KFF Health News, partnering with researchers at the Johns Hopkins Bloomberg School of Public Health and Shatterproof, a national nonprofit focused on addiction, undertook a yearlong investigation to find out.

Dozens of interviews, thousands of pages of documents, an array of public records requests, and outreach to all 50 states resulted in a first-of-its kind database that catalogs more than 7,000 ways opioid settlement cash was used in 2022 and 2023. It’s the most comprehensive resource to date tracking some of the largest public health settlements in American history.

Among the findings:

• States and localities received more than $6 billion in opioid settlement funds in 2022 and 2023. According to public records, they spent or committed about a third of that amount and set aside about another third for future use. The final third was untrackable, as many jurisdictions did not produce public reports on the funds.
• Reports of spending tracked the minuscule to the monumental, from $11.74 to buy postage in Yavapai County, Arizona, to more than $51 million to increase the addiction treatment workforce in California.
• States allotted, on average, about 18% of their funds for addiction and mental health treatment; 14% for recovery services such as housing, transportation, and legal aid; 11% for harm reduction efforts such as overdose reversal medications; and 9% for prevention programs that aim to stop people from developing substance use disorders. States committed, on average, about 2% for syringe service programs, through which people can get sterile needles. (A variety of entities received this money, from law enforcement to nonprofit organizations to government agencies.)
• Governments reported spending more than $240 million on purposes that did not qualify as opioid remediation. (Most settlements allow states to spend up to 15% of their funds this way.) Most of this tranche went to legal fees, but several jurisdictions funneled money to their general fund. One county even sent funds to its road and bridge department.
• Several cities and counties reported expenditures they said addressed the overdose crisis but that would leave an average person scratching their head — such as $33.07 to an anti-abortion pregnancy center in Sandborn, Indiana, and $30,362 to screen first responders for heart disease in Oregon City, Oregon.

“When people know that people aren’t watching and there’s no accountability, then they can kind of do what they want,” said Tonja Myles, a community activist in Baton Rouge, Louisiana, who is in recovery. “That’s why we have to have some kind of database and accountability.”

Despite the recent decline in overall overdose deaths in the U.S., more than 90,000 people still died in the 12 months ending July 2024 and rates are rising in many Black and Native American communities.

“We can’t mess up or miss this moment,” Myles said.

Opioid settlement payouts are expected to total about $50 billion over nearly two decades, paid by more than a dozen companies that made or distributed prescription painkillers, including Johnson & Johnson, Walgreens, and Walmart. Although it’s a large sum, it’s dwarfed by the size of the crisis, making each dollar that’s spent critical.

KFF Health News and its partners reviewed hundreds of settlement spending reports, extracting expenditures line by line, and developed a methodology to sort the expenditures into categories like treatment or prevention. States were given an opportunity to review the data and comment on their spending.

To be sure, the database does not capture the full picture of opioid settlement spending nationwide. Some places do not publish spending reports, while others declined to engage with this project. The data presented here is a snapshot as of the end of 2023 and does not account for further spending in 2024. The differences in how states control, process, and report on the money make apples-to-apples comparisons nearly impossible. Still, the database helps fill a gap left by a lack of national reporting requirements and federal government inaction.

It is “a tool for those who want to objectively measure whether everything that can be done is being done,” said Matthew Myers, a former president of the Campaign for Tobacco-Free Kids, which compiles similar annual reports on tobacco settlement money.

Treatment a Clear Winner

The top priority to emerge from early opioid settlement spending was treatment, with more than $416 million spent or committed to residential rehabs, outpatient counseling, medications for opioid use disorder, and more.

The state of New York — which spent the most on treatment — allocated about $22 million of that for programs that make the gold standard for care as easy as possible for patients: providing same-day prescriptions for buprenorphine, a medication that decreases cravings for opioids.

The result was a program that John Greene said changed his life.

Greene, 57, used to live in the woods down the street from Family & Children’s Counseling Services in Cortland, New York. He cycled through jails and hospitals, overdosing half a dozen times and trying rehab just as many.

But now he has four months of recovery under his belt — the longest stint since he started regularly using drugs at 14.

He said it’s because the counseling center’s new program — funded by a mix of state and local opioid settlement dollars — has a different approach. Counselors aren’t didactic and judgmental. They don’t force him to stop smoking marijuana. Several staff members have experienced addiction themselves. They drive Greene, who doesn’t have a car, to doctor appointments and the pharmacy for his buprenorphine prescription.

Now Greene lives and works with his brother, looks forward to weekly counseling sessions, and is notching small victories — such as buying his nephew toy cars as a stocking stuffer.

“It made me feel good to do something for somebody and not expect nothing back,” Greene said.

Emily Georgia, one of Greene’s counselors, said the center has worked with nearly 200 people like him in the past year. Without the settlements, “the program probably wouldn’t exist,” she said.

Across the country, the money supports other innovative treatment approaches:

• $21 million for a new program in Kentucky that diverts people with mental illness or addiction who face low-level charges away from incarceration and into treatment, education, and workforce training
• More than $3 million for, in part, three new mobile methadone programs in Massachusetts, to bring the medication to rural and underserved areas
• Tens of thousands of dollars each in Iowa and Pennsylvania to cover out-of-pocket treatment costs for people without insurance or those with high deductibles

Philip Rutherford, an expert on substance use disorder at the National Council for Mental Wellbeing, said these efforts “are really positive” and many have been “historically difficult or impossible to achieve with federal or state funding.”

But some funds are also flowing to treatment approaches that defy best practices, such as denying people medications for opioid use disorder.

Some in the recovery community consider methadone and buprenorphine a crutch. But study after study show that the medications help people stay in treatment and reduce the risk of overdose and death. Research even suggests that treatment without these medications can be more harmful than no treatment at all.

Although not everyone will want medication, settlement funds shouldn’t “prop up a system that doesn’t allow people to have that choice,” said Regina LaBelle, a professor of addiction policy at Georgetown University.

Babies, Forgotten Victims of the Epidemic

While treatment received a windfall in early opioid settlement spending, another aspect of the crisis was neglected: neonatal abstinence syndrome, a condition in which babies exposed to drugs in the womb experience withdrawal.

Nationwide, more than 59 newborns a day are diagnosed with it. Yet only about $8.4 million in settlement money was committed to the issue — less than 0.5% of all funds publicly reported as spent or committed in 2022 and 2023.

Experts in public health and addiction, as well as affected families, say it’s due to stigma.

“A mom using drugs and being a parent is a very uncomfortable reality to face,” said Ashley Grant, a 38-year-old mother of three in Mesa, Arizona. “It’s easier to just push it under the rug or let them fall through the cracks, as sad as that is.”

It almost happened to her.

Grant learned she was pregnant with her third child last year. At the time, her partner was in jail and she was using drugs after an eight-year period of recovery, was estranged from her family, and didn’t know how she’d survive the next nine months.

During a visit to a methadone clinic, she saw a booth about Jacob’s Hope, a specialty nursery that cares for substance-exposed newborns and their moms. Nursery staff connected her with a therapist, helped her enroll in parenting classes, and dropped off diapers and a playpen at her home.

