Safer Solutions: What To Do with National Opioid Settlement Funds
“Who will pay for it?” might be one of the most powerful questions in policymaking, as limited governmental budgets can derail even the most promising, evidence-supported policy interventions. But in the case of a windfall, the question often becomes “What can we spend this on?”
That is what happened as states and localities began receiving money from the National Opioid Settlements. These funds exist because many plaintiffs sued to hold opioid manufacturers and distributors accountable for their role in the rise of opioid overdoses in the 1990s and early 2000s. The lawsuits resulted in a number of settlements that will distribute at least $52 billion to state and local governments over about 18 years. Designated for activities that will “abate opioid-related harms,” these funds offer policymakers a rare opportunity to address a public health issue with a significant sum of dedicated funding. However, policymakers must make wise spending decisions in order to produce the greatest benefit for communities affected by opioid addiction.
Understand the epidemic
To make smart use of National Opioid Settlement funds, policymakers must understand that we face different challenges now than we did during other phases of the opioid overdose epidemic. It began in the late 1990s, when providers started writing more opioid prescriptions for medical reasons; however, by 2010 policies had restricted access to prescription opioids. This led people who were already addicted to switch to heroin because it was easier to get. Three years later, synthetic opioids like fentanyl accelerated overdose deaths until they peaked in 2022. Today, many argue that the co-use of stimulants and opioids has moved us into a fourth wave of the epidemic.
Invest in the right programs for today’s challenges
Although the National Opioid Settlement funds result from lawsuits against prescription opioid manufacturers and distributors, prescription opioids have not been the primary driver of overdose deaths for many years. Nevertheless, some opioid settlement-funded programs still treat prescription opioid misuse as the primary problem. For example, although drug-disposal programs that include prescription drug take-back days and deactivation kits are an important public health intervention, they do not address illicit substances—and there is little to no evidence that they decrease overdose deaths. In spite of these shortcomings, drug-disposal programs have received millions of dollars in National Opioid Settlement funds.
Drug-checking programs are a more appropriate intervention for today’s illicit drug supply. Because illicit opioids are unregulated, they may contain unknown substances, and their potency may vary from batch to batch. What’s more, the illicit drug supply is constantly changing. Drug checking helps people who use drugs find out exactly what is in the substance they are about to consume. Drug-checking tools like fentanyl and xylazine test strips identify the presence of unknown substances so that people can make informed decisions about whether to take the drugs and if so, how to do so more safely. Unfortunately, a few states do not allow people to possess test strips or community service providers to offer drug-checking services, and recent federal guidance prohibits the use of federal funds to distribute test strips. Thus, purchasing and distributing test strips in states where they are allowed would be opioid settlement funds well spent.
Syringe services programs (SSPs) are supported by nearly three decades of research and proven to decrease overdoses. SSPs have expanded their service offerings well beyond providing sterile syringes in response to changes in overdose and drug-use trends. Among other benefits, SSPs reduce the spread of infectious diseases, distribute naloxone to reverse overdoses, and connect people who use drugs to supportive services—including treatment. These programs are highly cost-effective but grossly underfunded, making them an excellent place to invest opioid settlement funds.
Medications for opioid use disorder (MOUD) are another proven and underutilized tool. The two most effective MOUD, buprenorphine and methadone, reduce overdose deaths and opioid-related acute care use. Some communities are using opioid settlement funds to expand access to these medications, especially buprenorphine. Programs are experimenting with different approaches to expanding MOUD access, including equipping ambulances with buprenorphine to give patients after an overdose, establishing mobile treatment programs, and incentivizing hospitals to provide treatment interventions during emergency department visits.
Engage the community and build in accountability
National Opioid Settlement funds can be used in many ways, allowing policymakers to allocate funds to address their community’s specific needs. Tailoring interventions to local conditions is vital because substance use does not affect every community in the exact same ways. Engaging community members who represent a variety of perspectives is a best practice for public health program development, and working with communities to develop locally relevant programs increases cost-effectiveness and impact.
Another best practice is to ensure that accountability, evaluation, and monitoring are built into programs from the start. Involving the community in these decisions is important to ensure these elements are feasible for staff and acceptable to program participants and community members. Agreeing on clear goals and desired outcomes is essential in order to assess a program’s impact and accountability effectively.
Resist spending on enforcement
Laws that penalize people who use drugs also are shown to increase drug-related harms, perpetuate poverty, and discourage engagement with healthcare and other supportive services. Mounting evidence also suggests that many supply-side interventions are ineffective at reducing overdose and substance use. Nevertheless, some states are allocating opioid settlement funds to law enforcement programs and functions.
Instead of focusing on enforcement, communities can implement programs that expand MOUD access to people in jails and prisons and help connect people to substance use and social resources upon reentry to the community. These strategies aid in decreasing overdose deaths and reincarceration, helping people achieve stability and benefiting communities at the same time.
Plan for the long term
One concerning trend in the use of National Opioid Settlement funds is supplantation—the practice of replacing existing funding with settlement funds rather than using settlement funds to increase resources to address the crisis. Supplantation is ineffective because it does not supplement existing programs, which are already insufficient for addressing the epidemic and losing existing federal funding. It is also short sighted because people with opioid use disorder often need many years of treatment and support, and the condition’s social impacts linger even after a person is stable in treatment.
The opioid overdose epidemic started more than 25 years ago, and despite overdose rates decreasing over the past few years, they are still much higher than they were at the beginning. How we spend National Opioid Settlement funds today should account for the reality that there are no easy solutions to the opioid overdose epidemic.