Support Key Legislative and Policy Changes

Introductory Paragraph

Educating policymakers and the general public about the legislative or policy changes necessary to create community change is an important step to addressing substance misuse. Policies help states and local communities in three important ways:

• Providing direct funding to communities for treatment and other services.
• Improving access and/or affordability of care to individuals in need of assistance.
• Removing barriers that prevent or limit the use of best practices across government agencies.

Many organizations may be opposed to strategies that appear to be lobbying because of their grant commitments. However, advocacy and lobbying are two distinct activities and there are clear ways that communities can be advocates without engaging in lobbying. Policy change can take place at all levels of government. This page will provide information about how policy changes typically take place, as well as some examples of federal, state, and local laws that have helped local communities.

Key Information

Initial Steps for Policy Advocacy

In order to bring about policy changes through laws or ordinances, any group of citizens must be able to become a "constituency of consequence" to those with the ability to create and change policy. This can be accomplished with a number of different advocacy approaches, as highlighted below. A few key principles to change policy at any level of government include:

• Have clear policy objectives. The more specific and narrow the objective the better. If the policy goals are too broad or general, it is easy for legislators to object on that basis.
• Support your position. Have research and data to support why the policy change would be beneficial. For example, if seeking to improve harm reduction through the creation of a needle exchange program, data should be provided on expected lives that will be saved, reduced medical costs, improved linkages to care, and other benefits.
• Build a coalition. It is important to build a network of support to increase political clout. Identification of other groups with aligned goals could be willing to take action in order to achieve policy objectives. For example, advocacy for a needle exchange program could receive support from harm reduction organizations including hospitals, community health organizations and professionals, the recovery community, families in support of recovery, the treatment community, and potentially many others.
• Know the opposition. If a policy change hasn't happened, it is likely that opposition exists. It is important to learn why policymakers may be hesitant to make a certain change, including what groups oppose the policy and why. Learning about the other side is critical to developing an effective advocacy strategy. Overcoming opposition may require education, effective counterarguments, financial resources, and increased public awareness.

• Identify champions. The most successful efforts resulting in desired policy changes are led by individuals who are passionate about the issue. Identifying and working with champions in the state or local government is a big key to success. It is important to have people "on the inside" that can hold hearings, develop legislation, utilize input and information from stakeholders, and provide insight on the process.
• Every voice matters. Individuals or groups with minimal advocacy experience are often intimidated by the process. It is important for them to remember that those "in power" are there because they were elected to serve. Lawmakers across all levels of government represent the people of their states, districts, cities, and towns. Those representing the people need to hear the concerns of all those they represent -- who have a constitutional right to petition the government to be heard.

After taking the initial steps delineated above, the next step is to identify and implement a set of strategies which will grow public and political support for those policies. Approaches and specific strategies are almost innumerable, but taking action always requires communication and messaging which effectively educates and influences. Grassroots Advocacy generally refers to engaging the public to actively educate and promote a desired policy objective. Communication occurs through letters, emails, calls to legislators, rallies, social media campaigns, letters to the editor, and other forms of messaging campaigns designed to put political pressure on policymakers to enact desired changes. Direct Lobbying refers to direct communication and meetings with policy makers, including governors, mayors, county executives, and the legislative branch. This key activity provides the opportunity to meet with decision makers and their staff to gauge the receptiveness of the policymakers and to discuss the desired policy goals, benefits, support, and potential points of opposition. Opportunities for direct lobbying often take place during the legislative session, which varies from jurisdiction to jurisdiction. Some advocates and interest groups will organize a "lobby day" where members converge in Washington, state capitols, or with local legislative bodies to advocate for desired policy objectives. When the legislative body is not in session, advocates can meet with their representatives at their local offices.

Lobbying Rules and Restrictions

Lobbying rules vary widely between levels of government and across all states. Therefore, it is important to know how lobbying is defined and what the restrictions are in specific jurisdictions. Some fundamentals include:

• 501(c)3 organizations (tax-exempt nonprofits) have some restrictions on lobbying in the government.

