An Economic Analysis of Community Costs Incurred to Implement the Communities That HEAL Intervention to Reduce Opioid Overdose Deaths in Four States

Abstract

Background:

The HEALing Communities Study (HCS) was conducted across four states with the goal of decreasing opioid-related overdose deaths by increasing community-level adoption of evidence-based practices (EBPs). Providing communities with training, technical assistance, and resources to aid them in addressing opioid overdoses was central to the Communities That HEAL (CTH) intervention. The intervention included 1) community engagement (CE) to facilitate data-driven EBP selection and implementation, 2) a menu of EBPs to implement, and 3) communication campaigns.

Methods:

We performed an economic cost analysis for the 33 communities implementing CTH over a 30-month intervention period in Kentucky, Massachusetts, New York, and Ohio. Cost data were obtained from community members, consultants, and research faculty and staff. This study focuses on the communities’ perspective and reports costs paid directly with HCS funds and the opportunity costs of community members’ time and other unreimbursed resources. We report average costs across communities and for each component of the CTH.

Results:

The average cost per community of CE was $1,030,405, EBPs was $668,030, and communication campaigns was $235,915. The total community cost of CE was $34,003,373, of EBP implementation was $22,044,987, of communications campaign was $7,785,182.

Conclusions:

Our study provides insight into the scope and value of resources incurred to implement community-based interventions to reduce opioid overdose deaths across four states.

1. INTRODUCTION

More than 80,000 opioid-related overdose deaths occurred in 2023 in the US (Ahmad et al., 2022). The number of people with opioid use disorder (OUD), a risk factor for overdose, remains high with more than 7.6 million people having OUD (Krawczyk et al., 2022). Opioid-related overdose deaths reflect, in large part, the lack of access to and retention on medications for opioid use disorder (MOUD), inadequate access to harm reduction services, and the continued stigmatization towards people who use substances and those on MOUD (Volkow & Wargo, 2018). Fewer than 20% of individuals with OUD receive any form of MOUD treatment (Krawczyk et al., 2022; Wu et al., 2016).

Though evidence-based practices (EBPs) exist to reduce opioid-related overdose deaths, adoption of EBPs has been suboptimal. The HEALing (Helping to End Addiction Long-term^®) Communities Study (HCS) sought to decrease opioid-related overdose deaths by increasing community-level adoption of EBPs. While the term “community” in HCS varied across states and included counties, municipalities, or clusters of rural towns, the need for an intervention rooted in the community did not. HCS tested the impact of the Communities That HEAL (CTH) intervention (Walsh et al., 2020) which had three major components: 1) community engagement to facilitate data-driven EBP selection and implementation (Young et al., 2022); 2) the Opioid-overdose Reduction Continuum of Care Approach (ORCCA), a menu of opioid education and naloxone distribution, MOUD, and other EBPs, and safer prescribing and disposal practices (Winhusen et al., 2020); and 3) communication campaigns to reduce stigma and raise awareness and demand for EBPs (Lefebvre et al., 2020). The protocol was implemented across communities in Kentucky, Massachusetts, New York, and Ohio. Communities across the states were selected to participate based on the following eligibility criteria established by the National Institute on Drug Abuse: 1) expressed willingness to address the implementation of MOUD and overdose education and naloxone distribution; 2) expressed willingness to develop partnerships across health care, behavioral health, and justice settings for EBPs to address opioid misuse, OUD, and overdoses; 3) within each state, ≥30% of selected communities were rural; 4) Across the HCS communities in each state, ≥150 opioid-related overdose fatalities (at least 15% occurring in rural communities) and a rate of ≥25 opioid-related overdose fatalities per 100,000 people, based on 2016 data.

The community as decision maker was a core component of HCS. The study provided a framework and resources to develop a community-driven intervention wherein community coalitions, with members from various backgrounds and expertise, including people with lived/living experience, worked together to prioritize EBPs targeting overdose for their communities. One objective of the HCS was to assess the economic impact of the CTH intervention including the costs incurred by communities to implement the CTH. The CTH is unique as it represents the first (and largest) multi-state, multi-community, multi-EBP initiative designed to significantly reduce opioid overdose deaths. We present economic cost findings for communities implementing the CTH (these are often referred to as intervention communities—those communities randomized to receive the intervention first), which include resources that were paid for directly with HCS funds, as well as the opportunity costs of community members’ time and other unreimbursed resources. This paper focuses on these economic costs from a community perspective, which reflects the full value of resources that communities would need to invest to implement the CTH intervention. Cost results are meant to inform a community’s efforts in addressing overdose deaths as if they were the primary stakeholder in the CTH intervention.