After delivering at the hospital, Grant and her baby boy stayed at Jacob’s Hope for about a week. Nurses showed her how skin-to-skin contact calmed his withdrawal symptoms and more frequent feedings and burpings decreased gastrointestinal discomfort, which is common among substance-exposed newborns.

Today, Grant has roughly five months of recovery. She got certified as a peer recovery specialist and hopes to join Jacob’s Hope one day to help moms like her.

But the nursery’s future is uncertain.

After opening in 2019, Jacob’s Hope nearly shut down this summer due to low reimbursements and delayed payments from insurers, said Lyndsey Steele, its associate director. Community donations kept the nursery afloat, but “it’s still hanging on by a thread,” she said.

She’s hoping opioid settlement money can help.

In 2022, Jacob’s Hope received about $250,000 from Arizona’s opioid settlements. But this year, the legislature captured the state’s share of remaining funds and, in a controversial move, gave it to the Department of Corrections.

Jacob’s Hope has now turned to local governments, which control their own settlement dollars. Its home city of Mesa said a first round of grant applications should open in the spring.

Steele prays it won’t be too late for babies in need — the epidemic’s “forgotten victims,” she called them.

Heart Disease Screening, Robot Ambulances, and More

Some opioid settlement expenditures have sparked fierce disagreement. They generally fall into three buckets: money for law enforcement, funding for youth prevention programs, and purchases unrelated to the opioid crisis.

Settlement dollars nationwide have bought body scanners, K-9 units, bulletproof vests, patrol trucks, and laptops and printers for police and sheriffs.

Some spending strayed even further from the spirit of the settlement. In Oregon City, Oregon, more than $30,000 was spent on screening first responders for heart disease. Police Chief Shaun Davis said his staff respond to opioid-related emergencies and experience trauma that increases their risk of heart attack.

But some people question if settlement funds should be footing the bill.

“This looks to me like you’re trying to defray other costs” from the police budget, said Stephen Loyd, chair of Tennessee’s Opioid Abatement Council. “I don’t think that there’s any way that this opioid money was earmarked for stuff like that.”

A second area of contention is youth prevention.

Although most people agree that stopping children from developing addictions is important, the execution is tricky.

Nearly half a million settlement dollars have gone to the Drug Abuse Resistance Education program, commonly known as D.A.R.E. Decades of research suggest its original curriculum is ineffective.

Robeson County, North Carolina, spent about $10,000 in settlement money to buy “Andy the Ambulance,” a robot ambulance with big eyes and an audio system through which a human operator can discuss the dangers of drugs. EMS Director Patrick Cummings said his team has taken the robot to churches and elementary schools.

We “don’t have any studies that show it’s working,” he said, but educating kids seems like a good investment because “if they never try it, they don’t get addicted.”

Then there’s the chunk of money — up to 15% of each state’s funds — that’s a free-for-all.

Flint, Michigan, spent nearly $10,000 on a sign for a community service center. The city reported that the expense did not qualify as “opioid remediation.” In other words, it’s unrelated to addressing the crisis.

But Caitie O’Neill, a city spokesperson, said that “the building sign makes it possible for residents to find” the center, which houses city services, “including Narcan kits, fentanyl testing strips, and substance abuse referrals.”

Jurisdictions across 29 states reported non-remediation spending in 2022 and 2023. Most opioid settlements require such reports but operate on an honor system. No one is checking if the other 21 states and Washington, D.C., were truthful.

Jackie Lewis, an Ohio mother whose 34-year-old son, Shaun, died of an overdose in October 2022, finds that hard to stomach.

“This is blood money,” she said. Some people have “lost sight of that.”

Lewis is raising Shaun’s daughter, ensuring the 9-year-old receives counseling at school and can attend the hip-hop music classes she enjoys — all on Lewis’ Social Security payments. This year they moved to a smaller town with lower costs.

As settlement funds continue flowing, she wants officials in charge of the money to help families like hers.

“We still exist and we’re still struggling,” she said.

KFF Health News’ Henry Larweh and Megan Kalata, Johns Hopkins Bloomberg School of Public Health’s Sara Whaley and Vivian Flanagan, and Shatterproof’s Kristen Pendergrass and Sahvanah Prescott contributed to this article.

The Johns Hopkins Bloomberg School of Public Health has taken a leading role in providing guidance to state and local governments on the use of opioid settlement funds. Faculty from the school collaborated with other experts in the field to create principles for using the money, which have been endorsed by over 60 organizations.

Shatterproof is a national nonprofit that addresses substance use disorder through distinct initiatives, including advocating for state and federal policies, ending addiction stigma, and educating communities about the treatment system.

Shatterproof is partnering with some states on projects funded by opioid settlements. KFF Health News, the Johns Hopkins Bloomberg School of Public Health, and the Shatterproof team who worked on this report are not involved in those efforts.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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That’s because there is no federal standard dictating the information that must be made public. That determination falls to states.

Christine Minhee, founder of OpioidSettlementTracker.com, found last year that 12 states promised to publicly report expenditures of 100 percent of their funds in a way any person could find and understand.

But when Minhee and I checked up on those states this year, we found a significant gap between meeting the letter of the law and actually communicating to the public in a clear and informative manner.

Take Idaho. The attorney general’s website hosts more than 90 standardized spending reports from state and local entities. Sounds great. But in reality, it reads like this: In fiscal 2023, the city of Chubbuck spent about $39,000 on Section G, Subsection 9.

Cracking that code requires a separate document. And even that provides only broad outlines.

G-9 refers to “school-based or youth-focused programs or strategies that have demonstrated effectiveness in preventing drug misuse.”

“What does that mean? How exactly are you doing that?” asked Corey Davis, a project director at the Network for Public Health Law, when he first saw the Idaho reports.

Does a school-based program involve hiring mental health counselors or holding a one-time assembly? Without details on the organizations receiving the money and the projects being pursued, it’s impossible to know where the funds are going. It’s like saying 20 percent of your monthly salary goes to food. But does that mean grocery bills, eating out at restaurants or hiring a cook?

The Idaho attorney general’s office, which oversees the state’s opioid settlement reports, did not respond to requests for comment.

In New Hampshire, the state government controls 85 percent of the state’s settlement funds and posts reports from grant recipients on its opioid abatement website. The reports explain the projects and populations served but lack a key detail: how much money each organization received.

To find dollar figures, you have to search through the opioid abatement advisory commission’s meeting minutes, which date back several years, or search the governor and executive council’s meeting agendas for the proposed contracts. Typing in the search term “opioid settlement” brings up no results. Searching “opioid” instead surfaces results about opioid settlements as well as federal opioid grants. To tell which results are relevant requires opening each link.

People in recovery, parents who lost their children to overdose and others interested in the money “shouldn’t have to go click through the meeting notes and then control-F and look for opioids,” Davis said.

James Boffetti, New Hampshire’s deputy attorney general, who helps oversee the opioid settlement funds, defended the state’s reporting. “It’s all publicly out there,” he said. “We’ve certainly been more than transparent.”

