Six years ago, Alexa Eggleston and Tym Rourke called on philanthropy to launch a national philanthropic campaign in response to the opioid epidemic. At the time, Eggleston was a national program officer at the Conrad N. Hilton Foundation, and Rourke was director of substance use disorders grantmaking at the New Hampshire Charitable Foundation.
“Philanthropy cannot solve this problem alone,” the two wrote in an article for Grantmakers in Health. “But philanthropic organizations can help drive a national movement to address this epidemic. And it is essential that we do so.”
Philanthropy didn’t respond to Eggleston and Rourke’s call, at least not at the level they had in mind, and the opioid crisis has only accelerated. Overdose deaths from both illicit drugs and prescription opioids increased steadily over the last decade, according to the National Institute on Drug Abuse. There was a temporary dip in 2018 and 2019, then deaths surged during the pandemic. In 2021, an estimated 108,000 people in the U.S. died from drug-involved overdoses; that number rose to about 109,000 in 2022, according to preliminary figures. “The third-leading cause of death, unintentional injury, was largely driven by a high number of drug overdose deaths in 2022 amid the opioid epidemic,” Axios reported.
A majority of the overdose deaths were caused by fentanyl, a synthetic opioid that is cheap, widely available, and frequently added to other drugs. Fentanyl overdose deaths nearly quadrupled between 2016 and 2021, as Axios reported. “It’s really fentanyl — fentanyl is what’s killing people,” Jon Zibbell, a senior scientist at RTI International, told the Washington Post.
Death totals provide a vivid measurement of the crisis, but many more lives are scarred by chronic drug use than show up in the statistics. Those with substance use disorder suffer, and so do their children, their families, their communities and society as a whole.
As the opioid crisis rages on with little sign of abating, where is philanthropy? Largely missing in action, according to Inside Philanthropy’s report “Giving for Substance Use and Addiction,” which examined funding for substance use overall and concluded, “This segment of the nonprofit sector has long suffered from donor neglect and is perennially underfunded.”
Why has philanthropy fallen so wildly short? It’s clearly not a matter of resources: Health foundations are among the largest and best-endowed philanthropies in the country. Despite their collective wealth, few of the nation’s large health funders, or major funders with broader missions, have taken up this issue, despite urgent calls from many in the field to do more.
One likely reason is that a number of foundations, including some of the nation’s largest health funders, shifted their focus to social determinants of health over the last several decades. These funders have chosen to target resources on upstream issues that influence overall wellbeing — adverse childhood experiences, poverty, lack of access to healthcare, environmental injustice and other factors. While these are all worthy causes, and play their own roles in substance use disorder, funding them doesn’t necessarily provide relief for the downstream impacts of substance use currently hammering American communities.
Another reason may be geographic. The opioid crisis first began surfacing in rural America, in the Rust Belt and in small, remote towns in Appalachia and across the country, regions that philanthropy has long overlooked. Most philanthropies are based in large metropolitan areas and tend to prioritize problems affecting cities and impacting urban populations, versus rural America. (Today, of course, the opioid epidemic is an urban as well as a rural issue; it affects every sector of the population, and is having a particularly devastating impact on Black communities, as Scientific American reported.)
Stigma is another factor that may influence funders’ priorities. Although attitudes are changing, and most of those in the health field, and in health philanthropy, now consider substance use disorder a disease (and therefore a health issue), there remains a lingering perception that those who use drugs are suffering from their own poor decisions, or are otherwise morally flawed. These perceptions aren’t just held by those in philanthropy, of course. Many Americans share them. But Johns Hopkins Medicine points out that stigma hurts patients and undermines the care they receive: “Research demonstrates that stigma damages the health and wellbeing of people with substance use disorder and interferes with the quality of care they receive in clinical settings.” Such underlying attitudes often go unexpressed and unacknowledged, so it is impossible to say how much stigma influences philanthropic decision-making, but many of those we talked to believe it plays a significant role.
A final cause could be the simple fact that big institutional philanthropy is not agile in responding to crises. Having made commitments in other areas, many foundations hesitate to shift gears and broaden their focus or to move in a different direction — no matter how urgent the crisis.
We decided to take a closer look at philanthropic funding for drug use, its prevention and treatment, and reached out to a range of those working in the field. While experiences and perspectives varied, virtually everyone we spoke to believes there is much more philanthropy could and should do to address one of the major health emergencies of our time.
It isn’t too late for philanthropy to step up; today, the need is greater than ever.
The “Harvard of foundations” opts out
Philanthropic support for substance use prevention and treatment took a one-two punch in recent years when two of the country’s largest health philanthropies phased out their funding after years of support.