2. METHODS

2.1. Analytic overview

The HCS Health Economics Work Group (HEWG) developed economic data collection tools to comprehensively track the resources used to implement CTH. These tools adapted micro-costing techniques to track resources associated with the three core CTH components: 1) community engagement, 2) ORCCA EBP strategies, and 3) communication campaigns. For each component, the HEWG collected resource data used for CTH implementation (e.g., time spent in community coalition meetings), information to translate these resources into dollars, and costs of purchased services or materials (excluding direct purchases of naloxone, buprenorphine). In cases where direct expenditures were not available (e.g., community member time for training), quantities of goods/services/hours relevant to CTH implementation were counted and translated into dollars using unit costs representing fair market value per unit of good or service.

The time costs of community members were fundamental to evaluating overall CTH costs. Time costs comprised of both time spent in meetings as well as time spent between meetings by individuals actively involved in the CTH (i.e., coalition members) or their staff to support CTH activities. Community implementation costs of the CTH intervention were gathered for the intervention communities from January 1, 2020 through June 30, 2022 (intervention period = 30 months). While the trial included 34 communities in the intervention, we conducted a per-protocol analysis (n=33) excluding one intervention site that withdrew prior to intervention initiation and thus contributed no cost data.

2.2. Data collection

2.2.1. Community Engagement

CTH intervention was implemented over seven phases, each with specific planning and implementation tasks (See Supplemental Appendix Table A1). In this cost analysis, we focus on the total community-level costs of implementing the CTH intervention across Phases 1 through 6 which occurred over the 30 months. The Preparation Phase 0 included CTH start-up activities which, while important in preparing to implement CTH, are not part of the ongoing management or sustainment costs of CTH and are thus reported separately (Montoya et al., 2022).

Community coalitions were the hubs of decision making on EBP selection and implementation and met approximately monthly throughout the study period. The process for establishing coalitions and selection of EPBs is described in more detail elsewhere (Sprague Martinez et al., 2020; Young et al., 2022). Coalition members were surveyed monthly using the RedCAP web application to obtain information on time spent on HCS activities including attending coalition meetings and time spent working on CTH-related activities between meetings (See Supplemental Appendix Table A2). Coalition members were asked to report their own time and time spent by staff in their organizations as it related to CTH activities. In the cases where more than one staff within the same organization were represented in a coalition, they did not report data on each other. In addition, we collected time spent by non-coalition members such as HCS staff and researchers who fulfilled specific implementation roles. Details on community-level characteristics of coalition meetings are provided in Appendix Table A2.

2.2.2. ORCCA EBPs

The ORCCA included EBPs in the three main areas described above and in detail in Walsh et al., 2020 (Walsh et al., 2020). Costs for ORCCA strategies included time spent on activities in support of ORCCA facilitation and services (e.g., transportation) and products that were purchased to implement the EBPs. These costs were primarily collected from invoices the communities sent to HCS for reimbursement and from financial records of grant-supported expenditures made directly by HCS. At the end of the intervention period, HCS staff met with provider organizations and community liaisons to ensure an accurate interpretation of invoice amounts and to identify costs not reflected in the invoices in Kentucky, Massachusetts, and New York. Staff conducted key informant interviews at provider organizations to estimate the additional resources used to implement the ORCCA strategies (Tin et al., 2024). These data were then used to estimate the additional costs not captured in the invoice and HCS accounting data (Tin et al., 2024). Ohio estimates relied solely on invoices.