Check out the whole series for more information on the opioid settlements and how the money is being used across the country.

This article is not available for syndication due to republishing restrictions. If you have questions about the availability of this or other content for republication, please contact NewsWeb@kff.org.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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What you’ll find is a lot of bureaucratese.

Nearly three years ago, these jurisdictions signed an agreement promising annual reports “specifying the activities and amounts” they have funded.

But many of those reports remain difficult, if not impossible, for the average person to decipher.

It’s a scenario playing out in a host of states. As state and local governments begin spending billions in opioid settlement funds, one of the loudest and most frequent questions from the public has been: Where are the dollars going? Victims of the crisis, along with their advocates and public policy experts, have repeatedly called on governments to transparently report how they’re using these funds, which many consider “blood money.”

Last year, KFF Health News published an analysis by Christine Minhee, founder of OpioidSettlementTracker.com, that found 12 states — including Idaho — had made written commitments to publicly report expenditures on 100% of their funds in a way an average person could find and understand. (The other 38 states promised less.)

But there’s a gap between those promises and the follow-through.

This year, KFF Health News and Minhee revisited those 12 states: Arizona, Colorado, Delaware, Idaho, Massachusetts, Minnesota, Missouri, New Hampshire, New Jersey, Oregon, South Carolina, and Utah. From their reports, it became clear that some did not fulfill their promises. And several just squeaked by, meeting the letter of the law but falling far short of communicating to the public in a clear and meaningful manner.

Take Idaho, for instance. Jurisdictions there completed a standard form showing how much money they spent and how it fell under approved uses of the settlement. Sounds great. But in reality, it reads like this: In fiscal year 2023, the city of Chubbuck spent about $39,000 on Section G, Subsection 9. Public Health District No. 6 spent more than $26,000 on Section B, Subsection 2.

Cracking that code requires a separate document. And even that provides only broad outlines.

G-9 refers to “school-based or youth-focused programs or strategies that have demonstrated effectiveness in preventing drug misuse.” B-2 refers to “the full continuum of care of treatment and recovery services for OUD and any co-occurring SUD/MH conditions,” referring to opioid use disorder and substance use disorder or mental health conditions.

“What does that mean? How exactly are you doing that?” asked Corey Davis, a project director at the Network for Public Health Law, when he first saw the Idaho reports.

Does a school-based program involve hiring mental health counselors or holding a one-time assembly? Does treatment and recovery services mean paying for someone’s rehab or building a new recovery house?

Without details on the organizations receiving the money or descriptions of the projects they’re enacting, it’s impossible to know where the funds are going. It would be similar to saying 20% of your monthly salary goes to food. But does that mean grocery bills, eating out at restaurants, or hiring a cook?

The Idaho attorney general’s office, which oversees the state’s opioid settlement reports, did not respond to requests for comment.

Although Idaho and the other states in this analysis do better than most in having any reports publicly available, Davis said that doesn’t mean they get an automatic gold star.

“I don’t think we should grade them on a curve,” he said. It’s not “a high bar to let the public see at some reasonable level of granularity where their money is going.”

To be sure, many state and local governments are making concerted efforts to be transparent. In fact, seven of the states in this analysis reported 100% of their expenditures in a way that is easy for the public to find and understand. Minnesota’s dashboard and downloadable spreadsheet clearly list projects, such as Renville County’s use of $100,000 to install “a body scanner in our jail to help staff identify and address hidden drugs inside of inmates.” New Jersey’s annual reports include details on how counties awarded funds and how they’re tracking success.

There are also states such as Indiana that didn’t originally promise 100% transparency but are now publishing detailed accounts of their expenditures.

However, there are no national requirements for jurisdictions to report money spent on opioid remediation. In states that have not enacted stricter requirements on their own, the public is left in the dark or forced to rely on ad hoc efforts by advocates and journalists to fill the gap.

Wading Through Reports

When jurisdictions don’t publicly report their spending — or publish reports without meaningful details — the public is robbed of an opportunity to hold elected officials accountable, said Robert Pack, a co-director of East Tennessee State University’s Addiction Science Center and a national expert on addiction issues.

He added: People need to see the names of organizations receiving the money and descriptions of their work to ensure projects are not duplicating efforts or replacing existing funding streams to save money.

“We don’t want to burden the whole thing with too much reporting,” Pack said, acknowledging that small governments run on lean budgets and staff. But organizations typically submit a proposal or project description before governments give them money. “If the information is all in hand, why wouldn’t they share it?”

Norman Litchfield, a psychiatrist and the director of addiction medicine at St. Luke’s Health System in Idaho, said sharing the information could also foster hope.

“A lot of people simply are just not aware that these funds exist and that these funds are currently being utilized in ways that are helping,” he said. Greater transparency could “help get the message out that treatment works and treatment is available.”

Other states that lacked detail in some of their expenditure reports said further descriptions are available to the public and can be found in other state documents.

In South Carolina, for instance, more information can be found in the meeting minutes of the Opioid Recovery Fund Board, said board chair Eric Bedingfield. He also wrote that, following KFF Health News’ inquiry, staff will create an additional report showing more granular information about the board’s “discretionary subfund” awards.

In Missouri, Department of Mental Health spokesperson Debra Walker said, further project descriptions are available through the state budget process. Anyone with questions is welcome to email the department, she said.

Bottom line: The details are technically publicly available, but finding them could require hours of research and wading through budgetary jargon — not exactly a system friendly to the average person.

Click Ctrl+F

New Hampshire’s efforts to report its expenditures follow a similar pattern.

Local governments control 15% of the state’s funds and report their expenditures in yearly letters posted online. The rest of the state’s settlement funds are controlled by the Department of Health and Human Services, along with an opioid abatement advisory commission and the governor and executive council.

Grant recipients from the larger share explain their projects and the populations they serve on the state’s opioid abatement website. But the reports lack a key detail: how much money each organization received.

To find those dollar figures, people must search through the opioid abatement advisory commission’s meeting minutes, which date back several years, or search the governor and executive council’s meeting agendas for the proposed contracts. Typing in the search term “opioid settlement” brings up no results, so one must try “opioid” instead, surfacing results about opioid settlements as well as federal opioid grants. The only way to tell which results are relevant is by opening the links one by one.

Davis, from the Network for Public Health Law, called the situation an example of “technical compliance.” He said people in recovery, parents who lost their kids to overdose, and others interested in the money “shouldn’t have to go click through the meeting notes and then control-F and look for opioids.”

James Boffetti, New Hampshire’s deputy attorney general, who helps oversee the opioid settlement funds, agreed that “there’s probably better ways” to share the various documents in one place.

“That doesn’t mean they aren’t publicly available and we’re somehow not being transparent,” he said. “We’ve certainly been more than transparent.”

The New Hampshire Department of Health and Human Services said it will be compiling its first comprehensive report on the opioid settlement funds by the end of the year, as laid out in statute.

Where’s the Incentive?

With opioid settlement funds set to flow for another decade-plus, some jurisdictions are still hoping to improve their public reporting.