Robert Wood Johnson Foundation (RWJF), the country’s largest health philanthropy, left the field first. RWJF began investing in substance use prevention and treatment in the mid-1980s, including tobacco and alcohol, as well as illegal drugs, as part of that portfolio. Over the next two decades, the foundation poured $700 million into that effort — “the largest investment in substance use prevention and treatment ever made by a nonprofit, philanthropic funder,” according to a retrospective report on the foundation’s work in the field. That 2014 report was commissioned by RWJF and conducted by the nonprofit consulting firm FSG.
Kristin Schubert, interim vice president of program at RWJF, worked at the foundation at the time; she said the decision reflects the foundation’s desire to address the upstream conditions that underlie and typically lead to substance use. She pointed out that it was a period of increasing understanding of the many external factors that influence health.
“The early 2000s were a really important time, overall, in U.S. public health and an important moment for us at the foundation,” she said. “We were starting to really open up to how we, as an organization, could influence those upstream factors, what we call the social determinants of health.”
Schubert pointed to evidence linking early childhood trauma and substance use disorder. “We know that trauma has a lot to do with stress,” she said. “And stress has a lot to do with factors like not having stable housing, and not having access to safe and high-quality schools, and so many other issues. We realized it was very difficult to influence that whole space if we weren’t going to move upstream to figure out how to get people better support so that they weren’t living in traumatic conditions.”
Based on that growing understanding, the foundation began exploring other approaches. “We started to engage leading thinkers on social determinants of health to get underneath what we could do as a foundation to influence that, rather than try to really focus on the problematic behaviors, if you will, that result from poor opportunities,” Schubert said. “We made the decision to start moving in that direction, so that meant sunsetting important areas of work for us. It always comes down to, ‘We have a lot of resources, but we can’t do everything.’”
RWJF has continued to provide discrete and time-limited support for substance use programs over the years, and will likely continue to do so, Schubert said.
FSG’s report acknowledges the impact of the foundation’s decision to pull out of this area: “As the largest private funder in the area, RWJF’s exit sent shockwaves through the field.” One RWJF program officer told FSG, “‘[RWJF’s] exit left a vacuum, and it was serious.’” While citing RWJF’s many important contributions, the report suggests that the foundation should have done more to involve and collaborate with other funders; by not doing so, its enormous footprint in the area made its exit all the more shattering.
”The level of RWJF’s investment in substance use enabled the foundation to ‘own’ the issue among private funders, but may have limited investment by others,” according to the report. It quotes an external stakeholder who observed, “‘RWJF really put a flag in the ground and went for it. It wasn’t their intention, but the net effect of [RWJF’s] investment, scaling, and spending, spending, spending was that substance abuse became known as their issue. That’s fine, but if others aren’t there with you, it’s hard to wind out of.’”
RWJF’s longtime contribution to the field was significant, and, of course, it’s common practice for philanthropies to shift strategies over time, electing to phase out of a particular funding area to pursue other priorities. At the same time though, RWJF also serves as a good example of how, in a philanthropic sector founded largely on corporate wealth, grantmakers addressing systemic problems need to reckon with the origins of their endowments — and sometimes, with those industries’ continuing culpability in the very problems they’re trying to solve.
After all, RWJF — though it has now “substantially diversified” its investment portfolio — was established with shares of Johnson & Johnson, which has profited from the opioid epidemic. The company supplied opiate ingredients to drug companies and for years touted the benefits of the drugs while playing down their risks. Johnson & Johnson joined distributors in paying a total of $26 billion for the national opioid settlement in 2022.
In any case, RWJF’s decision to phase out its work in the area was a significant loss — not just in terms of resources, but also in its ability to attract attention to the issue, as the report pointed out. “As one of the nation’s largest domestic health funders, RWJF had the unique ability to elevate the substance-use issue to the national stage. As one external stakeholder observed, ‘RWJF is like the Harvard of foundations — highly credible and respected. When RWJF got involved in substance use, it made Congress, NIH agencies and the public pay attention.’”
The reverse is also true, of course — when a major funder quits an area of funding, that also sends a signal. It’s impossible to gauge if and how much RWJF’s withdrawal from the field influenced other funders, but after RWJF began elevating social determinants of health, many other public health funders did, too.
Hilton exits next
The field experienced another major loss in 2018 when the Conrad N. Hilton Foundation announced that it was transitioning out of the area of substance use prevention and treatment, a process it completed in 2021.