2.2.3. Communication campaigns

Communication campaign efforts were conducted with a sub-contracted agency, the Oak Ridge Associated Universities (“Oak Ridge”). Oak Ridge worked with HCS staff, community coalition members, and appointed communication champions to develop and implement the campaigns (Stein et al., 2023). Communication champions were recruited from the coalition to serve as the main points of contact or as liaisons between the research site team and the coalition. Oak Ridge costs were documented through their itemized invoices to HCS, and HCS staff were surveyed to collect their time spent on the communication campaigns. Coalition members who spent time supporting the development and launch of the communications campaigns reported this time in their monthly survey responses.

2.3. Calculating CTH Costs

2.3.1. Cost Estimation Overview

For the three main components of the CTH intervention, we multiplied 1) time reported by coalition members or HCS staff in support of the CTH intervention, plus 2) time that was volunteered or was not invoiced to HCS, by hourly wage estimates to produce labor costs per hour. We valued all time reported by coalition members, HCS staff, researchers, and others involved with CTH using national wage data from the Occupational Information Network (O*NET) that is supported by the Bureau of Labor Statistics. See Supplemental Materials for full details of wage estimation (Occupation and Wage Linkages section).

In addition to labor costs, each CTH intervention component included non-labor costs. For community engagement, non-labor costs included travel and other meeting attendance costs (e.g., food, equipment). For the ORCCA, invoiced costs were organized by menu and strategy as well as labor and non-labor resources. Non-labor costs included mobile van purchases, equipment, and space and overhead costs. For the communications campaign, we collected Oak Ridge contracted services costs for each of the four states. We summed labor costs with other categories of costs to estimate the total economic cost of the CTH. Descriptive statistics for summary cost measures (e.g., mean, median, standard errors) were calculated at the community level and reported as total CTH costs by state and across all communities. To support comparability across states, the total and average of community per capita costs based on the total population in the participating communities were calculated and are presented in the results tables. All costs are reported in 2021 US dollars.

2.4. Missing Data and Sensitivity Analyses

The coalition attendee survey data were the primary source of missing data though the meeting attendance data were collected regularly. Coalition sizes varied during the study, as did coalition member involvement. The response rate across all coalition member survey-months was 42.9%. For cost estimation, excluding missing data would likely produce a lower bound on total costs. Therefore, missing coalition member time responses were imputed, conditional on a variety of individual, meeting month, and community characteristics, but under assumptions that reflect non-missing-at-random uncertainty (See Supplemental Appendix section on Imputation of Coalition Member Labor Measures) (Faria et al., 2014). The imputation of coalition member time was a multi-step process used to improve the validity of estimates of labor costs associated with community engagement and communication campaign activities in the CTH intervention. Other missing data included EBP-related activities not reported in invoices and unable to be estimated using micro-costing data. Sensitivity analyses were used to explore missing data that impacted the cost analysis results, including using alternative assumptions for multiple imputation and assigned wages including overall high- and low- scenarios (See Supplemental Appendix Table A4).

3. RESULTS

3.1. Total CTH Costs borne by Communities

There was a wide range of time and other resources spent on various aspects of the CTH. Table 1 reports the community level labor hours associated with CTH implementation for community engagement and communications campaign activities. In brief, community coalition members invested more than 8,000 hours on average per community (range 171 to 36,124) during the study period to support community engagement and more than 2,700 hours (range 82 to 7,230) on average per community to support the communications campaigns. The community-level costs of CTH implementation in intervention communities are reported in Table 2, by intervention component. Across all intervention communities, the average cost of community engagement was $1.03 million per community (average $23.00 per capita) (range $322,678 to $1.70 million). The communications campaign cost $235,915 on average (range $122,094 to $427,405) and $5.30 per capita; and average EBP strategies cost $668,030 (range $0 to $1.69 million), $13.50 per capita. Average total payments from HCS to implement CTH per community were $1,136,472 (range $367,500 to $2.45 million and $24.20 per capita). The average opportunity costs were $797,877 (range $187,305 to $1.85 million and $17.70 per capita). Average total economic cost of CTH per community was $1.90 million (range $617,565 to $3.20 million and $41.80 per capita). Appendix Table A3 details the community-level averages for each component of the CTH. Table 3 shows results stratified by rural and urban designations. The largest cost differences between rural and urban communities were in community engagement and EBP strategies.

Table 1.

