By Rachana Pradhan and Brianna Ehley

Congress sent states hundreds of millions of dollars to fight an opioid crisis claiming more than 100 lives a day — money they've largely been unable to spend after a year.

Mixed signals from the Trump administration on how to use the money and state challenges ramping up their efforts have left untouched more than three-quarters of the $500 million Congress set aside under the 21st Century Cures Act in late 2016.

As President Donald Trump heads to hard-hit New Hampshire today to tout his plan to combat the crisis, the slow drip of dollars into communities hit hard by addiction has put state officials in a bind and frustrated addiction experts and some treatment organizations.

“This is a total failure,” said Andrew Kolodny, former chief medical officer at Phoenix House and now a Brandeis University researcher, likening the situation to food and water “stuck in an airport somewhere, while people are starving to death.”

The grants for opioid addiction and prevention efforts were part of a $1 billion commitment over two years authorized in the Cures Act, which then-President Barack Obama signed just before leaving office.

But state officials were quickly caught in a dilemma: They were happy to receive new money, but it was guaranteed for only two years, making it difficult to get long-term commitments from health care providers and others to build programs and hire a workforce.

Many of those trying to expand access to medication-assisted treatment, buy overdose reversal drugs and bolster recovery programs say they were hamstrung in their efforts to solve a magnifying public health emergency with a short-term program. They’re calling on Congress for a longer-term financial commitment.

"One-time money really changes the parameters of what you think you can fund," said Katie Marks, project director for the Kentucky Opioid Response Effort, where officials will receive $21 million in grants over two years. "Some of these programs are going to take a fair amount of development before they can sustain themselves."

Congress is set to release the second $500 million tranche of aid soon, and weighing whether to extend the grants beyond two years while making other changes, according to aides in both parties.

The funding is valuable to boost certain types of programs, but doesn’t come close to paying for aggressive treatment for those suffering from addiction, said Robin Parsons of the Fairbanks Alcohol and Drug Addiction Treatment Center in Indianapolis.

“This isn’t going to go away in a couple years,” Parsons, the hospital’s chief clinical officer, said of the epidemic.

Regina LaBelle, who served as chief of staff at the Office of National Drug Control Policy during the Obama administration, likens the states' challenge to “flying a plane while you’re building it ... They have to build infrastructure at the same time they have to get money out the door.”

Many projects are just getting off the ground, even though the first year of the program ends April 30 — with officials expecting to request the money be carried over into the new year.

Kentucky officials had spent nearly $2 million as of early this month, Marks said. They began finalizing contracts for roughly 30 projects in July, she said.

"It has been a challenge with that many contracts, and using a state procurement process and partnering with community agencies," said Allen Brenzel, clinical director for the Kentucky Department for Behavioral Health, Developmental and Intellectual Disabilities.

Other states found workarounds to spend it faster. California legislators gave their health department new authority to quickly roll out contracts using the nearly $45 million the state will get annually, most of it to increase the use of medication-assisted treatment. The programs were up and running by last fall.

"One-time money really changes the parameters of what you think you can fund," said Katie Marks, project director for the Kentucky Opioid Response Effort, where officials will receive $21 million in grants over two years. "Some of these programs are going to take a fair amount of development before they can sustain themselves."

Congress is set to release the second $500 million tranche of aid soon, and weighing whether to extend the grants beyond two years while making other changes, according to aides in both parties.

The funding is valuable to boost certain types of programs, but doesn’t come close to paying for aggressive treatment for those suffering from addiction, said Robin Parsons of the Fairbanks Alcohol and Drug Addiction Treatment Center in Indianapolis.

“This isn’t going to go away in a couple years,” Parsons, the hospital’s chief clinical officer, said of the epidemic.

Regina LaBelle, who served as chief of staff at the Office of National Drug Control Policy during the Obama administration, likens the states' challenge to “flying a plane while you’re building it ... They have to build infrastructure at the same time they have to get money out the door.”

Many projects are just getting off the ground, even though the first year of the program ends April 30 — with officials expecting to request the money be carried over into the new year.

Kentucky officials had spent nearly $2 million as of early this month, Marks said. They began finalizing contracts for roughly 30 projects in July, she said.

"It has been a challenge with that many contracts, and using a state procurement process and partnering with community agencies," said Allen Brenzel, clinical director for the Kentucky Department for Behavioral Health, Developmental and Intellectual Disabilities.

Other states found workarounds to spend it faster. California legislators gave their health department new authority to quickly roll out contracts using the nearly $45 million the state will get annually, most of it to increase the use of medication-assisted treatment. The programs were up and running by last fall.

In Indiana, which received about $11 million the first year, concerns about future funding led Aspire Indiana to not move ahead with a proposed expansion of residential substance abuse services, according to Matt Brooks, president of the Indiana Council of Community Mental Health Centers.

There is no guarantee that SAMHSA grant funding will continue in the future," said Brooks.

Federal officials say such spending delays are normal for new programs. The first four months of the state opioids grants were dedicated to setting up infrastructure, followed by a half year focused on delivering services, SAMHSA spokesperson Chris Garrett said. He said that states have spent just under a quarter of the $500 million Congress appropriated so far.

But the start-up experience has underscored the need for greater clarity from the federal government. Last year, Ex-HHS Secretary Tom Price sent mixed signals about how much funding states would receive in round two and what it might be spent on. That rattled state officials, who worried that changes halfway through would require them to reapply and potentially delay projects.

Congress and SAMHSA also went back and forth about whether to change the funding formula— it is based on a combination of population and total drug deaths, which left small states like West Virginia and New Hampshire with proportionately less money than big states that had lower mortality rates.

"We had to kind of wait for the green light that the second-year funding would be allocated to the same priorities," said Kentucky's Brenzel.

State officials are now awaiting the second round of funding and hoping for more after that.

"My No. 1 ask" would be for them to continue the program as is, said Marlies Perez, chief of the California Department of Health Care Services Substance Use Disorder Compliance Division. "For them to come up with a whole new system? That would definitely add delays."

Some in Congress are nonetheless examining possible tweaks. Sen. Tammy Baldwin (D-Wis.) and others have proposed broadening the funding targets to address additional substance use issues like methamphetamine, which has plagued her state.

Other lawmakers, from states with the highest drug-related death rates, are pushing for more money, faster.

"How do we deal with small communities that don't have two nickels to rub up against each other to file a grant application?" said GOP Rep. David McKinley, whose home state of West Virginia has the highest overdose mortality rate in the country. "How can we streamline this so that it does get out?"