M

F

M

F

M

F

M

F

M

F

J. Hispanic
or Latino

M

F

1. 17 and
under
3. 18-24
4.

25-44

5.

45-64

5. 65 and
over
6. Total
7. Pregnant
Women

Opioid STR Table B2
Report Period- From:
To::
State Identifier:
Number of Persons Served (Unduplicated Count) for Opioid Use Disorder Recovery Support Services by Age, Sex and Race/Ethnicity
Sex and Race/Ethnicity
Age
A. Total
B. White
E. Asian
H. Unknown
D. Native
G. More
C. Black or
F. American
I. Not
Hawaiian/
African
Indian/Alaska Than One
Hispanic or
Other Pacific
Race
American
n Native
Latino
Islander
Reported
M
1. 17 and
under
7. 18-24
8.

25-44

9.

45-64

5. 65 and
over
10. Total
7. Pregnant
Women

F

M

F

M

F

M

F

M

F

M

F

M

F

M

F

J. Hispanic
or Latino

M

F

1

Report Year

Area Served (Statewide or Sub-state Planning Area

IBHS-ID

Provider/Program Name

Street Address

State

Zip Code

Opioid STR Funds

Naltrexone-Injectable

Naltrexone-Oral

Medication Assisted Treatment
(Drop down menu)

Buprenorphine-Combo

Methadone

Detoxification-24 hourservice Hospital Inpatient

Detexification-24 hour
service, Free-Standing
Residential

Rehabilitation/Residential
-Hospital (other than
Detoxification)

Rehabilitation/Residential
=Long term (>30days)

Ambulatory-Intensive
Outpatient

Ambulatory-NonIntensive Outpatient

AmbulatoryDetoxification

Recovery Support
Services
Tele-Health

Type of Treatment Service/Setting1
(drop down menu)

Rehabilitation/Residential
-Short term (<30 days)

Opioid State Targeted Response to the Opioid Crisis
(Opioid STR)
Statewide Entity Inventory – Treatment and Recovery

Buprenorphine-Mono

Attachment C

HHS Region

Opioid

STR
Table C

Treatment Episode Data Set (TEDS)/Minimum Data Set (MDS)

State/Jurisdiction

Attachment D
Non-direct Services/Systems Development
Table D1
State:
Report Period- From:
Activity

To::
A. Prevention

B. Treatment

C. Recovery

1.
2.
3.

Information Systems
Infrastructure support**
Partnerships, community outreach and needs
assessment

$
$
$

$
$
$

$
$
$

D. Opioid STR
Combined
$
$
$

4.
5.
6.

Quality assurance and improvement
Research and evaluation
Training and education*

$
$
$

$
$
$

$
$
$

$
$
$

7.

Total

Non-direct Services/Systems Development
Table D2
State:
Report Period- From:
To::
Activity
Training and education
a. Physicians
b. Physicians Assistants
c. Nurse/Nurse Practitioners
d. Social Workers
e. Addiction Counselors
f. Peer Recovery
g. Prevention
h. Other, please specify
8.

E. Quarter 1

F. Quarter 2

G. Quarter 3

H. Quarter 4

Total

Non-direct State Targeted Response to the Opioid Crisis
(Opioid STR)
Table D3
State:
Report Period- From:
Activity

9.

To::

Training and education
i. Physicians
j. Physicians Assistants
k. Nurse/Nurse Practitioners
l. Social Workers
m. Addiction Counselors
n. Peer Recovery
o. Prevention
p. Other, please specify

10. Total

I.

Overdose
Education and
Naloxone
Distribution

J.

Prescribing
Guidelines

K. Other

L. Other

Attachment E
Table E
Please respond to the following questions:

1. Opioid Treatment Program (OTP) Patient New Admissions:
a. Has your state utilized Opioid STR funds to expand the number of newly admitted Opioid Use Disorder (OUD) patients served in Opioid Treatment Programs (OTP) with methadone, buprenorphine, or
naltrexone?
Yes
No
b. If "Yes", approximately how many newly admitted OUD patients have been served to date in OTPs using Opioid STR funds?
1 - 24 persons
25 - 49 persons
50 - 99 persons
100 - 249 persons
250 - 499 persons
500 - 999 persons
1000 or more persons
c. Does the state have any other activities related to OTPs that you would like to highlight?