In Michigan, the state is using some of its opioid settlement money to incentivize local governments to report on their shares. Counties were offered $1,000 to complete a survey about their settlement spending this year, said Laina Stebbins, a spokesperson for the Michigan Department of Health and Human Services. Sixty-four counties participated — more than double the number from last year, when there was no financial incentive.

In Maryland, lawmakers took a different approach. They introduced a bill that required each county to post an annual report detailing the use of its settlement funds and imposed specific timelines for the health department to publish decisions on the state’s share of funds.

But after counties raised concerns about undue administrative burden, the provisions were struck out, said Samuel Rosenberg, a Democrat representing Baltimore who sponsored the House bill.

Lawmakers have now asked the health department to devise a new plan by Dec. 1 to make local governments’ expenditures public.

Toni Torsch, a Maryland resident whose son Dan died of an overdose at age 24, said she’ll be watching to ensure the public gets a clear picture of settlement spending.

“This is money we got because people’s lives have been destroyed,” she said. “I don’t want to see that money be misused or fill a budget hole.”

Methodology

In March 2023, KFF Health News published an analysis by Christine Minhee, founder of OpioidSettlementTracker.com, assessing states’ written commitments to report how they use opioid settlement dollars. That analysis determined that 12 states had promised to publicly report expenditures on 100% of their funds in a way an average person could track.More than a year later, KFF Health News senior correspondent Aneri Pattani and Minhee revisited those 12 states’ reporting practices to determine if they had fulfilled their promises and to assess how useful the resulting expenditure reports were to the public.Expenditure reports were gathered via state and local government websites, Google searches, and Minhee’s Expenditure Report Tracker. If Minhee and Pattani were unable to find public reports, they contacted state governments directly.For expenditures to be considered “publicly reported,” they had to meet the following criteria:1. Expenditures had to be expressed as specific dollar amounts. Descriptions of how the money was used without a dollar figure would not qualify.2. The report passes the “Googleability test”: Could a typical member of the public reasonably be expected to find expenditure information by keyword-searching online? If people had to file a public records request, navigate lengthy budget or appropriations documents, or rifle through meeting minutes for the information, it would not qualify.For an expenditure report to be considered “publicly reported with clarity,” it had to meet one additional criterion:3. Reports had to contain some combination of vendor name (e.g., an individual or organization) that received the money and a description of the money’s use such that a typical member of the public could understand the specific service, product, or effort the money supported.Each state divides opioid settlement funds into shares controlled by different entities. The majority of expenditures in each share were required to meet the above-listed criteria in order for that share to be classified as “publicly reported” or “publicly reported with clarity.”For example, in Utah, 50% of opioid settlement funds are controlled by county governments. As of Oct. 9, less than half of all counties had reported expenditures in a manner that was easily accessible to the public. As such, that 50% share was not counted as “publicly reported.”This analysis was conducted by Pattani and Minhee from July to October. Classifications were made based on states’ expenditure reports as of Oct. 9.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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The Philadelphia neighborhood is a critical center of the nation’s opioid crisis, and the city had decided to spend $7.5 million in opioid settlement money to improve the quality of life there. But on that day, a Pennsylvania oversight board was about to vote on whether to reject the city’s decision.

It was a thorny issue with major implications — both for Kensington residents and people across the state, as the decision could set a precedent for what kind of spending the board would allow for years to come.

But a lot of people were shut out of the discussion.

Pennsylvania’s board doesn’t allow members of the public to speak at its meetings, a rule that sets it apart from about two dozen similar opioid councils nationwide.

“It’s another moment where folks not connected to this community are making decisions for this community, and I think that’s inappropriate,” said Bill McKinney, a Kensington resident whose nonprofit is involved in some of the city’s settlement-funded initiatives. “Those that are sort of most affected are not at the table.”

It’s one example of how the public, including people who have lost loved ones to the opioid crisis or are dealing with it daily, are routinely shut out of having a meaningful say in how this windfall can be best used to address the damage. They are eager to suggest solutions for dollars that many of them consider blood money. But a first-of-its-kind survey conducted by KFF Health News and Spotlight PA found that, in many places, their voices are systematically dismissed.

In at least 39 states and Washington, D.C., councils consisting of government officials, clinicians, law enforcement officers, and others guide decisions about how to spend settlement dollars. These powerful groups are influencing addiction policy and funding at a time when more than 100,000 Americans are dying of overdoses annually.

At least 14 of these councils — including Pennsylvania’s — routinely block members of the public from speaking at their meetings. Four of those typically conduct their meetings in secret, barring the public from even attending or observing.

The survey also found:

• The majority of councils do not make video recordings of their meetings readily available online for those who cannot attend live. Although some councils said recordings can be accessed through public records requests, at least one — Minnesota’s Opioid Epidemic Response Advisory Council — deletes its recordings after using them to create meeting minutes. (Minnesota law does not require the council to record its open meetings or post recordings online.)
• At least five states have used committees or work groups that meet in private, or have a policy for allowing such private meetings. In Pennsylvania, such work groups have become a point of contention, with victims, advocates, and even one member of the council questioning their legality. (The Pennsylvania Opioid Misuse and Addiction Abatement Trust’s administrative director said the work groups’ meetings are not required to be public. They make recommendations that the full council decides on.)

Practices that close the public out of settlement spending discussions are “unconscionable,” said Stephen Loyd, chair of Tennessee’s Opioid Abatement Council, which regularly allows public attendance and comment at its meetings. “This is the population we’re there to serve. They have to have a voice in this process.”

Different Stances on Public Comment

People directly affected by the issue are a staple of the Tennessee council’s meetings. This year, commenters have included several parents holding photos of their deceased children and choking back tears, and at least one frustrated community member.

At the June meeting in Memphis, Peter Hossler, an associate professor at Rhodes College, said he was “very angry” about how the council’s recent grant awards of $81 million seemed to shortchange the western part of the state.

Loyd called such critique “invaluable,” comparing it to the feedback he received from loved ones during his recovery journey.

“We have to be held accountable,” he told KFF Health News and Spotlight PA. “And then we have to fix it.” Hossler’s comments are changing the council’s conversation about its next round of grants, Loyd added.

Loyd believes people who have been failed by the current system know what needs to be improved “better than anybody.”

“I want to talk to the people who had medication stopped in jail and laid there and withdrew,” he said. “I want to talk to the people who got out of jail with no money, a couple of felonies hanging over their heads, three meetings they had to make that week or they're going to be in violation of their probation, and they ain't got a car or driver's license.”

States cited a variety of reasons for limiting public involvement. In some, state law does not require councils to take public comment at meetings. Several officials said they’ve sought feedback in other ways. An official in New Jersey said its council held public listening sessions, but that its monthly meetings are not public.

Some officials may worry that public comment would add to meetings that already run multiple hours, but several states manage that by limiting each person’s comment to a few minutes.

For communities of color, being shut out of opioid settlement discussions can compound the negative effects not just from today’s overdose crisis but from the earlier crack cocaine epidemic. Many people considered the government’s response at that time to be ineffective and harmful.