Community-level labor hours associated with implementation of the Communities That HEAL Intervention in HCS Intervention Communities (N=33) (Total Community Hours, January 2020 through June 2022)

CTH Component Labor Category	Mean	Median	Standard Error	Minimum	Maximum
Community Engagement
HCS-funded Staff to Support Community Engagement a,b	9,740	9,375	541	6,386	14,662
Community Coalition Members - Time in Coalition Meetings c	422	359	49	34	1,299
Community Coalition Members - Time outside of Coalition Meetings c	4,824	4,001	566	140	11,888
Community Coalition Member Associates c,d	8,079	4,157	1,443	171	36,124
CTH Intervention Specialists a, e	1,572	333	397	73	5,501
Training and Technical Assistance - Trainers f	211	124	35	13	887
Training and Technical Assistance - Trainees g	925	817	131	34	3,371
Communication Campaign
Communication Specialists a	849	915	37	583	1,149
Community Coalition Members c,h	2,739	2,155	353	82	7,230

Footnotes

^a.Some staff time was collected at the site level and equally apportioned to each community within site.

^b.HCS-funded staff for key CTH intervention roles, e.g., community engagement facilitators and data coordinators not focused on research.

^c.Estimates reflect multiple imputation (mi=30). Standard errors are bootstrapped (replications=1000) community estimates (overall or within-state) with one exception. The standard errors for cost estimates associated with Coalition Members and their Associates reflect multiple imputation (mi=30).

^d.Community Coalition Member Associates’ time spent on Community Engagement activities outside of meetings.

^e.Faculty members and other community subject matter experts who provided direct support CTH implementation (excludes research related activities).

^f.Only included HCS-supported trainings provided to an intervention community; trainings for multiple communities were equally proportioned to each community.

^g.Time spent attending or participating in training and technical assistance activities was not paid for by the HCS grant; attendee time for multiple communities were equally apportioned to each community.

^h.Community Coalition Member time spent on the communication campaign.

Table 2.

Community-level costs to Implement the Communities That HEAL Intervention in HCS Intervention Communities (N=33) (2021 $US, January 2020 through June 2022)

CTH Cost ($) Component	Cost	Average (Std Erra)	Median (IQR)	Minimum	Maximum
Community Engagement	Unadjusted	1,030,405 (404,700)	1,019,058 (688,063,1,304,258)	322,678	1,747,113
	Per Capita b	23.0 (22.4)	15.1(8, 34.7)	0.9	113.0
Communication Campaign	Unadjusted	235,915 (80,314)	200,679 (183,933,297,135)	122,094	427,405
	Per Capita	5.3 (5.5)	4.0 (2.2, 7.3)	0.2	29.7
EBP Strategies Total	Unadjusted	668,030 (371,763)	565,448 (431,137,840,328)	0	1,689,647
	Per Capita	13.5 (11.9)	11.2 (5.7, 20.5)	0.0	43.8
Total Paymentsc to Implement CTH	Unadjusted	1,136,472 (437,863)	1,048,516 (817,796,1,488,194)	367,500	2,450,957
	Per Capita	24.2 (19.7)	19.0 (9.5, 36.4)	0.7	68.8
Total Other Opportunity Costsd to Implement CTH	Unadjusted	797,877 (480,495)	621,453 (425,600,1,186,937)	187,305	1,852,156
	Per Capita	17.7 (21)	11.1 (5.5, 22.6)	0.5	109.4
Total Economic Costs to Implement CTH	Unadjusted	1,934,350 (721,849)	1,818,514 (1,383,670,2,429,101)	617,565	3,231,021
	Per Capita	41.8 (38.1)	30.1 (15.4, 58.3)	1.5	178.2

Footnotes

^a)Standard errors are bootstrapped (replications=1000) community estimates (overall or within-research site) with one exception. The standard errors for cost estimates associated with Coalition Members and their Associates reflect multiple imputation (mi=30).

^b)Per capita costs are calculated by dividing community costs by the community population for each community. The per capita cost for each community is averaged over the 33 communities for the per capita average.

^c)Payments made by HCS to implement CTH.

^d)Opportunity costs are costs not paid for by HCS, e.g., in-kind time from community members and non-HCS financial support.

Table 3.