• The IRS defines direct lobbying as: "A direct lobbying communication is any attempt to influence any legislation through communication with: Any member or employee of a legislative body; or Any government official or employee (other than a member or employee of a legislative body) who may participate in the formulation of the legislation, but only if the principal purpose of the communication is to influence legislation" and as "Referring to specific legislation and reflects a view on such legislation."

• The IRS defines grassroots lobbying as: "any attempt to influence any legislation through an attempt to affect the opinions of the general public or any segment thereof."

• Grassroots Lobbying Communication is defined as: "Referring to specific legislation; reflecting a view on such legislation; and encouraging the recipient of the communication action with respect to such legislation."

The Legislative Process

Governments at all levels will frequently create their own set of policy goals to address a particular issue. This has been true for several public health issues including the current opioid epidemic. This process typically involves bringing numerous stakeholders together to provide education and input in coordination with government representatives who initiate the process and finalize the set of policy objectives. States and localities vary widely on what types of laws are implemented across multiple policy areas. The legislative process varies between different levels of governments and in jurisdictions across the country. There are typically several steps in the process that provide opportunities to influence policymakers, such as when they are in session. Some states and localities have relatively short time frames to consider and pass new laws or ordinances, while other states and the federal government are in session for many more weeks throughout the year. It is important to know when the actual work of policy development and consideration takes place.

• Sponsors and Early Support. In any legislative body, a successful policy enactment starts with one or more members of the legislative body drafting legislation that would bring about the desired change. Members can do this individually or as a group. A group of members that introduce a legislative proposal are typically referred to as sponsors or "original" sponsors of the proposal. Other members can then sign on in support of the bill as co-sponsors. Effective advocacy can help build momentum for a bill during this process. The more sponsors and cosponsors, the better. It is also extremely beneficial to have early supporters from both political parties - especially at the state and federal level. Bipartisan support, and support among a broad base of members at the local level, can show other members that the bill is not likely to be controversial. It is also especially helpful to have support for the proposed legislation from key leaders of the committees with jurisdiction. Advocates can provide their champions within the legislature with all of the supporting information and research to help their champions in the legislative body attract as many co-sponsors as possible and to respond to questions or objections as they arise.
• Committee Process. Typically, legislative proposals are taken up by the committee (or committees) of jurisdiction. Actual consideration of a proposal often takes place after one or more committee hearings on the proposal. This often involves hearing from witnesses in support of, and potentially in opposition to, a given proposal. Written testimony is also included in the public record to provide additional information to both the public and the legislators. The hearing process provides another opportunity for advocates to testify as witnesses and/or provide information to be included in the record. Hearings can take place in front of the full committee or by a sub-committee which oversees the specific policy area impacted. After the hearing process, the bill may be taken up by the full committee for consideration. Although the bill can be altered by the manager of the bill at any time, consideration by the committee is the first time lawmakers have an opportunity to propose amendments to the proposal. These amendments are voted and adopted, or not adopted, by a majority vote. Following the amendment process the committee chair can call for a final vote on the legislation. If passed, the bill can move to the full legislative body for consideration. Advocacy efforts can move quickly during the committee process, as unexpected challenges may surface due to an unfriendly amendment that might weaken the bill and the policy impact desired. It is important to work with allies to carefully track this process and respond to any negative developments.

• Consideration by the Full Body. At the local level, there is a single body that approves local legislative proposals. This is typically a Board of Commissioners or other duly elected body. At the state and federal levels, there are two legislative chambers, with delegates and senators at the state level, and the House and Senate at the federal level. The process is usually relatively simple at the local level. Legislation (or ordinance) proposals are taken up at regularly scheduled meetings where a debate occurs, amendments are offered, and the proposals are voted on. Often, the chief executive at the local level has a vote along with the other members. At the state and federal level, the process is more complex. A bill has to pass both chambers before it can be reconciled, voted on again by both bodies, and sent to the Governor or President for signature. While on the floor, members can again offer amendments that can be voted on individually or "en bloc" as two amendments in one. Typically, more controversial amendments will be voted on by individual basis. Assuming the bill passes, it is sent to the other body for consideration. A similar or identical bill may be in process in that other chamber already, or it may be that no companion legislation exists. In the latter case the chamber that did not originate the bill will take up the version that was passed in the other chamber. When a bill does pass both chambers, there are almost always differences that must be worked out. The committee chairs will select a reconciliation committee with a bi-partisan group of legislators from both chambers to accomplish this. Assuming any differences can be worked out, the bill then goes back to the floor of each chamber for a final vote. If passed, the bill is finally referred to the Governor or President. As with the Committee process, advocacy must continue throughout the time in which a bill is considered by the full legislative body. At the state and federal levels, this can be a challenge with many steps involved and a larger number of legislators to contend with - some of whom may not be supportive. Again, it is critical to stay in constant contact with supporters within the legislative body to keep track of potential harmful amendments and keep count of likely supporters within the full body. At times advocacy efforts need to be focused on a handful of legislators who have reservations or are undecided.