If settlement money is used only to “build on what's already in place, you've already failed,” said Philip Rutherford, an expert on substance use disorder at the National Council for Mental Wellbeing.

At a July 2023 meeting of Illinois’ settlement council, Fanya Burford-Berry said the current system doesn’t work for women of color with substance use disorder — they can risk losing custody of their children. Burford-Berry, director of the West Side Heroin/Opioid Task Force in Chicago, hopes comments like hers will prompt the council to support solutions tailored to women of color, including bringing together more organizations that already work in those communities.

“When you allow more people to be involved, and then they have an idea, and they get excited about it, then they get more people involved and the circle of healing can become larger,” she said.

‘A Retraumatizing Moment’

In Pennsylvania, the state’s 13-member opioid settlement board has the power to withhold future funding if it decides local governments spent their money inappropriately. At its June meeting, the board — which includes a state senator representing part of Kensington — voted to disapprove of Philadelphia’s use of $7.5 million for park improvements, home repairs, rent relief, and other initiatives in Kensington. (Philadelphia later appealed the rejection; the issue is pending.)

McKinney, the Kensington resident and executive director of the New Kensington Community Development Corporation, called the board’s decision “a retraumatizing moment” for residents and criticized the way they were silenced.

“I think it’s unfortunate that things were chosen to be done that way,” McKinney said.

Others have also been frustrated by Pennsylvania’s settlement council.

Gail Groves Scott, a public health policy advocate who has a child in sustained recovery from an opioid use disorder, attended a board meeting in person last year. Not allowing the public to comment at meetings, she said, prevents them from offering feedback at critical times, such as when the board is considering county spending plans or contracts for its operations.

“We could be questioning those decisions or adding information they may not be aware of,” Groves Scott said. “It’s disappointing that, despite pushback from multiple people, they have not changed.”

Some advocates say the closed sessions of work groups, which make recommendations about which programs to approve, obscure why the full board takes certain action.

Pennsylvania trust officials have defended their practices.

Briana Anderson, the trust’s administrative director, downplayed the group’s role, saying it does not make specific spending decisions on settlement money but reviews choices made by local governments. State law doesn’t require the trust to offer public comment at its meetings but the public is encouraged to participate at the local level, Anderson added.

Pennsylvania’s practices contrast sharply with the way councils operate in places like Illinois, Kentucky, and Oregon, which routinely allow public comment at both full council and smaller committee meetings. In Kentucky, the open process has allowed members of the public to weigh in on a fierce debate over funding research into ibogaine, a psychedelic drug that has shown potential to treat addiction. At least eight people spoke in favor of the drug at the council’s January meeting.

Back in Tennessee, council chair Loyd said he hopes to increase public participation by creating an advisory panel that consists primarily of people who have personally experienced addiction or their loved ones.

He also encouraged other settlement councils to embrace opportunities to hear from people in their states.

“You’ll make better decisions as a result. I can’t be convinced otherwise,” he said.

Methodology

In June and July, reporters from KFF Health News and Spotlight PA surveyed opioid settlement councils in 39 states and Washington, D.C., to assess their general and standard practices for engaging with the public. The team also reviewed council websites, meeting minutes, agendas, and, in some cases, hours of meeting recordings. These councils have various roles, including directly deciding how to spend the money, making recommendations, or providing oversight. Although they go by different names, including advisory councils, boards, committees, and commissions, we refer to them as councils as a broad, encompassing term.

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Of course, that means there’s also plenty of controversy. The latest development comes this morning, as a coalition of 192 recovery and harm reduction organizations across dozens of states issued a call to action — shared first with KFF Health News — saying the windfall must be spent on public health approaches and “not a single dollar” on law enforcement.

“We’re demanding it be spent in ways that actually solve problems and don’t continue to increase deaths or perpetuate the war on drugs,” said Elizabeth Burke Beaty, founder of the National Sea Change Coalition, one of the groups that led the effort.

Many law enforcement agencies and elected officials disagree, saying officers are on the front lines of the opioid crisis and deserve these dollars.

Opinions are fierce, given the money’s potential to shape addiction treatment and prevention efforts for years. Annual payouts are expected through 2038. Meanwhile, hundreds of thousands of Americans continue dying of drug overdoses.

Every state is handling its funds in its own way, and the federal government, which was not a party to most of the settlements, has remained largely silent.

The document released by advocates today — which they’re calling a “roadmap” to guide officials in charge of the funds — builds on themes that have been resonating nationwide.

It lists priorities such as increasing access to medications to treat opioid-use disorder and overdose prevention centers, where people can use drugs under supervision, as well as housing services, legal aid and recovery-to-work programs. The advocates point to a $1 million allocation to Queen City Harm Reduction in Mecklenburg County, N.C., for housing supports as a good example.

The document also identifies six ways in which advocates do not want money to be spent. Topping the list is funding law enforcement personnel and equipment. Further down are abstinence-only treatment centers, unproven youth-focused prevention programs and services that are already funded through other mechanisms. The advocates call out Jackson County, W.Va., for giving about $290,000 to a law enforcement shooting range.

But not everyone agrees. Some people see harm reduction as enabling drug use. They say law enforcement is a key player in addressing the crisis — especially in rural communities that lack hospitals or treatment facilities.

“Sheriffs are at the forefront of the effects of the opioid crisis, including with response and recovery,” Jonathan Thompson, executive director and CEO of the National Sheriffs’ Association, said in a statement.

An estimated 65 percent of people in prison have a substance use disorder, and over the past decade, sheriffs have “led the way” in providing medical treatment behind bars, Thompson said.

With each group standing firmly behind its perspective, the debate over how to use settlement funds is set to continue for years.

Follow our ongoing coverage of settlement dollars here.

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Yet Verdugo didn’t know that hundreds of millions of dollars annually are flowing to California communities to combat the opioid crisis, a payout that began in 2022 and continues through 2038.

The money comes from pharmaceutical companies that made, distributed, or sold prescription opioid painkillers and that agreed to pay about $50 billion nationwide to settle lawsuits over their role in the overdose epidemic. Even though a recent Supreme Court decision upended a settlement with OxyContin maker Purdue Pharma, many other companies have already begun paying out and will continue doing so for years.

California, the most populous state, is in line for more than $4 billion.

“You can walk down the street and you see someone addicted on every corner — I mean it’s just everywhere,” Verdugo said. “And I’ve never even heard of the funds. And to me, that’s crazy.”

Across the nation, much of this windfall has been shrouded in secrecy, with many jurisdictions offering little transparency on how they’re spending the money, despite repeated queries from people in recovery and families who lost loved ones to addiction.

Meanwhile, there’s plenty of jockeying over how the money should be used. Companies are lobbying for spending on products that range from medication bottles that lock to full-body scanners to screen people entering jails. Local officials are often advocating for the fields they represent, whether it’s treatment, prevention, or harm reduction. And some governments are using it to plug budget gaps.

In California, local governments must report how they spend settlement funds to the state’s Department of Health Care Services, but there’s no requirement that the reports be made public.

KFF Health News obtained copies of the documents via a public records request and is now making available for the first time 265 spending reports from local governments for fiscal year 2022-23, the most recent reports filed.

