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