Hilton’s work in the area began in 2013, and in subsequent years, it became a major funder, specifically in the area of adolescent substance use. Its focus was prevention through early intervention, and by all accounts, its contribution was significant.
In particular, the foundation worked to expand the use of a screening program known as Screening, Brief Intervention, and Referral to Treatment (SBIRT), which is widely used today. Several people we spoke with suggested that Hilton doesn’t receive enough credit for this work.
“SBIRT was an enormous success,” said Allen Smart, who founded PhilanthropywoRx, a national consulting organization that works with the philanthropic community on pursuing rural opportunities. “It was Hilton’s baby — they didn’t invent it, but they promoted and advocated for it, and I don’t think they get recognized enough for that. That’s partly because Hilton doesn’t do much self-promotion compared to other funders. As a foundation, they are super modest.”
Rosemary Veniegas, senior program officer for health at the California Community Foundation, which received support from Hilton, underscored the importance of the foundation’s youth focus. Most substance use treatment programs are designed for adults, she said, and don’t respond to the needs of young people in terms of creating a safe environment for them to seek out and receive help.
“Our health systems are not youth-centered or youth-oriented,” she said. “That was what was so important about Hilton’s approach. They were trying to lift up youth voices and ask, ‘How do we design systems or recovery that are youth-centric and youth driven?’ While the California Community Foundation has continued its work in the area, Veniegas said it was extremely helpful to have the backing of a large and influential ally like Hilton.
When we reached out to Hilton to find out why it phased out its funding in this area, a spokesperson referred us to a statement released when the decision was announced. According to that statement, a strategic planning process resulted in the decision to focus on seven program areas and transition out of four others. Substance use prevention was one of the areas that was scrapped.
“Our time as a partner in the substance use prevention field has brought many successes and substantial learnings,” the statement read. Beyond that, Hilton offered no explanation for the exit, and we were unable to learn more in interviews with several people familiar with the foundation’s work.
In 2014, IP pointed out that Hilton’s agenda was overly broad: “Even for a place with a couple billion dollars, it’s spread pretty thin, funding 11 different ‘priority areas,’” Alyssa Ochs wrote. And in 2018, when Hilton cut four program areas, IP’s David Callahan commended it for tightening its focus, but questioned why it would whack its successful substance abuse disorder program just as overdose deaths were rising sharply.
“The move comes amid the worst drug epidemic in U.S. history, with opioid overdoses claiming tens of thousands of lives every year,” Callahan wrote. “Why pull the plug on this program, especially given that Hilton is one of the only big funders for substance abuse prevention?” When he asked Hilton President and CEO Peter Laugharn this question, “Laugharn didn’t provide an exact rationale, but said the foundation had been working on substance abuse since 1982, and added, ‘There’s never a good time to transition out of a field like that.’”
As noted above, philanthropies often stop funding specific program areas, and sunsetting out of a particular area can create space for other players to step in with fresh perspectives and innovations to advance the work. But there is little question that the loss of support from RWJF and Hilton created a tremendous gap — in terms of both funding and leadership — while the opioid epidemic continued to gain ground.
Who’s minding the gap?
While the sector’s overall response has fallen short, a number of funders do include substance use prevention and treatment as part of their work. Bloomberg Philanthropies, which in 2018 launched an initiative to combat overdose deaths, focuses specifically on the seven states most impacted by the crisis. Bloomberg has teamed up with the Pew Charitable Trusts, the Centers for Disease Control and other partners to boost prevention and treatment programs.
Open Society Foundations, which is funded by billionaire George Soros, has long been committed to funding in the area of substance use and prevention. Arnold Ventures has also done some work in the area of substance use disorder, but several people we spoke to suggested it may be stepping back; we reached out to the organization, but it declined to comment for this article. A review of Arnold Ventures’ grants database shows some relatively recent grants for substance use disorder research and treatment efforts, including support for the Drug Policy Alliance (in years 2019 to 2021), programs at Johns Hopkins University (2020 to 2023), and Legal Action Center of the City of New York (2021 to 2023).
There is also a number of small foundations with personal connections to the substance use issue, and many health conversion and community funders address the issue in their regions. (See our brief, Giving for Substance Use Disorders and Addiction, to find out more about funders in this sector.)
Only one national private foundation, the Foundation for Opioid Response Efforts (FORE) makes opioid use prevention and treatment its sole focus. Like RWJF, FORE benefited from interests that helped drive the opioid crisis: It was created in 2018 by McKesson Corporation, formerly a major distributor of prescription opioids, as IP previously reported. McKesson was also part of the national opioid settlement.