The reports provide a snapshot of the early spending priorities, and tensions.

Naloxone an Early Winner

As of June 2023, the bulk of opioid settlement funds controlled by California cities and counties — more than $200 million — had yet to be spent, the reports show. It’s a theme echoed nationwide as officials take time to deliberate.

The city and county of Los Angeles accounted for nearly one-fifth of that unspent total, nearly $39 million, though officials say that since the report was filed they’ve begun allocating the money to recovery housing and programs to connect people who are homeless with residential addiction treatment.

Among local governments that did use the cash in the first fiscal year, the most popular object of spending was naloxone, a medication that reverses opioid overdoses and is often known by the brand name Narcan. The medication accounted for more than $2 million in spending across 19 projects.

One of those projects was in Union City, in the San Francisco Bay Area. The community of about 72,000 residents had five suspected fentanyl overdoses, two of them fatal, within 24 hours in September.

The opioid settlement money “was invaluable,” Corina Hahn, the city’s director of community and recreation services, said in her report. “Having these resources available helped educate, train and distribute the Narcan kits to parents, youth and school staff.”

Union City bought 500 kits, each containing two doses of naloxone. The kits cost about $13,500, with an additional $56,000 set aside for similar projects, including backpacks containing Narcan kits and training materials for high school students.

Union City also plans to expand its outreach to homeless people to fund drug education and recovery services, including addiction counseling.

Those are the sorts of lifesaving services that Verdugo, the Los Angeles advocate, said are desperately needed as deaths of people living on the streets pile up.

She lost her 46-year-old husband, Jesse Baumgartner, in June of last year to an addiction that started after he was prescribed pain medications for a high school wrestling injury. He tried kicking his habit for six years using methadone, but each time prescribers lowered his dosage the cravings drove him back to illicit drugs.

“It was just this horrible roller coaster of him not being able to get off of it,” Verdugo said.

By then the couple had survived 4½ years of being homeless and had been in stable housing for about two years.

Fentanyl use, particularly among homeless people, “is just rampant,” she said. People sometimes are initially exposed to the cheap, highly addictive substance unknowingly when it is mixed with something else.

“Once they start using it, it's like they just can't backtrack,” said Verdugo, who works as a community organizer for Ground Game LA.

So she leaves boxes of naloxone at homeless encampments in the hope of saving lives.

“They definitely use it, because it's needed right then — they can't wait for an ambulance to come out,” she said.

Cities Backtrack on Spending for Law Enforcement

By contrast, the cities of Irvine and Riverside, both in Greater Los Angeles, listed plans to prioritize law enforcement by buying portable drug analyzers, though neither city did so in the first fiscal year, 2022-23. Their inclination mirrored patterns elsewhere in the country, with millions in settlement funds flowing to police departments and jails.

But such uses of the money have stirred controversy, and both cities backed away from the drug analyzer purchase after the Department of Health Care Services issued rules that opioid settlement funds may not be used for certain law enforcement efforts. The rules specifically excluded “equipment for the purpose of evidence gathering for prosecution, such as the TruNarc Handheld Narcotics Analyzer.”

In Hawthorne, also near Los Angeles, the police department had already spent about $25,000 of settlement funds on an initial installment to buy 80 BolaWraps, devices that shoot Kevlar tethers to wrap around a person’s limbs or torso.

After the state said BolaWraps were not an allowable expense, the city said it would find other funding sources to pay the remaining installments.

Santa Rosa, in California’s wine country, spent nearly $30,000 on police officer wellness and support.

The funds allowed the police department to boost its contracted wellness coordinator from a part-time to a full-time position, and to buy a mobile machine to measure electrical activity in the brain, said Sgt. Patricia Seffens, a spokesperson.

The goal is to use the technology on police officers to help “assess the traumatic impact of responding to the increasing overdose calls,” Seffens said in an email.

In Dublin, east of San Francisco, officials are using part of their $62,000 in settlement cash for a D.A.R.E. program.

D.A.R.E., which stands for Drug Abuse Resistance Education, is a series of classes taught by police officers in schools to encourage students to resist peer pressure and avoid drugs. It was initially developed during the “Just Say No” campaign in the 1980s.

Studies have found inconsistent results from the program and no long-term effects on drug use, leading many researchers to dismiss it as “ineffective.”

But on its website, D.A.R.E. cites studies since the program was updated in 2009, which found “a positive effect” on fifth graders and “statistically significant reductions” in drinking and smoking about four months after completing the program.

“The D.A.R.E. program when it first came out looks a lot, lot different than what it looks like right now,” said Nate Schmidt, the Dublin police chief.

Schmidt said additional settlement money will be used to distribute naloxone to residents and stock it at schools and city facilities.

Other local governments in California spent modest sums on a wide range of addiction-related measures. Ukiah, in Mendocino County, north of San Francisco, spent $11,000 for a new heating and air conditioning system for a local drug treatment center. Orange and San Mateo counties spent settlement funds in part on medication-assisted treatment for people incarcerated in their jails. The city of Oceanside spent $16,000 to showcase drug prevention art and videos made by middle school students in local movie theaters, in public spaces, and on buses and taxis.

The Department of Health Care Services said it plans to release a statewide report on how the funds were spent, as well as the individual city and county reports, by year’s end.

This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

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Since the case was first heard, victims of the opioid crisis and recovery advocates have been split on the desired outcome. Some wanted the bankruptcy deal to go through so that settlement money could start flowing and fund urgently needed addiction services. Others said it would be unacceptable to allow the Sacklers to evade responsibility for their actions.

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✍️: Aneri Pattani/KFF Health News

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PRESQUE ISLE, Maine — Outside the Mi’kmaq Nation’s health department sits a dome-shaped tent, built by hand from saplings and covered in black canvas. It’s one of several sweat lodges on the tribe’s land, but this one is dedicated to helping people recover from addiction.

Up to 10 people enter the lodge at once. Fire-heated stones — called grandmothers and grandfathers, for the spirits they represent — are brought inside. Water is splashed on the stones, and the lodge fills with steam. It feels like a sauna, but hotter. The air is thicker, and it’s dark. People pray and sing songs. When they leave the lodge, it is said, they reemerge from the mother’s womb. Cleansed. Reborn.

The experience can be “a vital tool” in healing, said Katie Espling, health director for the roughly 2,000-member tribe.

She said patients in recovery have requested sweat lodges for years as a cultural element to complement the counseling and medications the tribe’s health department already provides. But insurance doesn’t cover sweat ceremonies, so, until now, the department couldn’t afford to provide them.

In the past year, the Mi’kmaq Nation received more than $150,000 from settlements with companies that made or sold prescription painkillers and were accused of exacerbating the overdose crisis. A third of that money was spent on the sweat lodge.

Health care companies are paying out more than $1.5 billion to hundreds of tribes over 15 years. This windfall is similar to settlements that many of the same companies are paying to state governments, which total about $50 billion.