2. Buprenorphine Waiver Office-Based Opioid Treatment (OBOT) Patient New Admissions:
a. Has your state utilized Opioid STR funds to expand the number of newly admitted Opioid Use Disorder (OUD) patients served in Buprenorphine Waiver Office-Based Opioid Treatment (OBOT)
practice settings?
Yes
No
b. If "Yes", approximately how many newly admitted OUD patients have been served to date in OBOTs using Opioid STR funds?
1 - 24 persons
25 - 49 persons
50 - 99 persons
100 - 249 persons
250 - 499 persons
500 - 999 persons
1000 or more persons
c. Does the state have any other activities related to OBOTs that you would like to highlight?

3. Naltrexone Treatment Patient New Admissions:
a. Has your state utilized Opioid STR funds to expand the number of Opioid Use Disorder (OUD) patients served with naltrexone in settings other than OTPs or OBOTs?
Yes
No
b. If "Yes", approximately how many newly admitted OUD patients have been served to date with naltrexone in settings other than OTPs or OBOTs using Opioid STR funds?
1 - 24 persons
25 - 49 persons
50 - 99 persons
100 - 249 persons
250 - 499 persons
500 - 999 persons
1000 or more persons
c. Does the state have any other activities related to the use of naltrexone in settings other than OTPs or OBOTs that you would like to highlight?

4. Naloxone Overdose Reversal Kit Distribution and Utilization:
a. Has your state utilized Opioid STR funds to expand the availability, distribution, and use of naloxone overdose reversal kits (Narcan, Evzio, and others)?
Yes
No
b. If "Yes", approximately how many naloxone overdose reversal kits purchased and distributed to date with Opioid STR funds?
1 - 249 kits
250 - 499 kits
500 - 999 kits
1000 - 2499 kits
2500 - 4999 kits
5000 - 9999 kits
10,000 or more kits
c. If available, provide the number of overdose reversals during the reporting period.

d. Does the state have any other activities related to the availability, distribution, and use of naloxone that you would like to highlight?

5. MAT Patient Admissions from Hospital Emergency Departments or Hospital Inpatient Treatment Units:
a. Has your state utilized Opioid STR funds to admit new patients to Medication-Assisted Treatment of those who were identified as having an OUD in Hospital Emergency Departments or Hospital
Inpatient Treatment Units?
Yes
No
b. If "Yes", approximately how many admitted OUD patients have been admitted to date to Medication-Assisted Treatment using Opioid STR funds?

1 - 24 persons
25 - 49 persons
50 - 99 persons
100 - 249 persons
250 - 499 persons
500 - 999 persons
1000 or more persons
c. Does the state have any other activities related to patient admissions to Medication-Assisted Treatment from Hospital Emergency Departments or Hospital Inpatient Treatment Units that you would like
to highlight?

6. Patient Admissions from Detoxification Services (Hospital Withdrawal Management Services or Residential Withdrawal Management Services):
a. Has your state utilized Opioid STR funds to admit new OUD patients to Medication-Assisted Treatment of those patients who were served for OUD in Detoxification Services (Hospital Withdrawal
Management Services or Residential Withdrawal Management Services)?
Yes
No
b. If "Yes", approximately how many newly admitted OUD patients have been admitted to date to Medication-Assisted Treatment using Opioid STR funds?
1 - 24 persons
25 - 49 persons
50 - 99 persons
100 - 249 persons
250 - 499 persons
500 - 999 persons
1000 or more persons
c. Does the state have any other activities related to patient admissions to Medication-Assisted Treatment from Detoxification Services that you would like to highlight?

7. Patient Admissions from Substance Abuse Residential Services (Any Level of Residential Services):
a. Has your state utilized Opioid STR funds to admit new OUD patients to Medication-Assisted Treatment of those Opioid Use Disorder (OUD) patients who were served in any level of Substance Abuse
Residential Services?
Yes
No
b. If "Yes", approximately how many of these new OUD patients have been admitted to date to Medication-Assisted Treatment using Opioid STR funds?
1 - 24 persons
25 - 49 persons
50 - 99 persons

100 - 249 persons
250 - 499 persons
500 - 999 persons
1000 or more persons
c.
Does the state have any other activities related to patient admissions to Medication-Assisted Treatment from any level of Substance Abuse Residential Services that you would like to highlight?