• Potential Veto and Override. Governors and the President may veto a bill passed by the state and federal legislators. If the vote on final passage was close, it is unlikely that the bill will be taken up again, as a two-thirds majority is needed to override a veto. If the original vote approached the two-thirds number, there is a better chance to find the supporters needed for a successful override.

• Continued Funding (Budget and Appropriations). Even when a law or ordinance is passed and signed by the chief executive, advocacy efforts often do not end. This is due to the fact that legislation containing funding to implement programs is authorized (usually for a period of years), but there is still a budget and appropriations process that must be monitored over the authorization period. Typically, the executive branch of government produces an annual budget that reflects their policy and spending priorities. This budget may or may not be approved by the legislative body. After this point the legislative body will take up annual appropriations bills, which set spending levels for all agencies and their programs. These bills often work through the regular order of other legislation, but sometimes will have a different, often expedited process. It is important for community coalitions and advocates to understand that funding for the agencies and programs they support can change through each step of the budget and appropriations process. There is a need to stay vigilant to ensure that full funding is achieved. Advocates must stay in touch with their champions in the executive branch and legislature to keep informed of any changes and be ready to advocate just as vigorously in order to restore any proposed cuts in funding.

Impactful Federal, State, and Local Policies

The policy inventory below provides examples on what has been successful in a variety of policy initiatives. It begins with four major federal actions, then provides five types of state initiatives organized by specific topic. An example from Illinois on a successful advocacy process is included in the Promising Practices section of this article.

Biden-Harris Drug Policy Priorities. On April 1, 2021, President Biden and Vice President Harris released their administration's Drug Policy Priorities for the upcoming year. President Biden made clear that addressing the overdose and addiction epidemic was an urgent priority for his administration. Specific objctives included:

• Expanding access to evidence-based treatment
• Advancing racial equity issues in drug policy
• Enhancing evidence-based harm reduction efforts
• Supporting evidence-based prevention efforts to reduce youth substance use
• Reducing the supply of illicit substances
• Advancing recovery-ready workplaces and expanding the addiction workforce
• Expanding access to recovery support services

Recommendations from the 2017 President's Commission on Combating Drug Addiction and the Opioid Crisis

• Establish and fund a federal incentive to enhance access to Medication-Assisted Treatment (MAT)
• Mandate prescriber education
• Require that all modes of MAT are offered at every licensed MAT facility and that decisions are based on what is best for the patient.
• Partner with the National Institutes of Health (NIH) and the industry to facilitate testing and development of new MAT treatments.
• Provide model legislation for states to allow Naloxone dispensing via standing orders, as well as requiring the prescribing of Naloxone with high-risk opioid prescriptions;
• Equip all law enforcement in the United States with Naloxone to save lives
• Develop and disseminate Fentanyl detection sensors
• Support and fund interstate sharing of PDMP data
• Better align, through regulation, patient privacy laws specific to addiction with the Health Insurance Portability and Accountability Act (HIPAA) to ensure that information about SUDs be made available to medical professionals treating and prescribing medication to a patient. This could be done through the bipartisan Overdose Prevention and Patient Safety Act/Jessie’s Law
• Enforce the Mental Health Parity and Addiction Equity Act (MHPAEA) with a standardized parity compliance tool to ensure health plans cannot impose less favorable benefits for mental health and substance use diagnoses versus physical health diagnoses.