To some people, the lower payout for tribes corresponds to their smaller population. But some tribal citizens point out that the overdose crisis has had a disproportionate effect on their communities. Native Americans had the highest overdose death rates of any racial group each year from 2020 to 2022. And federal officials say those statistics were likely undercounted by about 34% because Native Americans’ race is often misclassified on death certificates.

Still, many tribal leaders are grateful for the settlements and the unique way the money can be spent: Unlike the state payments, money sent to tribes can be used for traditional and cultural healing practices — anything from sweat lodges and smudging ceremonies to basketmaking and programs that teach tribal languages.

“To have these dollars to do that, it’s really been a gift,” said Espling of the Mi'kmaq tribe. “This is going to absolutely be fundamental to our patients’ well-being” because connecting with their culture is “where they’ll really find the deepest healing.”

Public health experts say the underlying cause of addiction in many tribal communities is intergenerational trauma, resulting from centuries of brutal treatment, including broken treaties, land theft, and a government-funded boarding school system that sought to erase the tribes’ languages and cultures. Along with a long-running lack of investment in the Indian Health Service, these factors have led to lower life expectancy and higher rates of addiction, suicide, and chronic diseases.

Using settlement money to connect tribal citizens with their traditions and reinvigorate pride in their culture can be a powerful healing tool, said Andrea Medley, a researcher with the Johns Hopkins Center for Indigenous Health and a member of the Haida Nation. She helped create principles for how tribes can consider spending settlement money.

Medley said that having respect for those traditional elements outlined explicitly in the settlements is “really groundbreaking.”

‘A Drop in the Bucket’

Of the 574 federally recognized tribes, more than 300 have received payments so far, totaling more than $371 million, according to Kevin Washburn, one of three court-appointed directors overseeing the tribal settlements.

Although that sounds like a large sum, it pales in comparison with what the addiction crisis has cost tribes. There are also hundreds of tribes that are excluded from the payments because they aren’t federally recognized.

“These abatement funds are like a drop in the bucket compared to what they’ve spent, compared to what they anticipate spending,” said Corey Hinton, a lawyer who represented several tribes in the opioid litigation and a citizen of the Passamaquoddy Tribe. “Abatement is a cheap term when we’re talking about a crisis that is still engulfing and devastating communities.”

Even leaders of the Navajo Nation — the largest federally recognized tribe in the United States, which has received $63 million so far — said the settlements can’t match the magnitude of the crisis.

“It’ll do a little dent, but it will only go so far,” said Kim Russell, executive director of the Navajo Department of Health.

The Navajo Nation is trying to stretch the money by using it to improve its overall health system. Officials plan to use the payouts to hire more coding and billing employees for tribe-operated hospitals and clinics. Those workers would help ensure reimbursements keep flowing to the health systems and would help sustain and expand services, including addiction treatment and prevention, Russell said.

Navajo leaders also want to hire more clinicians specializing in substance use treatment, as well as primary care doctors, nurses, and epidemiologists.

“Building buildings is not what we want” from the opioid settlement funds, Russell said. “We’re nation-building.”

High Stakes for Small Tribes

Smaller nations like the Poarch Band of Creek Indians in southern Alabama are also strategizing to make settlement money go further.

For the tribe of roughly 2,900 members, that has meant investing $500,000 — most of what it has received so far — into a statistical modeling platform that its creators say will simulate the opioid crisis, predict which programs will save the most lives, and help local officials decide the most effective use of future settlement cash.

Some recovery advocates have questioned the model’s value, but the tribe’s vice chairman, Robert McGhee, said it would provide the data and evidence needed to choose among efforts competing for resources, such as recovery housing or peer support specialists. The tribe wants to do both, but realistically, it will have to prioritize.

“If we can have this model and we put the necessary funds to it and have the support, it'll work for us,” McGhee said. “I just feel it in my gut.”

The stakes are high. In smaller communities, each death affects the whole tribe, McGhee said. The loss of one leader marks decades of lost knowledge. The passing of a speaker means further erosion of the Native language.

For Keesha Frye, who oversees the Poarch Band of Creek Indians’ tribal court and the sober living facility, using settlement money effectively is personal. “It means a lot to me to get this community well because this is where I live and this is where my family lives,” she said.

Erik Lamoreau in Maine also brings personal ties to this work. More than a decade ago, he sold drugs on Mi’kmaq lands to support his own addiction.

“I did harm in this community and it was really important for me to come back and try to right some of those wrongs,” Lamoreau said.

Today, he works for the tribe as a peer recovery coordinator, a new role created with the opioid settlement funds. He uses his experience to connect with others and help them with recovery — whether that means giving someone a ride to court, working on their résumé, exercising together at the gym, or hosting a cribbage club, where people play the card game and socialize without alcohol or drugs.

Beginning this month, Lamoreau’s work will also involve connecting clients who seek cultural elements of recovery to the new sweat lodge service — an effort he finds promising.

“The more in tune you are with your culture — no matter what culture that is — it connects you to something bigger,” Lamoreau said. “And that’s really what we look at when we’re in recovery, when we talk about spiritual connection. It’s something bigger than you.”

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Local officials say they’re trying to stretch tight budgets, especially in rural areas. But critics say it’s a lost opportunity to bolster responses to an ongoing addiction crisis and save lives.

“To think that replacing what you’re already spending with settlement funds is going to make things better — it’s not,” said Robert Kent, former general counsel for the Office of National Drug Control Policy. “Certainly, the spirit of the settlements wasn’t to keep doing what you’re doing. It was to do more.”

The debate is playing out in Scott County, Ind. The rural community made headlines in 2015 after intravenous drug use led to a massive HIV outbreak and then-Gov. Mike Pence (R) legalized syringe service programs. (The county has since shuttered its syringe program.) 

In 2022, the county received more than $570,000 in opioid settlement funds. It spent about 45 percent of that on salaries for its health director and emergency medical services staff, according to reports it filed with the state. The money usually budgeted for those salaries was freed to buy an ambulance and create a rainy-day fund for the health department.

In public meetings, Scott County leaders said they hoped to reimburse the departments for resources they dedicated to the HIV outbreak years ago. 

Their conversations echo the struggles of other rural counties, which have tight budgets in part because for years they poured money into combating the opioid crisis. Now they want to recoup some of those expenses.

But many families affected by addiction, recovery advocates, and legal and public health experts say that misses the point, that the settlements were aimed at helping the nation make progress against the overdose epidemic.

Thirteen states and Washington, D.C., have restricted substituting opioid settlement funds for existing government spending, according to state guides created by OpioidSettlementTracker.com and the public health organization Vital Strategies. A national set of principles created by Johns Hopkins University also advises against the practice, known as supplantation.

But it’s happening anyway. 

County commissioners in Blair County, Pa., used about $320,000 of settlement funds for a drug court that has been operating with other sources of money for more than two decades, according to a report the county filed with a state council overseeing settlement funds.

In New York, some lawmakers and treatment advocates say the governor’s proposed budget substitutes millions of opioid settlement dollars for a portion of the state addiction agency’s normal funding.

