Optimizing Opioid Settlement Funds To Save Lives: Investing In Equitable Solutions

As the nation confronts an ongoing overdose crisis, families continue to lose loved ones every day. While no community has been spared, people from impoverished neighborhoods and those from racial and ethnic minoritized communities carry a disproportionate toll of overdose deaths. Other vulnerable groups, such as people with criminal legal system involvement and people experiencing homelessness also continue to experience skyrocketing overdose rates. Decades of structural racism and social disinvestment along with a deadly fentanyl supply and a global pandemic have led many already-neglected communities alone to battle this crisis. As such, reducing overdose deaths will require targeted and long-needed investment of resources that can effectively reach our most marginalized communities and address their health and social needs.

At the same time, US communities are at an unprecedented moment in which proceeds from lawsuits against opioid manufacturers, distributors, and pharmacies for their role in propagating the overdose crisis have led to billions of dollars becoming available to distribute across states, local jurisdictions, and tribal communities. Experts have developed extensive guidance on how states and local governments can use these flexible funds to support evidence-based approaches to address opioid use and ensure we don’t repeat mistakes from our past—as in the wake of the tobacco settlements. To further avoid previous missteps, an equitable framework is necessary to ensure resettlement funds are allocated appropriately to those disproportionately impacted by structural racism, othering, and a failing public health infrastructure. The funds must match the needs of the populations at greatest risk for negative outcomes tied to structural neglect and disinvestment.

Below, we outline immediate, medium, and long-term investments that local jurisdictions can use to target their opioid settlement funds toward addressing overdose in their hardest-hit communities. These recommendations will help decision makers prioritize evidence-based and equitable solutions that can effectively reduce deaths, suffering, and health disparities.

1. Immediate Investments: Expand Harm Reduction Services And Supplies To Prevent Overdose

Reducing overdose deaths will require sustained investment in strategies to build trust and prevent serious morbidity and mortality among individuals who use drugs. A public health approach begins with core harm reduction principles, including the understanding that people who die cannot improve their health or address their substance use. To this end, investments should be made to:

Expand The Reach Of Overdose Prevention Centers

Overdose prevention centers have been highly effective in other countries at both reducing overdose and increasing uptake of substance use disorder treatment and other health and social services. In November 2021, the US saw the opening of the first two publicly recognized overdose prevention centers in New York City. These sites have already shown great promise with hundreds of overdose reversals and many lives saved in their first year of operation. Investing in resources and advocacy to support expansion of overdose prevention centers across the country, and particularly in high-overdose areas, will be critical in preventing further deaths. Doing so will require courageous and creative leadership on behalf of local leaders and lawmakers to overcome ongoing political and legal hurdles that continue to prevent critical use of funds to support these centers.

Make Naloxone Ubiquitous Across Jurisdictions

Administration of naloxone during an opioid overdose can rapidly reverse symptoms and prevent mortality. While there have been efforts to expand access to naloxone, there continue to be barriers to access among those who need it. In a recent survey of individuals who use opioids in New York City, nearly half of individuals reported that naloxone was never available during past-month opioid use, with Black individuals being less likely than White individuals to report having access to naloxone. Investments should be made to purchase and distribute naloxone widely, via harm reduction programs, pharmacies, mail-order programs, other health services, and street outreach teams. Efforts to effectively expand naloxone should prioritize neighborhoods and localities with the highest rates of overdose and should be informed by input from individuals who use drugs and their networks.

Support Other Harm Reduction And Social Programs That Serve People Who Use Drugs

Harm reduction organizations play a critical role in reaching structurally disadvantaged individuals who are at greatest risk of overdose and other drug-related health problems. However, these organizations are often short staffed and underresourced. It is imperative to invest additional resources in these organizations to ensure ready access to critical services for people at highest risk of overdose. This includes support for overdose education and drug checking materials, which can provide information to prevent overdose among people who use drugs, and other supplies such as sterile syringes, which are highly effective in reducing infectious disease transmission. Allocating funds to support additional wrap-around services, including case management, linkage to housing, nutrition, health care, and other social services can be critical in improving the health of individuals who come into contact with these services.