Total Economic Costs to HCS Intervention Communities (N=33) to Implement the Communities That HEAL Intervention, Overall and by Rural/Urban, Gross and Per Capita (2021 $US, January 2020 through June 2022)

CTH Component	Total (Pop. = 4,411,601, N=33)		Rural (Pop. = 645,817, N=15)		Urban (Pop. = 3,765,784, N=18)
	Unadjusted	Per Capita b	Unadjusted	Per Capita	Unadjusted	Per Capita
Community Engagement	34,003,373	7.71	14,095,543	22	19,907,830	5.29
Paymentsc for Staff to Support Community Engagementd	14,259,751	3.23	6,395,719	9.90	7,864,032	2.09
Community Coalition Members e	6,506,139 (137,137)	1.47 (0.03)	2,414,497 (122,885)	3.74 (0.19)	4,091,643 (144,383)	1.09 (0.04)
Community Coalition MemberAssociates f	6,974,756 (157,048)	1.58 (0.04)	2,924,310 (151,725)	4.53 (0.24)	4,050,446 (164,419)	1.08 (0.04)
CTH Intervention Specialists g	3,559,622	0.81	1,224,460	1.90	2,335,162	0.62
Training and Technical Assistance	2,703,104	0.61	1,136,557	1.76	1,566,547	0.42
Communication Campaign	7,785,182	1.76	3,322,637	5.14	4,462,545	1.19
Paymentsc to Communication Campaign Partner (ORAU)	2,497,484 (13,552)	0.57 (0.003)	1,183,782 (11,210.316)	1.83	1,313,703 (15,009.185)	.35 (0.004)
Communication Specialists	1,929,946	0.44	838,104	1.30	1,091,841	0.29
Community Coalition Members e	3,357,752 (79,634)	0.76 (0.09)	1,300,751 (74,688)	2.01 (0.12)	2,057,001 (83,532)	0.55 (0.02)
EBP Strategies Total	22,044,987	5.00	7,691,835	11.91	14,353,152	3.81
Paymentsc to Providers and Other Community Partners	20,746,357 (355,497)	4.70 (0.08)	7,552,338 (238,995)	11.69 (0.37)	13,194,019 (406,814)	3.50 (0.11)
Other Community Support	1,298,630 (124,951)	0.29 (0.03)	139,497 (16,297)	0.22 (0.03)	1,159,133 (166,460)	0.31 (0.04)
Total Paymentsc to Implement CTH	37,503,592 (437,863)	8.50 (1.00)	15,131,839 (340,071)	23.43 (0.53)	22,371,754 (489,162)	5.94 (0.13)
Total Other Opportunity Costsh to Implement CTH	26,329,949 (480,495)	5.97 (0.11)	9,978,177 (428,158)	15.45 (0.66)	16,351,772 (505,123)	4.34 (0.13)
Total Economic Costs to Implement CTH	63,833,541 (721,849)	14.47 (0.16)	25,110,015 (600,890)	38.88 (0.93)	38,723,526 (757,517)	10.28 (0.20)

Footnotes

^a.Standard errors (denoted by parentheses in the table) are bootstrapped (replications=1000) community estimates (overall or within-state) with one exception. The standard errors for cost estimates associated with Coalition Members and their Associates reflect multiple imputation (mi=30). As such, not all rows have standard errors.

^b.Per capita costs are calculated by dividing total costs (sum of community costs) by the total population (sum of community populations).

^c.Payments made by HCS to implement CTH.

^d.HCS funded staff for key CTH intervention roles, e.g., community engagement facilitators and data coordinators for non-research activities.

^e.Community Coalition Member time includes both meeting Coalition Meeting time and time spent between meetings supporting CTH.

^f.Community Coalition Member Associates’ time was spent on Community Engagement activities outside of meetings.

^g.Faculty members and other community subject matter experts who provided direct support for CTH implementation (excludes research related activities).

