But in at least one California county, history is repeating itself. And across the country, many local leaders are finding themselves in similar positions: choosing between paying bills due today or investing in the fight against an ongoing crisis.

Mendocino County in rural Northern California has reported the highest rate of overdose deaths in the state. Its board of supervisors decided to use more than $63,000 of opioid settlement funds — about 6.5% of all the settlement cash the county has received in the first two years of distribution— to help fill a budget shortfall of about $6 million. Specifically, the money has been allotted to cover employee health insurance premiums, wage increases, and cost-of-living adjustments. County officials plan to use that amount as a recurring source of payment, since opioid settlements are scheduled to arrive annually till 2038.

The board also used retirement reserves and delayed repair projects and equipment purchases to plug the gap.

“We have to balance our budget by law,” said Glenn McGourty, chair of the board of supervisors. “You find money where you can.”

Vice Chair Mo Mulheren added that health insurance deficits were caused, in part, by the overprescribing of opioids and the costs of addiction treatment for county employees or their family members. Now the settlement dollars can make the county “whole again,” she said.

But many people with substance use disorders and their loved ones want the money to be used to make their communities whole again in a different way — by supporting people in recovery and preventing opioid-related deaths. More than 100,000 Americans died of drug overdoses last year.

The settlement funds are the result of thousands of lawsuits filed against a host of health care companies, including Johnson & Johnson, McKesson, CVS Health, and Walmart, for aggressively promoting and distributing painkillers. The money should remediate the effects of that corporate behavior, say attorneys general, treatment providers, and those directly affected by the crisis.

In Mendocino County, McGourty said, “we certainly expend a lot of money on substance abuse.” But tourism and tax revenues, which were boosted at the height of the pandemic as Bay Area residents escaped to the rural county, have recently decreased. Meanwhile, costs for the sheriff’s office, jail, and behavioral health programs often run over budget, partly due to the opioid epidemic, he said.

The story is all too familiar to Matthew Myers, former president of the Campaign for Tobacco-Free Kids, which monitors how states spend money from the tobacco master settlement agreement of 1998.

Back then, states won more than $240 billion to be distributed over the first 25 years and continued annual payments for as long as the companies are selling cigarettes. In theory, the money was to be used to help people stop smoking, but there were no legal restrictions on how it was spent. In a 2007 report, the Government Accountability Office reported states had allocated $16.8 billion, or 30% of the money they’d received, to health care and $12.8 billion, or 23%, to budget shortfalls.

“Almost from the beginning, a significant number of states used the tobacco settlement money for anything but tobacco,” Myers said. “What’s most concerning, though, is that over time the track record of the states has gotten worse.”

People who made the original agreements left office, budget needs arose — especially during recessions — and oversight from the public and nonprofit organizations waned. Tobacco settlement money flowed to transportation departments to fill potholes, support corporate tax breaks, and even subsidize tobacco farmers. Today, less than 3% of the annual payouts is used for smoking cessation or prevention.

It’s a sobering statistic that many attorneys general kept in mind when negotiating the opioid settlements. To avoid the same scenarios, they set restrictions: At least 85% of the money has to be spent on opioid remediation, with a menu of suggested strategies.

Some states are stricter than others. In California, for example, 70% of the settlement funds funnel into an abatement account from which the state doles it out to counties and cities. All money from that account must be spent on future opioid remediation efforts, with at least half for creating treatment infrastructure, diverting people from the criminal justice system, preventing youth addiction, or other activities the state identified as high-impact. The state Department of Health Care Services has issued written guidance, held webinars, and offered customized assistance to local governments to ensure the money is used appropriately.

“We really want to make sure that all of this funding is for opioid remediation,” said Marlies Perez, who oversees opioid settlement funding at the department.

If her team finds examples of misspending, they can take local governments to court.

But there’s a caveat: The department has authority only over money that comes from the abatement fund and an additional 15% the state receives directly. The final 15% of the state’s settlement money goes straight to local governments and can be used for anything the localities define as opioid-related.

That’s why Mendocino County was able to use $63,000 to plug its budget hole and plan to spend a chunk of future funds similarly. (It has received roughly $780,000 more through the state abatement fund, which must be spent on opioid remediation.)

Even if that use of funds is legal, some people question whether it is appropriate.

Jacqueline Williams is executive director of the Ford Street Project, a nonprofit that runs a food bank, homeless shelter, and Mendocino County’s only adult residential addiction treatment program. “It’s disheartening that the need is so great,” she said, yet some of the settlement money is not going directly to the crisis.

She has asked the county for $4 million to build a 24-bed sober living facility, where clients — many of whom are homeless — can stay after completing residential treatment. “The hardest thing is when somebody asks for help if you don’t have a bed,” said Williams, who hasn’t received a final response to her request.