2. Medium-Term Investments: Facilitate Engagement In Low-Barrier Treatment With Medications For Opioid Use Disorder

Medications for opioid use disorder (MOUD), especially methadone and buprenorphine, are highly effective treatments that reduce opioid use, decrease transmission of HIV and hepatitis c, and cut overdose risk by more than half. However, many of the most high-risk individuals do not access MOUD, largely due to burdensome regulations and requirements and a dearth of supportive services to facilitate entry to and long-term retention in care. Moreover, many substance use treatment programs do not even offer MOUD and instead rely on ineffective practices such as abstinence-oriented detoxification. To this end, investments should be made to:

Expand Access To Low-Barrier MOUD Treatment For Populations At Greatest Risk

Many of the most vulnerable populations, including individuals with criminal legal system involvement, those experiencing homelessness, those with co-occurring disorders, and those who inject drugs, are least likely to access or stay engaged in treatment. This is often due to difficult-to-meet conditions for accessing services such as frequent required visits and drug screening, strict appointment scheduling, and a lack of tolerance for any ongoing drug use. In addition, programs that do not provide ancillary support services to help participants with transportation, housing, and linkage to other harm reduction and social services often fail to meet the most basic needs of these individuals. Jurisdictions should expand resources for low-barrier MOUD treatment models, including within local detention facilities and community corrections settings, most of which currently have minimal to no access to MOUD, as well as expand MOUD programs that are located within syringe service programs and other community settings. Walk-in mobile units, telehealth-based services, and programs integrated with community and faith-based organizations, have shown success in engaging diverse patient populations. In addition, flexible settlement funds can be used to support ancillary transportation assistance, nutrition assistance, workforce training, and help with securing permanent housing for participants. These efforts can go a long way to support continuous engagement in treatment and stability in other aspects of patients’ lives that are critical for treatment success and well-being.

Expand Touchpoints In Acute Care Settings To Reach High-Risk Individuals And Link Them To Community-Based Treatment And Services

Individuals who use opioids frequently encounter acute care medical settings, including emergency medical services (EMS), emergency departments, and inpatient hospital units. Indeed, programs around the country have shown success in engaging at-risk individuals in emergency departments and hospitals. However, resources remain limited to support these programs, and many hospitals continue to stigmatize or insufficiently support the needs of patients who use opioids. Leveraging opioid settlement funds to support hospital-embedded bridge clinics and training for providers to initiate MOUD and link individuals to low-barrier community services can broaden the impact of these programs. Flexible settlement funds can be especially useful for integrating care coordinators and navigators, peer recovery specialists, and community health workers to improve outcomes of these programs. Investing in innovative models such as bridge clinics, EMS-initiated buprenorphine and naloxone leave behind programs, are other opportunities to expand access to life-saving services.

3. Long-Term Investments: Prevent Future Addiction And Overdose By Promoting Social Services And Prevention Programs Rooted In Evidence And Public Health

The addiction and overdose epidemic does not exist in a vacuum. As highlighted by the COVID-19 pandemic, health inequities and other social hardships are ingrained in a history of structural racism. Addressing the current epidemic and preventing future crises will require long-term investment in promoting healthy communities. This includes addressing key social determinants to unhealthy substance use, such as poverty, discrimination, marginalization, violent victimization, trauma, homelessness, and mental health disorders. For such efforts to be successful, sustained resources must be invested to ensure prevention, and social service programs have the high-quality leadership, infrastructure, and staffing needed to sustain positive impact on this and future generations. To this end, investments should be made to:

Invest In Social Programs That Reduce Poverty And Homelessness

Social determinants of health, including housing, employment, and education have a significant impact on initiation of risky substance use, progression toward substance use disorders, risk of overdose, and other health complications associated with drug use. These determinants also influence whether someone can succeed in substance use treatment and meet other health and personal goals. As such, jurisdictions should invest in the expansion of social and economic programs that raise income and provide buffers against job loss, including expanding workforce development programs among individuals with histories of substance use and criminal justice involvement. In addition, jurisdictions should allocate funds toward increasing availability of long-term housing options for individuals living in poverty with substance use and other mental health needs, such as housing first and other non-contingent housing models. Addressing our cities’ housing crisis can critically prevent homelessness, improve health, and support long-term stability among those who may otherwise be at great risk for developing substance use disorders and overdose.

