Tips for weaving equity into opioid settlement spending

A reported $54.9 billion and counting in settlement funds is being funneled to state and local governments from pharmaceutical companies for their part in fueling the devastating opioid crisis since the 1990s. 

Reaching the settlement was the first big challenge, and now state and local governments are left with a major question: How should the money be spent? 

Officials are facing mounting pressure to get the money out the door to support treatment and recovery efforts for individuals’ opioid use disorders over the next two decades, but they have faced criticism for using the money for new police tech or not spending it quickly enough as hundreds of thousands of victims die from overdoses each year. 

Also at the top of policymakers’ minds is how to distribute funds equitably to ensure those hit hardest by the opioid epidemic—such as individuals who are low-income, people of color or rural residents—can benefit from the nationwide push toward addiction treatment and recovery. 

“The settlements are very stringent about what the money can be spent on and even how it gets distributed,” said Lauren Nocera, an addiction policy scholar at Georgetown Law’s O’Neill Institute for National and Global Health Law. That leaves policymakers navigating a complex web of settlement spending restrictions and allowable use cases. 

For state and local officials allocating opioid settlement funds, some new guidance may help. The Equity Expectation Policy serves as a framework for leaders, such as officials serving on an opioid settlement advisory board, to weave equity into spending decisions. 

EEP, designed by Nocera, was created to be “broad enough that it could be relevant if you were a town with 9,000 people or if you were a place with a million people … but also specific enough that it was actionable,” he said. It features six focus areas to help officials decide how to disburse settlement funds. 

The first is transparency, which includes public reporting of how much money state and local governments are receiving and what programs or services it is being spent on. The information should be made available in the languages used in the community so residents know about the decisions that can significantly impact their life and health outcomes, Nocera said. 

Many individuals have long-standing mistrust toward government and health institutions that have contributed to socioeconomic disparities within communities. “If we want good outcomes in terms of community [and] public health, we have to heal the relationship between government and their constituents,” he said. With transparent, open data on settlement-related information, residents can hold governments accountable for the appropriate spending of funds, a step toward restoring the community’s trust in public health. 

Another way for officials to ensure a fair use of opioid settlement funds is through equity-focused decision-making. Leaders should review data on health or racial disparities, for instance, to identify where intervention measures need to be targeted, Nocera said. 

In 2022 for example, the Kentucky Opioid Response Effort required opioid treatment providers to collect data on access to treatment and outcomes by race and ethnicity. With that kind of data, leaders can identify barriers to recovery services or spot which recovery services are less effective at reducing overdose deaths, Nocera said. Those insights will help inform equitable distribution of settlement funds.

A growing body of research suggests, for example, that limiting individuals’ access to medications for opioid use disorder during incarceration, which disproportionately affects Black and brown individuals, can actually increase someone’s likelihood of dying from an overdose post-release. Equity-based data like that can be woven into policy discussions about  decriminalizing drug use or possession. It could also inform the direction of opioid settlement funds toward more harm reduction-based services and policies for incarcerated individuals, Nocera said. 

The procurement process is another area government can bake equity into their opioid abatement efforts, he said, as “procurement officials … are oriented toward creating a system that is fair, that is transparent, that is equitable.” 

The Rhode Island Overdose Settlement Advisory Committee, for instance, recently recommended that all grant proposals include a plan to address inequities in opioid addiction treatment efforts. Another way to foster equity through procurement would be requiring  providers to include a person with lived experience with opioid use disorders as part of their program oversight process. Agencies can also promote equity by contracting with smaller, less-resourced organizations that could have more innovative, equitable solutions than larger corporations.

Two other focus areas include improving the capacity and technical capability of organizations working to mitigate the opioid crisis as well as making communications and operations more equitable. Government could require that all opioid abatement providers are trained on the federal Culturally and Linguistically Accessible Services and Americans with Disabilities Act standards, Nocera said. That can ensure all events, operations and services fit the needs of vulnerable individuals, particularly those who don’t speak English or have limited resources to seek addiction treatment. 

EEP’s final focus area calls for officials to evaluate the implementation of opioid addiction mitigation efforts for equity. Reviewing and revising opioid abatement plans every year can help agencies stay on track with equity goals, as can public reporting of government’s EEP progress. 

Ultimately, EEP can help opioid abatement leaders ensure that the money meant to remedy communities and families harmed by the opioid crisis makes it to residents who actually need it. “These settlement funds are not government grant funds,” Nocera said. “The settlement funds have come to communities because communities were negatively impacted and continue to be negatively impacted by the actions of manufacturers, pharmaceutical companies and pharmacy chains. Those monies belong to the communities.”