The billions in opioid settlements are at risk of being wasted

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

This urgently needed infusion 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 been quick to raise money, investing in prevention, treatment, recovery and harm reduction programs, including the first authorized overdose by the state of the country. prevention center While states should move as quickly as possible to fund evidence-based programs that save lives, we must also learn the lessons of past master settlements and recognize the limitations of dollars alone to address this complex health crisis public

The story tells a cautionary tale about how public health funds can be misspent. Following the high-profile Big Tobacco case, the Tobacco Master Settlement Agreement was seen as a real victory to support 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 collected an estimated $26.7 billion from these settlements, but only 3% went to programs to prevent children from smoking and to help people. go out As a result, progress has stalled: smoking is still responsible for more than half a million deaths each year, a number that has not abated.

Now it seems to be happening again. There are nationally recognized guidelines for spending these funds, which include the use of scientific evidence to inform spending decisions. But many states have wide discretion in using opioid settlement funds. Funds will already go to ineffective strategies like bolstering police budgets and buying drug disposal bags (theoretically to prevent diversion of prescription drugs), while other communities continue to endlessly debate where the drugs should go. money

In Rhode Island, we’ve worked to ensure transparency in spending decisions that invest in evidence-based solutions. This work includes close collaboration with community organizations, multiple interdisciplinary task force committees, the use of public meetings and forums, and work to incorporate people with lived experience into decision-making processes. We developed a public website to track opioid clearance spending. Funds have supported mobile outreach, a 24/7 buprenorphine hotline, access to medication for the uninsured, low-threshold housing for people who use drugs, a racial equity task force and the expansion of naloxone distribution efforts. And unlike many states, Rhode Island has relatively easy access to low-barrier treatment programs, a high per capita rate of opioid treatment programs, and a robust treatment infrastructure for its jail and prison population. These programs likely contributed to the state’s recent 7.3% decrease in overdose death rates in 2023 from 2022, including a notable decrease in deaths among black and Hispanic/Latino Rhode Islanders by first time since 2018.

Despite the infusion of money, one of the few residential treatment programs for women in Rhode Island closed due to financial struggles. There are no hospital treatment centers for pregnant women in the state. Nationally, addiction services face low Medicaid billing rates and limited insurance coverage of life-saving medications. Challenges in workforce development create ubiquitous staffing struggles.

And while the state generally supports an overdose prevention center and other progressive efforts, stigma against harm reduction persists, as does an over-reliance on the criminal justice system to serve as a facility for de facto safety net treatment for people with addiction, one that, of course, 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 accurately design requests for proposals, ensure efficient procurement systems, evaluate programs effectively, and streamline the execution of funding ideas, or it will come to nothing. We’ve seen firsthand that bureaucratic processes can be extremely difficult for small organizations to navigate. That’s why it’s important to invest in building capacity and supporting grassroots organizations on the front lines of the overdose crisis.

Second, throwing money at the problem cannot be the only strategy for improvement. This is like trying to fill a bucket full of holes: treatment programs will not suffice if people’s basic needs are not met. To truly address the crisis, settlement funding must be combined with meaningful policy changes that rebuild our social safety net, address our housing and affordability crises, and provide real economic opportunity to people struggling with consumption of substances.

Some recent policy changes at the federal and state levels are to be applauded. The Substance Abuse and Mental Health Services Administration recently increased flexibilities in methadone access and take-home capabilities and identified harm reduction as a core pillar of the methadone strategy. overdose prevention. New York City has implemented two overdose prevention centers with great success: in the first year of operations, more than 2,800 people accessed the site and more than 75% received other comprehensive services. Rhode Island, Minnesota, and Vermont have begun supporting these evidence-based interventions. Buprenorphine teleprescriptions have become normalized. And the Centers for Medicare and Medicaid Services have encouraged Medicaid 1115 waivers to provide insurance coverage to people before they leave jail and prison to support the reentry period, a period of extremely high risk for overdose of opioids

However, regressive policies have gained momentum elsewhere. State opioid treatment authorities are not required to adopt the new federal flexibilities, and many have not. Buprenorphine telehealth prescription regulations are not permanent. Kentucky is even considering reducing the ability of doctors to prescribe buprenorphine. The nation still lacks enough doctors willing to prescribe treatment and a large enough workforce to build a truly robust addiction treatment infrastructure. And the recent ruling of the Supreme Court in Grants Pass vs. Johnson may open the door to more authorizations for tent camps, which have been shown to increase the deaths of people struggling with opioid use and who are not housed.

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 every opioid settlement funding decision. Black, Indigenous and other people of color have for too long been neglected by our health care and treatment systems as a result of stigma and racism. We will not solve the overdose crisis until we address the structural racism embedded in the addiction treatment system, in which access to life-saving medications is largely determined by the patient’s race and zip code. Unless states and other jurisdictions meaningfully incorporate addressing structural racism as a guiding principle in opioid settlement funding decisions (as Rhode Island and others have done), these resources could very well. increase existing inequalities (by driving even more resources to predominantly white communities).

Finally, settlement funds must be used to address the rapid increase in stimulant overdoses, particularly 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 substance use treatment programs, funds should be used to support multilingual and culturally tailored outreach to BIPOC communities to increase access to substance abuse reduction services. life-saving damage.

The involvement of community actors is essential. By partnering with community organisations, frontline workers and people with lived experience, we can ensure funds are spent wisely and effectively. These voices must be at the forefront of decision-making processes, providing insight into what is working on the ground.

Increasing reimbursement rates for addictions and social services is critical to sustainability, as adequate funding will prevent financial struggles and program closures, allowing vital services to thrive and provide reliable support. Expanding workforce development is necessary to ensure timely access to care; we need to leverage opioid settlement funds to train more health professionals in addiction treatment and harm reduction to build a strong treatment infrastructure. It is also crucial to maintain and expand federal and state policies that reduce barriers to treatment. Recent steps such as increased access to methadone, tele-prescribing buprenorphine, and Medicaid 1115 waivers for reentry support should be preserved and more widely adopted.

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

Throwing money at the problem won’t be a panacea and settlement funds will eventually run out. However, 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 director of the overdose prevention program 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, or the State of Rhode Island.