Given the complexities of state and local budgets, it’s often difficult to spot supplantation. But one place to start is identifying how much opioid settlement money your community has received so far. Use our searchable database to find out. Then ask elected officials how they’re spending those dollars. In many places, dedicated citizens are the only watchdogs for this money.

If you discover anything interesting, shoot me a note.

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Scott County, Indiana, for example, has spent more than $250,000 of opioid settlement dollars on salaries for its health director and emergency medical services staff. The money usually budgeted for those salaries was freed to buy an ambulance and create a financial cushion for the health department.

In Blair County, Pennsylvania, about $320,000 went to a drug court the county has been operating with other sources of money for more than two decades.

And in New York, some lawmakers and treatment advocates say the governor’s proposed budget substitutes millions of opioid settlement dollars for a portion of the state addiction agency’s normal funding.

The national opioid settlements don’t prohibit the use of money for initiatives already supported by other means. But families affected by addiction, recovery advocates, and legal and public health experts say doing so squanders a rare opportunity to direct additional resources toward saving lives.

“To think that replacing what you’re already spending with settlement funds is going to make things better — it’s not,” said Robert Kent, former general counsel for the Office of National Drug Control Policy. “Certainly, the spirit of the settlements wasn’t to keep doing what you’re doing. It was to do more.”

Settlement money is a new funding stream, separate from tax dollars. It comes from more than a dozen companies that were accused of aggressively marketing and distributing prescription painkillers. States are required to spend at least 85% of the funds on addressing the opioid crisis. Now, with illicit fentanyl flooding the drug market and killing tens of thousands of Americans annually, the need for treatment and social services is more urgent.

Thirteen states and Washington, D.C., have restricted the practice of substituting opioid settlement funds for existing dollars, according to state guides created by OpioidSettlementTracker.com and the public health organization Vital Strategies. A national set of principles created by Johns Hopkins University also advises against the practice, known as supplantation.

Paying Staff Salaries

Scott County, Indiana — a small, rural place known nationally as the site of an HIV outbreak in 2015 sparked by intravenous drug use — received more than $570,000 in opioid settlement funds in 2022.

From August 2022 to July 2023, the county reported using roughly $191,000 for the salaries of its EMS director, deputy director, and training officer/clinical coordinator, as well as about $60,000 for its health administrator. The county also awarded about $151,000 total to three community organizations that address addiction and related issues.

In a public meeting discussing the settlement dollars, county attorney Zachary Stewart voiced concerns. “I don’t know whether or not we’re supposed to be using that money to add, rather than supplement, already existing resources,” he said.

But a couple of months later, the county council approved the allocations.

Council President Lyndi Hughbanks did not respond to repeated requests to explain this decision. But council members and county commissioners said in public meetings that they hoped to compensate county departments for resources expended during the HIV outbreak.

Their conversations echoed the struggles of many rural counties nationwide, which have tight budgets, in part because they poured money into addressing the opioid crisis for years. Now as they receive settlement funds, they want to recoup some of those expenses.

The Scott County Health Department did not respond to questions about how the funds typically allocated for salary were used instead. But at the public meeting, it was suggested they could be used at the department’s discretion.

EMS Chief Nick Oleck told KFF Health News the money saved on salaries was put toward loan payments for a new ambulance, purchased in spring 2023.

Unlike other departments, which are funded from local tax dollars and start each year with a full budget, the county EMS is mostly funded through insurance reimbursements for transporting patients, Oleck said. The opioid settlement funds provided enough cash flow to make payments on the new ambulance while his department waited for reimbursements.

Oleck said this use of settlement dollars will save lives. His staff needs vehicles to respond to overdose calls, and his department regularly trains area emergency responders on overdose response.

“It can be played that it was just money used to buy an ambulance, but there’s a lot more behind the scenes,” Oleck said.

Still, Jonathan White — the only council member to vote against using settlement funds for EMS salaries — said he felt the expense did not fit the money’s intended purpose.

The settlement “was written to pay for certain things: helping people get off drugs,” White told KFF Health News. “We got drug rehab facilities and stuff like that that I believe could have used that money more.”

Phil Stucky, executive director of a local nonprofit called Thrive, said his organization could have used the money too. Founded in the wake of the HIV outbreak, Thrive employs people in recovery to provide support to peers with mental health and substance use disorders.

Stucky, who is in recovery himself, asked Scott County for $300,000 in opioid settlement funds to hire three peer specialists and purchase a vehicle to transport people to treatment. He ultimately received one-sixth of that amount — enough to hire one person.

In Blair County, Pennsylvania, Marianne Sinisi was frustrated to learn her county used about $322,000 of opioid settlement funds to pay for a drug court that has existed for decades.

“This is an opioid epidemic, which is not being treated enough as it is now,” said Sinisi, who lost her 26-year-old son to an overdose in 2018. The county received extra money to help people, but instead it pulled back its own money, she said. “How do you expect that to change? Isn’t that the definition of insanity?”

Blair County Commissioner Laura Burke told KFF Health News that salaries for drug court probation officers and aides were previously covered by a state grant and parole fees. But in recent years that funding has been inadequate, and the county general fund has picked up the slack. Using opioid settlement funds provides a small reprieve since the general fund is overburdened, she said. The county’s most recent budget faces a $2 million deficit.

Forfeited Federal Dollars

Supplantation can take many forms, said Shelly Weizman, project director of the addiction and public policy initiative at Georgetown University’s O’Neill Institute. Replacing general funds with opioid settlement dollars is an obvious one, but there are subtler approaches.

The federal government pours billions of dollars into addiction-related initiatives annually. But some states forfeit federal grants or decline to expand Medicaid, which is the largest payer of mental health and addiction treatment.

If those jurisdictions then use opioid settlement funds for activities that could have been covered with federal money, Weizman considers it supplantation.

“It’s really letting down the citizens of their state,” she said.

Officials in Bucks County, Pennsylvania, forfeited more than $1 million in federal funds from September 2022 to September 2023, the bulk of which was meant to support the construction of a behavioral health crisis stabilization center.

“We were probably overly optimistic” about spending the money by the grant deadline, said Diane Rosati, executive director of the Bucks County Drug and Alcohol Commission.

Now the county plans to use $3.9 million in local and state opioid settlement funds to support the center.

Susan Ousterman finds these developments difficult to stomach. Her 24-year-old son died of an overdose in 2020, and she later joined the Bucks County Opioid Settlement Advisory Committee, which developed a plan to spend the funds.

In a September 2022 email to other committee members, she expressed disappointment in the suggested uses: “Please keep in mind, the settlement funds are not meant to fund existing programs or programs that can be funded by other sources, such as federal grants.”

But Rosati said the county is maximizing its resources. Settlement funds will create a host of services, including grief groups for families and transportation to treatment facilities.

“We’re determined to utilize every bit of funding that’s available to Bucks County, using every funding source, every stream, and frankly every grant opportunity that comes our way,” Rosati said.

The county’s guiding principles for settlement funds demand as much. They say, “Whenever possible, use existing resources in order that Opioid Settlement funds can be directed to addressing gaps in services.”

Ed Mahon of Spotlight PA contributed to this report.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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