Divert Individuals Away From The Criminal Legal System Toward Social And Health Services

A long history of criminalization of addiction—disproportionately impacting Black people due to the War on Drugs—has led our criminal legal system to be a predominant provider of housing and health care for individuals with substance use disorders. It was estimated that between 2011 and 2017, 95 percent of individuals most frequently incarcerated (more than seven times in seven years) in the New York City jail system, for example, had a diagnosed substance use disorder. Unfortunately, individuals who are incarcerated remain at greatest risk for experiencing overdose when they re-enter the community, along with other barriers to accessing health care, employment, and housing. Non-police crisis intervention programs as well as alternative to incarceration and diversion programs, especially those that do not include charge or diagnostic exclusions, can provide intensive care management and assistance in helping individuals connect with treatment and harm reduction programs, as well as housing, skills development, and employment programs that can be a cost-effective and humane approach to prevent long-term legal and health consequences.

Support Early Childhood Interventions And Education Programs That Promote Mental Health And Healthy Coping

Individuals with substance use disorders who are at greatest risk of overdose often have co-occurring mental health conditions and/or a history of trauma and adverse childhood experiences. Horizontal evidence-based prevention programs that are informed and led by members of the community and that aim to build healthy environments and promote life skills can have cross-cutting impacts on health and save costs long term. Early intervention programs such as nurse visits for first-time mothers during pregnancy and early infancy can promote effective parenting and child development. In addition, adolescent psychosocial interventions to promote interpersonal skills training, emotional regulation, and prevent risk behaviors can prevent unhealthy substance use, promote positive mental health and coping skills, and offer longer-term benefits. Ensuring adoption of primary prevention programs that have a strong evidence base and that can be continuously evaluated and adapted to local needs, are key to preventing ineffective resource use and missed prevention opportunities.

Our recommended investments are only a starting point for addressing the overdose crisis and health disparities in our communities. For these efforts to be successful, the process of implementing such evidence-based interventions and allocating resources must involve ongoing leadership by and collaboration with people impacted by the drug overdose crisis. Key stakeholders, community members, leaders, public health experts, academicians, and health providers must equitably be involved in all steps of the implementation process, from planning to execution. An approach that is anti-racist, centered in racial justice, and promotes equity must include voices from racial and ethnic minoritized communities, cultivate leaders from neglected areas, and involve them in all stages of public health policy development and implementation related to treatment. Resettlement funds must support health programming that meets the needs of racial and ethnic minoritized communities by removing current and historic barriers to health. Finally, funds specifically geared toward addressing social determinants have to be integrated into program planning. Abiding by the above recommendations will support the existence of a system that strengthens the health of all our communities and is the right thing to do to prevent unnecessary suffering and loss of cherished lives.

Authors’ Note

Dr. Krawczyk is involved in ongoing opioid litigation. She is a member of the National Coalition to Liberate Methadone and collaborates with researchers at Johns Hopkins who have published guidance on use of opioid settlement funds. Dr. Jordan received funding from the National Institutes of Health (1U01D033241) to research how to develop and optimize methods for increasing access to, uptake of, and engagement in MAT for opioid use disorder among communities of color. She is also a member of the Liberate Methadone group. Dr. Cerdá contributed to the preparation of an expert report for opioid litigation. She is leading an effort to develop recommendations on how to address social determinants of the opioid crisis for the National Academy of Medicine Opioid Collaborative.