^h.In-kind resources and non-HCS financial support for CTH implementation

3.2. Community Engagement Costs

On average, the number of coalition meetings attended during the intervention phase was 24.1 and the average number of days between meetings was 38.2 (Appendix Table A2). Coalition meetings were relatively well attended with an average of 10.9 organizations represented per meeting; across all sites, 9.4 coalition members attended at least 50% of all meetings held during the study period. Due to the COVID-19 pandemic, more than 86% of the coalition meetings were virtual. Less than half of the coalition members reported spending time on community engagement activities outside of meetings (39%). Additionally, about 23% of members reported engaging their staff or other associates to support CTH community engagement. Over the 30-month study period, the total cost of community engagement for the CTH intervention was $34,003,373. Community engagement represents 54% of total community-level CTH costs (Table 3). These costs were largely driven by payments to HCS staff to support community engagement ($14,259,751). Time spent by community coalition members and their associates was the next largest category at $13.50 million.

3.3. EBP Implementation Costs

There was considerable heterogeneity in the number of EBP strategies implemented across states (Chandler et al., 2023). For OEND strategies, a total of 254 strategies were implemented (range 38 to 104 per state). For expanding access to and engagement with MOUD, a total of 256 strategies were implemented (range 52 to 92 per state), and for safer prescribing, a total of 105 strategies were implemented (range 9 to 38 per state). Total EBP cost across all communities was $22 million (Table 3). Although EBP implementation cost estimation relied heavily on invoice data reflecting community EBP expenditures, three states also collected other community EBP costs ranging from approximately $58,000 to $891,000. The average cost of implementing the EBP strategies across the three menus per community (all four states included) was $628,677 (SE $355,497) in payments to partners and $39,352 (SE $124,951) from other community sources (for 3 states, KY, NY, MA in which these were collected) (Appendix Table A3).

3.4. Communication Campaign Costs

The total cost of the HCS communications campaigns over the study period across all communities was $7.8 million (Table 3). Approximately $2.50 million of these costs were for contracted communications services, $2 million were attributable to HCS staff and $3.40 million were attributable to coalition members’ time.

3.5. Sensitivity Analyses

Community engagement costs per community varied most under alternative assumptions, from −20% when assuming lower (1^st quartile) wages and a 4-week top code on coalition member reporting weeks to +27% for higher (3^rd quartile) wages and no top code (Appendix Table A4). Under the most extreme low and high scenarios, total CTH costs per community ranged from 16% lower ($1.60 million) to 24% higher ($2.40 million) than the primary result of $1.90 million per community.

4. DISCUSSION

We estimated the total and average community costs of implementing the CTH, a community-based intervention delivered across health care, behavioral health, criminal legal, and other community-based settings in select communities in Kentucky, Massachusetts, New York, and Ohio representing a total population of more than 4.41 million (i.e., the combined populations living in HCS communities). The economic cost of implementing the CTH over a 30-month period was more than $63 million, with the average cost per community of $1.9 million. The costs were driven largely by community engagement efforts and EBP implementation. While not every community in the US has the resources to implement such a comprehensive intervention, our insights are timely, as community-based interventions to address the opioid crisis are increasingly being implemented across the U.S. using opioid settlement funds (Whaley et al., 2023). Insights, particularly around the cost of community engagement, can be gleaned to guide decision-making regardless of community resource availability.

To perform an economic evaluation of this large-scale community-engaged intervention required innovation and collaboration at nearly every step. First, while economic evaluation tools have been used in clinical trials for decades, our approach was framed from the community’s perspective, requiring input from multiple stakeholders. In working with community partners, we needed to develop a survey approach that obtained sufficient data but also respected their competing priorities. Participant burden regarding data collection was an initial concern as was obtaining data from all community members who participated in the intervention. By developing our costing tools alongside experts in community-engaged research and with community members themselves, we were able to estimate the total economic costs borne by the community including opportunity costs of community members’ time. Through this shared decision-making process, we were able to provide community-level average estimates of the amount of labor hours community members provided and the cost of those labor hours, the cost of payments to community partners, and community-specific costs of training, technical assistance, and communications. Where we were unable to obtain data directly, our team used innovative imputation methods to account for missing data.

Such an approach to costing was not done as a mere exercise for academicians. In general, funds are allocated for research studies based on costs likely to be expended “out of pocket” and intervention costs are calculated from the perspective of a provider or insurer. As community-based interventions are increasingly common, our study provides insights into how such interventions may need to be funded to cover “real-world” economic costs, including the uncompensated time spent by community members. Notably, many of the community-academic relationships were newly formed perhaps requiring more time and effort than if they were pre-existing relationships.