8. Patient Admissions from Correctional or Detention Facilities:
a. Has your state utilized Opioid STR funds to admit new OUD patients to Medication-Assisted Treatment who were transitioned to the community or were recently released (in the previous 30 days) to the
community from a state or local correctional or detention facility?
Yes
No
b. If "Yes" approximately how many of these new OUD patients have been admitted to date to Medication-Assisted Treatment using Opioid STR funds?,
1 - 24 persons
25 - 49 persons
50 - 99 persons
100 - 249 persons
250 - 499 persons
500 - 999 persons
1000 or more persons
c. Does the state have any other activities related to patient admissions to Medication-Assisted Treatment of those Opioid Use Disorder patients who were transitioned to the community or recently released
from a correctional or detention facility that you would like to highlight?

9. Patient Admissions of Pregnant Women with Opioid Use Disorders:
a. Has your state utilized Opioid STR funds to admit to Medication-Assisted Treatment (methadone and buprenorphine) of Opioid Use Disorder (OUD) patients who are pregnant?
Yes
No
b. If "Yes", approximately how many newly pregnant new OUD patients have been admitted to date to Medication-Assisted Treatment using Opioid STR funds?
1 - 24 persons
25 - 49 persons
50 - 99 persons
100 - 249 persons
250 - 499 persons
500 - 999 persons

1000 or more persons
c. Approximately what is the % of the state’s successes (if known) in actively maintaining these pregnant women in MAT for the duration of their pregnancies?
1 - 10% of admissions
11 - 24% of admissions
25 - 39% of admissions
40 - 59% of admissions
60 - 74% of admissions
75 - 89% of admissions
90% or more of admissions
Unknown % of admissions
d. Does the state have any other activities related to patient admissions to Medication-Assisted Treatment of pregnant women that you would like to highlight?

10. Patient Admissions of Veterans, Service Members, or Their Family Members with Opioid Use Disorders:
a. Has your state utilized Opioid STR funds to admit new OUD patients to Medication-Assisted Treatment who are veterans, service members, or members of the immediate families of these individuals?
Yes
No
b. If "Yes" approximately how many veterans, service members, or members of the immediate families of these individuals have been newly admitted to date to Medication-Assisted Treatment using
Opioid STR funds?,
1 - 24 persons
25 - 49 persons
50 - 99 persons
100 - 249 persons
250 - 499 persons
500 - 999 persons
1000 or more persons
c. Does the state have any other activities related to patient admissions to Medication-Assisted Treatment of veterans, service members, or members of the immediate families of these individuals that you
would like to highlight?

11. Patient Admissions of Members of Tribal Communities with Opioid Use Disorders:
a. Has your state utilized Opioid STR funds to admit new OUD patients to Medication-Assisted Treatment who are members of tribal communities?
Yes
No
b. If "Yes", approximately how many members of tribal communities have been newly admitted to date to Medication-Assisted Treatment using Opioid STR funds?
1 - 24 persons

25 - 49 persons
50 - 99 persons
100 - 249 persons
250 - 499 persons
500 - 999 persons
1000 or more persons
c. Does the state have any other activities related to patient admissions to Medication-Assisted Treatment of members of tribal communities that you would like to highlight?

12. Patient Admissions Facilitated through the Use of Peer Recovery Support Specialists:
a. Has your state utilized Opioid STR funds for the support of Peer Recovery Support Specialists to improve treatment access and retention and support long-term recovery of newly admitted Opioid Use
Disorder (OUD) patients who are identified, engaged, and served in Medication-Assisted Treatment?
Yes
No
b. If "Yes", approximately how many new admissions of OUD patients to date can be attributed, in whole or in part, to the facilitation efforts of Peer Recovery Support Specialists supported with Opioid
STR funds?
1 - 24 persons
25 - 49 persons
50 - 99 persons
100 - 249 persons
250 - 499 persons
500 - 999 persons
1000 or more persons
c. Does the state have any other activities related to the use of Peer Support Recovery Specialists in facilitating patient identification, admission, engagement, and retention in Medication-Assisted
Treatment that you would like to highlight?

