Billions from opioid settlements are at risk of being wasted

The opioid and overdose crisis is a national tragedy that has claimed more than 1 million lives since 1999. Over the past three years, more than $55 billion has flowed into state, county and city coffers from opioid manufacturers, distributors and pharmacies. result of their collective role in instigating and perpetuating this public health crisis.

This urgently needed injection of funding has the potential to turn the tide of the epidemic. Here in Rhode Island, where we are current and former members of the Opioid Settlement Advisory Committee, the state has quickly gotten money out the door by investing in prevention, treatment, recovery and harm reduction programs, including the first state-approved overdose . prevention center. While states must act as quickly as possible to fund evidence-based programs that save lives, we must also learn the lessons of past masterful settlements and recognize the limitations of dollars alone in addressing this complex public health crisis.

History tells a cautionary tale about how public health care funds can be misspent. Following the high-profile big tobacco case, the Tobacco Master Settlement Agreement was seen as a real victory in support of a community harmed by smoking and misinformation. Unfortunately, however, only a very small percentage of the money went to public health programs: In fiscal year 2023, states raised an estimated $26.7 billion from these settlements, but only 3% went to programs to prevent children from smoking and to help individuals to help you resign. As a result, progress has stalled: tobacco smoking is still responsible for more than half a million deaths per year, a number that has not decreased.

Now that seems to be happening again. There are nationally recognized guidelines for the expenditure of these funds, including the use of scientific evidence to inform spending decisions. But many states have broad discretion in using opioid settlement funds. The funds are already going to ineffective strategies such as strengthening police budgets and purchasing drug bags (in theory to prevent prescription drug abuse), while other communities continue to argue endlessly about where the money should go.

In Rhode Island, we have been working to ensure transparency in spending decisions that invest in evidence-based solutions. This work includes working closely with community organizations, multiple interdisciplinary task force committees, using public meetings and forums, and working to involve people with experience in decision-making processes. We have developed a public website to track opioid settlement spending. Funds have supported mobile outreach, a 24/7 buprenorphine hotline, access to medications for the uninsured, accessible housing for people who use drugs, a racial equity task force and expanding naloxone distribution. And unlike many other states, Rhode Island has relatively easy access to treatment programs with low barriers, a high rate of opioid treatment programs per capita, and a robust treatment infrastructure for the jail and prison population. These programs likely contributed to the state’s recent 7.3% drop in overdose death rates in 2023 compared to 2022, including a notable decline in deaths among Black and Hispanic/Latinos for the first time since 2018 Rhode Islanders.

Despite the influx of funding, one of the few residential treatment programs for women in Rhode Island closed due to financial problems. There are no inpatient treatment facilities for pregnant women in the state. Nationally, addiction-related services face low Medicaid billing rates and limited insurance coverage for life-saving medications. Workforce development challenges create pervasive workforce issues.

And while the state broadly supports an overdose prevention center and other progressive efforts, the stigma against harm reduction remains, as does an over-reliance on the criminal justice system to serve as a de facto safety net treatment facility for people with addiction — one that of course it doesn’t work.

Some states, including our home state of Rhode Island, offer valuable lessons.

First, responsible distribution of money is only the first step. Governments must also carefully design requests for proposals, ensure efficient procurement systems, effectively evaluate programs, and streamline the implementation of financing ideas, otherwise it will all be for naught. We have seen firsthand that bureaucratic processes can be extremely difficult to navigate for small organizations. That’s why it’s important to invest in capacity building and support for grassroots organizations on the frontlines of the overdose crisis.

Second, throwing money at the problem cannot be the only strategy for improvement. This is equivalent to trying to fill a bucket full of holes; no amount of treatment programs will suffice if people’s basic needs are not met. To truly address the crisis, settlement financing must be accompanied by meaningful policy changes that rebuild our social safety net, address our housing and affordability crises, and provide real economic opportunities to people struggling with substance use.