Community members’ time associated with implementing an intervention, including relationship building and problem-solving, is rarely, if ever, considered in resource allocation but is central to the work. The relative amounts of the cost components in our work are illustrative of this point. Across all the communities and for each of the four states, community engagement costs were either equal to or, in most cases, greater than the direct payments for implementing EBPs. While approximately $19 million was invested in implementing EBP strategies via direct payments, the cost of unpaid time of community members and their associates was $17 million. Although this $17 million is usually not included in grant funding, it is a real cost incurred by communities. Ultimately, if we expect transformational change to occur in communities – especially for complex societal health issues such as the overdose crisis – and for community members to be invested in the process – then their efforts need to be considered as part of a full accounting of economic costs. Resource allocation and funding should consider total economic costs, not only direct expenditures.

There was heterogeneity in how the four states allocated dollars to the three core CTH activities. Apart from differences in population demographics, this heterogeneity was, in part, a function of the infrastructure that existed prior to HCS and holds valuable lessons for future implementation elsewhere. States and communities were able to allocate resources to the CTH activities in a manner that was responsive to the identified needs of the communities, and within the limits of their own budgets. Resources also varied depending on which EBPs were selected and the scale at which they were implemented. Policy makers considering a CTH approach in their own community should interpret our results as a guide and base decision-making on their own existing infrastructure. Factors that may impact costs in other context include but are not limited to geographic variability (rural vs urban); the presence or absence of existing relationships with community, health care, and justice systems; and the existing infrastructure for naloxone distribution and MOUD.

A study of this scope and complexity has limitations. The primary limitation of this CTH implementation cost analysis is uncertainty around missing data. The main source of missing data was coalition members’ time spent on community engagement activities. We explored this uncertainty further with sensitivity analysis. A second limitation is the need to limit data collection burden on community members, which was a unique challenge for such a large study. As a result, there may be costs that we were unable to capture and, as described, there was variability in the level of data detail collected by each site. Because of that limitation, we focused on the high-level findings (i.e., Table 3 results) that could be derived reliably from the data we collected. Areas of future research may explore variations in per capita costs based on specific community characteristics and the distribution of costs across the phases of the intervention or for individual interventions. Additionally, given the short study period, we did not adjust costs for inflation because inflation likely had minimal impact during the study period; however, future implementation of the CTH should account for inflation as it may affect cost estimates in states with differing economic conditions or in time periods with more rapid inflation.

The COVID-19 pandemic erupted at the beginning of CTH implementation in intervention communities, which affected the implementation process (and the associated costs) as well as data collection approaches. Future analyses will explore the cost differences between intervention communities and those waitlisted to the second Wave of the study which occurred at a later stage of the pandemic response. Additionally, the community perspective does not account for EBP resources whose cost is not borne by the community (e.g., MOUD expenses covered by health insurance). Such costs would be included in a cost-effectiveness analysis taking on a broader societal perspective. Finally, the amount of money available to each community for the intervention differed by state and by how funds were allocated to communities within states, for example based on community population size (e.g., New York used an algorithm that included population size and a variety of community factors). As a result, there were real world budget constraints that may have limited decision making in one state that may not have been limiting in another. Together, these issues made it challenging to estimate all costs that may be needed to implement the CTH intervention, and whether the costs we report represent upper or lower bounds.

Our study provides cost insights that can inform future efforts by individuals working to address the overdose epidemic, and stakeholders motivated to implement community-based approaches to address overdoses and other health conditions. Although the financial investment in HCS was substantial, it did not account for all the resources that were necessary for communities to implement CTH. Our study helps to clarify the scope of resources that communities may need to implement community-based health interventions to combat pressing health issues such as reducing overdose deaths.

Highlights.

• This economic analysis of HCS represents one of the largest ever performed in the US

• Economic costs incurred by communities of implementing the CTH exceeded $63 million

• The average cost per intervention community was $1.9 million.

• Nearly $19 million was directly invested in implementing evidence-based strategies

• The cost of unpaid time of community members and their associates was $17 million