FORE provides funding for a wide range of partners working on innovative approaches to substance use prevention and treatment (learn more about FORE’s work here). While the number of overdose deaths remains alarmingly high, FORE President Karen Scott sees reasons for optimism.
“There’s been an increasing shift to focus on [substance use disorder] as a public health rather than a law enforcement issue,” she said. “That shift is represented in the plans that come out of this White House and its representatives, and the work that ourselves and others fund. We also now have effective treatments for opioid use disorder. Now, it’s a matter of, how do we get more people connected to treatment when those opportunities present themselves? So I think those are a couple of examples of ways we’re seeing progress, and something to build on.”
At the same time, Scott said that FORE is able to fund only a small number of the many the groups that need it. “We’ve now done five rounds of national requests for proposals,” she said. “For each one of those, we’ve received between four and five hundred proposals. And we’re able to fund about 5% of that.”
FORE is doing valuable work, but its assets are in the millions, compared to billions on the part of the Robert Wood Johnson and Conrad Hilton foundations, and it is able to give just a fraction of what the larger funders could have deployed if they’d continued their substance use disorder work. As of 2022, FORE’s assets stood at roughly $121 million, while RWJF’s assets topped $14 billion as of 2021 (the most recent year available) and Conrad Hilton’s were over $8 billion, according to Candid.
The funding shortfall can’t be laid entirely at the feet of these two health funders, however. After the two giants stepped away from the field, other mega-wealthy foundations, including new, tech-fueled philanthropies, have declined to step in to take their place.
Money on the table
Karen Scott and others we spoke to pointed out that providing funding isn’t the only role philanthropy can play in fighting the opioid epidemic. Today, there is an unprecedented amount of money available for substance use disorder prevention and treatment — both government dollars and funding from national opioid settlements. Philanthropy could play a vital role by helping organizations access those funds.
FORE is helping nonprofit partners build their capacity so they can tap into some of that funding. “If organizations don’t know how to access those funds, they could go unspent,” Scott said. “I think that’s a key role funders, particularly funders with a national presence and a lot of expertise, can play: to help organizations be in a position to draw down some of that funding from SAMHSA [the Substance Abuse and Mental Health Services Administration] and from their state agencies.”
Philanthropy can also play a role in helping communities access national opioid settlement dollars, as a total of $50 billion will be distributed over the next 18 years. According to settlement requirements, most of the funds must be used to address damage caused by the opioid epidemic or prevent future substance use. There is a strong push to prevent what happened to funds distributed in the huge national tobacco settlement, which saw only a fraction of the funding go to actual antismoking efforts (some filled local budget gaps, some was even used to subsidize tobacco farmers).
Sarah Evans, division director of drug policy and global programs at Open Society Foundations, made this point when we spoke to her recently. OSF has been focused specifically on reforming U.S. drug policy, and supports harm reduction and decriminalization efforts.
“This is an extraordinary opportunity to support cities, states, counties and civil society groups to ensure that there is transparency and accountability for the spending of that money,” Evans said, referring to the opioid settlements. “It’s important to ensure that it’s not a lost opportunity — or worse, used in ways that would enhance prohibitionist and punitive approaches, and have a negative impact on overdose rates in this country.”
OSF’s work seems particularly relevant now, as lawmakers in many parts of the country are responding to the rise in overdose deaths with tough criminal penalties, which most experts agree do not work. As Jennifer Carroll, a medical anthropologist at North Carolina State University, told the New York Times, “We are falling back on these really comfy, straightforward law-and-order solutions in spite of the fact that they didn’t work before, they’re not working now, and there’s growing evidence telling us they’re making things worse.” Meanwhile, harm reduction programs that have been shown to be effective struggle to get attention from philanthropy.
OSF is currently in discussions with other funders about how to support organizations in ensuring that opioid settlement dollars go to the right places. “People need capacity and they need resourcing,” she said.
In one recent example, OSF supported an Ohio group that sued the state government because a large portion of settlement dollars was being funneled to a nonprofit that wasn’t transparent about how the money was going to be allocated. OSF has also supported groups conducting public education campaigns to provide information about the settlements.
“Just because money is available doesn’t mean it gets to ground,” said Tym Rourke, previously director of the New Hampshire Charitable Foundation and now senior director at Third Horizon Strategies. “I think there continues to be opportunities for philanthropy to help stabilize organizations and help them develop the business acumen necessary to maximize these new resources. And to the extent that philanthropies choose to partner with the public sector, ways to help those decision makers take best advantage of the resources they now have at their disposal. So I think this is an area where there is plenty of opportunity for philanthropy.”