13. Prescription Drug Monitoring Program (PDMP) Support and Utilization:
a. Is your state using Opioid STR funds to promote and implement improvements in the design, structure, functioning, integration, and utilization of the state’s Prescription Drug Monitoring Program
(PDMP) and its available data in addressing individual patient clinical needs, and analyzing opioid prescriber patterns of prescribing medications and patient patterns of accessing medications?
Yes
No
b. Does the state have particularly noteworthy activities related to the Prescription Drug Monitoring Program that you would like to highlight?

c. Did your state use PDMP Data to guide prevention activities?
Yes
No
d. If "Yes", does the state have particularly noteworthy activities related to how the Prescription Drug Monitoring Program was used to guide prevention activities that you would like to highlight?

14. Providing Assistance to Patients with Treatment Costs, and Addressing Barriers to Receiving Prevention, Intervention, Treatment, and Recovery Support Services:
a. Is your state using Opioid STR funds to provide assistance to OUD patients with treatment costs or to eliminate or reduce treatment costs for under- and uninsured patients, and to address barriers to
receiving OUD prevention, intervention, treatment, and recovery support services, in such activities as reducing the cost of services, developing systems of care to expand rapid access to services,
successfully identifying, engaging and retaining patients in services, and addressing discrimination associated with accessing services, including discrimination that limits access to MAT?
Yes
No
b. Does the state have any particularly noteworthy activities related to providing assistance to patients with treatment costs and addressing barriers to receiving Opioid Use Disorder prevention,
intervention, treatment, and recovery support services that you would like to highlight?

15. Implementation of Broad-Based Public Information, Education, Prevention, and Recovery Support Initiatives:
a. Is your state using Opioid STR funds to implement any broad-based public information, education, prevention, and recovery support initiatives, including media campaigns, the targeted use of social
media, the promotion of statewide information and referral hotlines, or other similar strategies to address the state’s opioid crisis?
Yes
No
b. If "Yes", approximately how many people were reached through the implementation of broad based information, education, prevention and recovery support initiatives?
1 - 24 persons
25 - 49 persons
50 - 99 persons
100 - 249 persons
250 - 499 persons
500 - 999 persons
1000 or more persons
c. Does the state have particularly noteworthy activities related to any of these activities that you would like to highlight?

16. Implementation of Prevention Interventions; Evidence based programs and Promising Practices:
a. Is your state using Opioid STR funds to implement evidence based programs and promising practices to achieve the prevention goals?
Yes
No
b. If "Yes", approximately how many people were served through the implementation of evidence based prevention programs and promising practices?
1 - 24 persons
25 - 49 persons
50 - 99 persons
100 - 249 persons
250 - 499 persons
500 - 999 persons

1000 or more persons
c. Does the state have particularly noteworthy activities related to naloxone awareness and overdose education and training that you would like to highlight?
17. Naloxone Awareness and Overdose Education and Training of First Responders and Other Key Community Sectors:
a. Has your state used Opioid STR funds to educate and train any of the following sectors?
Yes

No

Check all that apply.
Fire fighters
Law enforcement
Paramedic
EMTs
Emergency medical staff
Nurse practitioners
Physician assistants
Pharmacists
Physicians
Harm Reduction Clinics
Family members
Criminal justice
Schools
Coalitions
Community groups
Friends of OD victims
Military
Train the trainer
Other (describe below)

b. If "Yes", approximately how many people were served?
1 - 24 persons
25 - 49 persons

50 - 99 persons
100 - 249 persons
250 - 499 persons
500 - 999 persons
1000 or more persons
c. Does the state have particularly noteworthy activities related to naloxone awareness and overdose education and training that you would like to highlight?

Attachment IV
Table IV
Recovery/After Care Service

Relapse Prevention
Recovery Coaching, Peer
Coaching, or Mentoring
Self-Help and Support Groups
Recovery Housing
Continuing Care
Other (specify)

Recovery/After Care Services
Number of Clients Offered
Number of clients
recovery/after care services
currently receiving
recovery/after care
services

Number of clients who have
completed recovery/after care
services