Some recent policy changes at the federal and state levels are to be welcomed. The Substance Abuse and Mental Health Services Administration recently increased flexibility in access to methadone and the ability to take methadone home, and identified harm reduction as a core pillar of its overdose prevention strategy. New York City has implemented two overdose prevention centers with great success: in the first year of operations, more than 2,800 people attended the site and more than 75% received other wraparound services. Rhode Island, Minnesota and Vermont have begun to support these evidence-based interventions. Teleprescriptions for buprenorphine have been normalized. And the Centers for Medicare and Medicaid Services has encouraged Medicaid 1115 waivers to provide insurance coverage to individuals prior to their release from jail and prison, to support the reentry period, a period of extremely high risk for opioid overdose.

Yet regressive policies have gained momentum elsewhere. State opioid treatment authorities are not required to adopt the new federal flexibility, and many have not. Telehealth prescriptions for buprenorphine are not permanent. Kentucky is even considering reducing doctors’ ability to prescribe buprenorphine. The country still does not have enough doctors willing to prescribe treatment, and a large enough workforce to build a truly robust addiction treatment infrastructure. And the recent Supreme Court decision in Grants Pass vs. Johnson could open the door to more tent camp clearances, which have been shown to increase mortality among people struggling with opioid use and without housing.

Third, we have learned that addressing long-standing, pernicious racial/ethnic disparities in access to prevention, treatment, and harm reduction services must be at the forefront of any funding decision for opioid settlements. For too long, Black, Indigenous and other people of color have been neglected by our healthcare and treatment systems due to stigma and racism. We will not solve the overdose crisis until we address the structural racism built into the addiction treatment system, in which access to lifesaving medications is determined in large part by the patient’s race and zip code. Unless states and other jurisdictions meaningfully incorporate addressing structural racism as a guiding principle in decisions about funding opioid settlements (as Rhode Island and others have done), these resources could well increase existing inequalities (by directing even more resources to predominantly white communities).

Finally, settlement funds should be used to address the rapid increase in overdoses involving stimulants, especially in Black and Hispanic/Latino communities. Here in Rhode Island, nearly two-thirds of all overdose deaths among black residents involved crack and/or cocaine (compared to less than 40% among white residents). In addition to supporting stimulant use treatment programs, funds should be used to support culturally responsive, multilingual outreach to BIPOC communities to increase access to life-saving harm reduction services.

Involving community stakeholders is essential. By working with community organisations, frontline workers and people with experience, we can ensure funds are spent wisely and effectively. These voices must be at the forefront of decision-making processes and provide insight into what works in practice.

Increasing reimbursement for addiction and social services is critical to sustainability because adequate funding will prevent financial hardship and program closures, allowing vital services to flourish and provide reliable support. Expanding workforce development is necessary to ensure timely access to care; we must use opioid settlement funds to train more healthcare professionals in addiction treatment and harm reduction so that a strong treatment infrastructure can be built. It is also critical to maintain and expand federal and state policies that reduce barriers to treatment. Recent steps, such as expanded access to methadone, teleprescriptions for buprenorphine, and Medicaid 1115 waivers for reentry assistance, should be preserved and more widely implemented.

And the governance of these efforts and programs must be conducted in an efficient and streamlined manner, minimizing unnecessary bureaucracy while maximizing accountability and evaluation.

Throwing money at the problem won’t be a silver bullet and the settlement funds will eventually run out. Nevertheless, they represent a once-in-a-generation opportunity to support real solutions to the nation’s overdose crisis.

Justin Berk, MD, MPH, MBA, is an assistant professor of medicine, pediatrics and epidemiology at Brown University. Dennis Bailer is the overdose prevention program director at Project Weber/RENEW. Brandon DL Marshall, Ph.D., is a professor of epidemiology at Brown University School of Public Health. The perspectives shared in this piece are those of the authors and do not represent the views or opinions of the Rhode Island Opioid Settlement Advisory Committee, nor the State of Rhode Island.