Filling a leadership gap
Allen Smart at PhilanthropywoRx sees an important facilitator role for regional and community philanthropies as rural communities determine how settlement money should be allocated. “Foundations in rural areas are well positioned to be this kind of neutral party between factions, because everyone knows each other and they’ve been fighting for years about 1,000 different things,” he said. “A foundation is well positioned to step in and say, ‘Hey, you know, we all agree this is serious. Let’s try to work toward something that can help rather than just spending more time arguing about it.’” (This KFF Health report explores the challenges rural communities face in accessing settlement dollars).
Alexa Eggleston has worked on substance use prevention and treatment issues for close to two decades. As a senior program officer at the Conrad N. Hilton Foundation, Eggleston led the foundation’s youth prevention and early intervention strategic initiative. Today, she heads Audacia Consulting LLC, which she founded, and is a consultant with the Substance Use Funders Collaborative.
I asked Eggleston if she had any insight into why Hilton stopped funding in this area. She said it’s her understanding that the foundation decided it was time to sunset their investment after a long history of funding in substance use in order to make way for new priorities.
Like most of those we spoke to, Eggleston sees a role for philanthropy in terms of leadership. Specifically, she would love to see a major national effort to collaborate and combine funding and ideas to combat the opioid epidemic.
“What has not emerged is a kind of joint funding strategy, like you see in other philanthropy sectors, like a pooled fund and real strategic alignment,” she said.
Karen Scott agreed. “I absolutely think that would be helpful,” she said. “It would be great to have that leadership and a way for funders to get together and think creatively about how to work together, versus pursuing one proposal at a time. Right now, people are all working in their own separate piece of the portfolio.”
Facing down an epidemic
In her book Raising Lazarus, Beth Macy calculated the grim scale of the opioid epidemic: “America’s 1 million overdose death count is predicted to double by this decade’s end. It is already as if a city the size of San Jose has vanished, and by 2029, those deaths will be Houston-sized.”
But it’s not too late to slow the rising death toll, and philanthropy could be playing a much bigger role. We pointed out earlier that stigma may underlie some funders’ reluctance to take on this issue. In Alexa Eggleston and Tym Rourke’s 2017 article, cited above, they described the sector’s critical role in an earlier crisis that was also characterized by stigma.
“Philanthropy has responded to epidemics before, and with astonishing success,” they wrote. “At the height of the AIDS epidemic, when the public sector was slow to respond, philanthropy stepped up. That response led to the healthcare innovations and policies that now give people with HIV the potential for a full life, albeit with a chronic, manageable condition. And that work paved the way for dramatic civil rights advances for people who are gay, lesbian, bisexual and [transgender]. We can do the same with addiction — but philanthropy must lean in further.”
By not leaning in, philanthropy is ignoring the reality that substance use disorder touches every aspect of our society — and the work many funders are already engaged in today.
“We have to stop talking about substance use in a vacuum from the rest of behavioral health,” Rourke said. “We’re coming out of the pandemic with a generation of children in mental health crisis, and increasing demand for mental health services that our nation cannot meet. Those individuals who do not get access to services for their mental healthcare are at incredibly high risk of developing a substance use disorder. And the vast majority of Americans with a substance use disorder have a co-occurring mental illness. Philanthropy needs to hold both because they don’t exist in isolation, and for far too long, both public and private investments have stuck in one of those two lanes and not brought them together.”
Many of those we talked to pointed out that social determinants of health, a priority for RWJF and so many other health funders today, are inextricably intertwined with and influenced by substance use, and vice versa, so it makes little sense to address one and not the other. In other words, it’s not that funding related to social determinants of health is misplaced, but rather that it would ideally go hand in hand with much more funding directly addressing substance use.
“If your focus is on social determinants of health, if it’s on housing and homelessness, for example, a disproportionate share of people who are dying from overdoses live in unstable housing or are living on the streets,” said Karen Scott. “If your focus is on early childhood development, disproportionately, kids who are referred into the foster care system have parents with an opioid use or another substance use disorder. So there are many opportunities to think about how the work you’re funding can be extended to have an impact on the opioid problem.”
Today, Alexa Eggleston and Tim Rourke stand by their call for a philanthropic agenda to fight addiction, which is even more urgent today than when they made that plea six years ago. As they wrote then, “Philanthropy has an opportunity to play a key role in turning the tide on this epidemic. It is an opportunity to lead, listen and inspire that we should not miss.”
Editor’s Note: This article has been updated to reflect that we spoke to Kristin Schubert at RWJF, not to Tricia Woodcome.
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