Federal SUPPORT Act. Section 7151, Building Communities of Recovery, amends the Building Communities of Recovery (BCOR) program that was first authorized in the Comprehensive Addiction and Recovery Act (CARA) of 2016 by redefining “recovery community organization” as an organization that mobilizes resources within and outside of the recovery community, including through a peer support network. This section authorizes $5 million for each of FY 2019-2023. Additionally, Section 7031, National Recovery Housing Best Practices, amends part D of title V of the Public Health Service Act to authorize the Secretary of HHS to identify or facilitate the development of best practices for operating recovery housing. The Secretary is directed to bring together a wide variety of stakeholders to develop best practices for recovery housing.

The Affordable Care Act of 2010 supports mental health and substance abuse treatment.

Prevention and Reduced Access to Prescription Medications

• New Jersey - New Jersey's Prescription Monitoring Program.
• California (Alameda County) - Local ordinances that require drug manufacturers to establish and fund a drug disposal program.
• Connecticut - Statute enacted May 2016: Seven-day limit for new opioid prescriptions for adults and all opioid prescriptions for kids. Exceptions for chronic and cancer pain, palliative care, and clinical judgement.
• Illinois - Statute enacted September 2015: Schedule II prescriptions limited to a 30-day supply (with exceptions). Allows multiple prescriptions up to a 90-day supply if the prescriber meets specified conditions.

Harm Reduction

• AmfAR Opioid & Health indicators Database - Syringe Access Locations.
• National Harm Reduction Coalition - Resources for Syringe Access and Policy.
• Rhode Island - Fentanyl Testing Strip Program.

Access to Treatment and Protecting Treatment Services

California legislation has a process for reducing treatment fraud and waste.

Criminal Justice Reform and De-criminalization.

• Good Samaritan Laws provide immunity from criminal prosecution for drug crimes to those who use drugs and those who act in good faith and call emergency services during an overdose. The Policy Surveillance Program provides an interactive database of current Good Samaritan Laws in the U.S. All 50 states and Washington D.C. have Good Samaritan Laws in place.

• Oregon - State Initiative to De-criminalize almost all narcotics: Measure 110, passed by a majority of statewide voters in November 2020, decriminalizes the possession of marijuana and small amounts of "harder" drugs including cocaine and methamphetamine and reduces criminal penalties for larger amounts.

• Washington State - Law Enforcement Assisted Diversion.

State Policy Plans to Address the Opioid Epidemic

• Rhode Island's Strategic Plan on Addiction and Overdose.
• Massachusetts’s Recommendations of the Governor's Opioid Working Group.

Available Tools and Resources

• SAMHSA has an Evidence-Based Practices Resource Center committed to improving prevention, treatment, and recovery support services for mental and substance use disorders. The Center provides communities, clinicians, policy-makers and others with the information and tools to incorporate evidence-based practices into their communities or clinical settings. SAMHSA's South-Southwest Prevention Technology Transfer Center (PTTC) Has published "The Ins and Outs of Advocating for Policy Change" as well as "The Ten Do’s and Don’ts of Successful Legislative Advocacy."
• The US Department of Health & Human Services has published "Guidebook for State by State Opioid Prescribing Guidelines."
• The National Council For Behavioral Health advocates for mental health and substance use policies.
• The National Harm Reduction Coalition advocates for numerous harm reduction approaches.
• The National Association of Counties has published "The Principles for the Use of Funds From the Opioid Litigation" -- a nationally recognized guidance for states, counties, and cities receiving money from the lawsuits against entities that contributed to the opioid epidemic. The planning principles, coordinated by faculty at the Johns Hopkins Bloomberg School of Public Health, can help jurisdictions create a foundation for effective spending of the monies to save lives from overdose.
• The Network for Public Health Law provides leadership in the use of law to protect, promote, and improve health and health equity through non-partisan legal technical assistance and resources, collaborating with a broad set of partners across sectors to expand and enhance the use of practical legal and policy solutions. It provides an online webinar titled, "Fighting for Public Health: How Do We Strengthen Public Health Advocacy at Local, State, and National Levels?"
• The Legislative Analysis and Public Policy Association (LAPPA) has published "State of the States: Legislative Roadmap for Reducing Overdose Deaths and Increasing Access to Treatment (the Roadmap)," which is a guide for state leaders on the most effective approaches to addressing the current drug epidemic. LAPPA also offers "Drug Checking Equipment, Needles/Syringes, and Drug Paraphernalia: Summary of State Laws" and "Naloxone: Summary of State Laws."
• FedUp! is a grassroots coalition formed in 2012 that seeks action from the federal government to end the public health epidemic created by opioids. FedUp! accepts no money from pharmaceutical corporations and 100% of the donations they receive are directly applied to managing the costs of hosting their FedUp! rallies.
• Grassroots Unwired provides an overview of grassroots advocacy.
• Model Law Virtual Knowledge Labs is a virtual learning series that provides state and county leaders with an opportunity to deepen their awareness and understanding of how model laws can assist jurisdictions in addressing substance use disorders and concomitant issues.
• Reasons Foundation has published the "Drug Legalization Handbook."

