Will States and Counties Spend Their National Opioid Settlements Effectively?

Five top experts in the field of opioid use disorder and the legalities and logistics of the opioid legal settlements convened in a University of Pennsylvania virtual seminar on February 10 to discuss the specifics of how the funding could or should be best used by the state and local governments that receive it. One point the panelists made is that the agreements are more carefully written in an effort to ensure that opioid settlement funds actually go toward the treatment and prevention of opioid addiction. But they also warned why that is not a guarantee.

The seminar was co-sponsored by Penn’s Leonard Davis Institute of Health Economics (Penn LDI) and the Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV (CHERISH).

The panelists were James Donahue, III, JD, Pennsylvania Executive Deputy Attorney General in the Public Protection Division; Christine Minhee, JD, attorney and founder of OpioidSettlementTracker.com; Rosalie Liccardo Pacula, PhD, Professor and Elizabeth Garrett Chair in Health Policy, Economics & Law at the University of Southern California’s (USC) Sol Price School of Public Policy; Joshua Sharfstein, MD, Vice Dean for Public Health Practice and Community Engagement at the Johns Hopkins School of Public Health; and moderator Shoshana Aronowitz, PhD, LDI Senior Fellow and Assistant Professor of Family and Community Health at the Penn School of Nursing.

Liccardo Pacula also sees important implementation issues. Her colleagues at USC have been studying buprenorphine access through pharmacies in poor, diverse neighborhoods. They are much less likely to have buprenorphine in stock behind the counter.

“So even if someone is willing to go see a doctor and initiate treatment and has a prescription, they can’t get it at their local pharmacy,” Liccardo Pacula said. “Another [one] of my biggest concerns with the settlement is that there is a lot of money being allocated for naloxone purchases. I think that’s a great strategy, but will that drive up the price of naloxone so communities can’t afford to distribute it widely? How do we make sure that this efficacious life-saving drug is affordable to people when there’s growing demand for it?”

She and the other panelists all emphasized that as with any large infusion of money into government entities, politics will be heavily involved in how the money is ultimately spent—and that is a key cause for worry, according to Sharfstein, who played a major role with Johns Hopkins in the development of the guiding principles for settlement allocations.

“The reason we have such a horrible overdose problem is not that we lack good ideas or good evidence, it’s that we often don’t put those ideas and evidence into practice for reasons that have to do with politics and the stigma around addiction,” said Sharfstein. “Sometimes, the people who are most politically persuasive at the state and local level are not those who advocate for evidence-based solutions. In some cases, they advocate for programs and approaches that make the problem worse. So, they put in money in ways that, in the end, generate more overdoses.”

Sharfstein cited five key principles for making allocation decisions:

1. Spend the money to save lives.
2. Use evidence to guide the spending.
3. Invest in creating supportive environments for youthful prevention.
4. Focus on racial equity in ways informed by decades of inequity throughout the substance use crisis.
5. Develop a fair and transparent process for deciding where to spend the funding.

Aronowitz noted that the impact and policy responses to the opioid overdose crisis have been transformed by the COVID-19 pandemic, with inequalities and structural racism being exacerbated in minority populations. “The CDC recently reported that drug overdose data show troubling trends and widening disparities between different population groups. In just one year, overdose death rates increased 44% for Black people and 39% for American Indian and Alaska Native people. At the same time, a lower proportion of people from racial and ethnic minority groups have received substance use disorder treatment compared with white people.”

Sharfstein responded that “the agreement makes it possible to address some of these inequities, but it does not guarantee that they will be addressed,” he said. “From a process perspective, we recommend that communities that have been overlooked in the past, particularly minority communities, have a seat at the table and are actively involved in making decisions. The explicit goal should be enhancing racial equity so that as the investments and other policy decisions are made, you can see whether it’s working and circle back. And a great deal of transparency is required to make that happen.”

There was agreement among the panelists that the street realities of the drug crisis are highly dynamic and require new thinking and approaches that may not yet be fully anchored in hard evidence. Liccardo Pacula pointed to the deadly situation now created by a fentanyl-laced street drug supply that makes the availability of fentanyl test strips a potentially effective life-saving device, even lacking comprehensive evidence. But much the same as safe consumption sites or other harm reduction strategies, the test strips are politically controversial and illegal in some states.