Promising Practices

Capitol Hill Day is an annual event sponsored by CADCA (Community Anti-Drug Coalitions of America). It is an opportunity for participants in the National Leadership Forum to meet with their members of Congress (2 Senators and 1 member of the House of Representatives) to discuss national substance use prevention policy priorities and substance use issues in their local community.

Illinois. The following illustrates some of the partnerships and strategies used to pass an important piece of legislation. Illinois SB2928 is a current law with the common name "Lake County Prescription Drug Disposal Pilot Program" which had been adopted in 2014 and is currently still functioning, losing its Pilot portion of title in 2015. It has been shown to be a model by which many organizations and local governments can partner with one another to improve outcomes in drug recovery and disposal efforts. The lead Project Coordinator Bill Gentes, has as a result, been awarded CADCA's Advocate of the Year. The following steps were used in the creation, adoption, and advocacy for this bill that allowed successful passing of it within the 98th general assembly:

• Investigation of Previous Regulation and Legislation - As is shown in the Securing Public-Private Partnerships section, it is required that one reviews current legal standings to determine if advocacy for amendment is required to allow for a more proactive approach to drug prevention to exist.
• Partnering with Local Law Enforcement - As stated by Gentes at an interview "“circling back to law enforcement and telling them, ‘look, you guys dropped off 500 pounds and I want to tell you what that means,” makes it easy for those police departments to then get their mayors, and their village boards invested in the process. "In many jurisdictions, it is regulated that only police forces may collect excess pharmaceutical products, which increases the need to partner with Local Law Enforcement even more.
• Gaining support of Local and Community Leaders - Primarily through the method discussed in Partnering with Local Law Enforcement and through advocacy and education efforts, to have a bill passed one must show support at the local level as well as demonstrable results of local programs to garner such support. As Stated in the Route 50 Article: "Another goal for Gentes was to uncover and take advantage of the data coming out of the collection boxes. When scheduled substances are found within the boxes, the contents and amount is noted. This isn’t merely a measure to satisfy curiosity. Rather, Gentes uses the data collected as a tool to recruit new police departments to the program, and to remind participating police departments that their efforts are making a difference.
• Securing Public-Private Partnerships - Walgreens was approached by Gentes and worked to create Prescription Drop Off and Secure Sites with partnership with local police forces and legislature. Currently expanding their drop off points to several states, there appears to be an issue with a need to review current laws regarding drug disposal. This increased the capacity of the project and accompanying police force in collection efforts.
• Advocating for Adoption from State Officials - Through previous methods listed, especially community advocacy efforts, the proposal was adopted as a bill partly through the efforts of sponsor Senator Terry Link, and went on to receive unanimous support.
• Securing Funding For A Statewide Program - In the Example of SB2928, funding would be secured in law through the Illinois EPA with the rationale that disposal of such materials would prevent drugs from tainting local water supplies, though it should be noted that labor and supplies were primarily used from local Law Enforcement Departments.