Jenine Miller, Mendocino County’s behavioral health director, said the county is using revenue from a local sales tax increase to build a psychiatric hospital, crisis respite facilities, and mobile response teams, but there is still a need for more residential treatment for addiction specifically.

“I can never say I have enough funds to do everything we need to do,” she said.

Miller signed off on a report the county is required to file with administrators of the settlement, saying it spent $63,000 on purposes that do not qualify as opioid remediation. She told KFF Health News that she understands the county’s need to recuperate costs to its health insurance plan, “but the largest amount of the money needs to be in our community doing prevention, early intervention, and treatment.”

Mulheren, the vice chair of the board of supervisors, said if the county has savings in future years, it may be able to put some of the recurring $63,000 toward addiction initiatives. The county recently switched from being self-insured to a group health insurance plan for its roughly 900 employees.

“We’re trying to constantly figure out how we can save money, especially when it comes to the health insurance premiums.” Mulheren said.

But Myers, of the Campaign for Tobacco-Free Kids, said his experience with the tobacco settlement suggests the first few years of spending set the tone for the future.

“If states don’t start spending money for the designated purpose effectively and build it into the DNA of the budget process, the risks down the road only grow,” he said.

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In 14 states, these councils have the ultimate say on the money, which comes from companies that made, distributed, or sold opioid painkillers, including Purdue Pharma, Johnson & Johnson, and Walmart. In 24 other states, plus Washington, D.C., the councils establish budget priorities and make recommendations. Those will affect whether opioid settlement funds go, for example, to improve addiction treatment programs and recovery houses or for more narcotics detectives and prisons.

KFF Health News, along with Johns Hopkins University and Shatterproof, a national nonprofit focused on the addiction crisis, gathered and analyzed data on council members in all states to create the first database of its kind.

The data shows that councils are as unique as states are from one another. They vary in size, power, and the amount of funds they oversee. Members run the gamut from doctors, researchers, and county health directors to law enforcement officers, town managers, and business owners, as well as people in recovery and parents who’ve lost children to addiction.

“The overdose crisis is incredibly complex, and it demands more than just money,” said Rollie Martinson, a policy associate with the nonprofit Community Education Group, which is tracking settlement spending across Appalachia. “We also need the right people in charge of that money.”

That’s the $50 billion question: Are the right people steering the decisions? Already, criticism of the councils has been rife, with stakeholders pointing out shortcomings, from overrepresentation to underrepresentation and many issues in between. For example:

• Council membership doesn’t always align with the states’ hardest-hit populations — by race or geography.
• Heavy presence of specific professional groups — treatment providers, health care executives, or law enforcement officials, for example — might mean money gets directed to those particular interests at the expense of others.
• Few seats are reserved for people who’ve dealt with a substance use disorder themselves or supported a family member with one.

Admittedly, no one can design a perfect council. There’s no agreement on what that would even look like. But when a pile of money this big is at stake, everyone wants in on the action.

More than $3 billion of opioid settlement funds has already landed in government coffers, with installments to come through 2038. The money is meant as restitution for the hundreds of thousands of Americans who have died from drug overdoses in recent decades.

But what restitution looks like depends on whom you ask. People running syringe service programs might suggest spending money immediately on the overdose reversal medication naloxone, while hospital officials might advocate for longer-term investments to increase staffing and treatment beds.

“People naturally want money to go toward their own field or interest,” said Kristen Pendergrass, vice president of state policy at Shatterproof.

And that can trigger hand-wringing.

In many parts of the country, for instance, people who support syringe service programs or similar interventions worry that councils with high numbers of police officers and sheriffs will instead direct large portions of the money to buy squad cars and bulletproof vests. And vice versa.

In most states, though, law enforcement and criminal justice officials make up fewer than one-fifth of council members. In Alaska and Pennsylvania, for instance, they’re not represented at all.

Outliers exist, of course. Tennessee’s 15-member council has two sheriffs, one current and one former district attorney general, a criminal court judge, and a special agent from the state Bureau of Investigation. But like many other councils, it hasn’t awarded funds to specific groups yet, so it’s too soon to tell how the council makeup will influence those decisions.

Pendergrass and Johns Hopkins researcher Sara Whaley, who together compiled the list of council members, say criticism of councils drawing too heavily from one field, geographic area, or race is not just a matter of political correctness, but of practicality.

“Having diverse representation in the room is going to make sure there is a balance on how the funds are spent,” Pendergrass said.

To this end, Courtney Gary-Allen, organizing director for the Maine Recovery Advocacy Project, and her colleagues chose early on to ensure their state’s 15-member council included people who support what’s known as harm reduction, a politically controversial strategy that aims to minimize the risks of using drugs. Ultimately, this push led to the appointment of six candidates, including Gary-Allen, to the panel. Most have personal experience with addiction.

“I feel very strongly that if these six folks weren’t on the council, harm reduction wouldn’t get a single dollar,” she said.

Others are starting to focus on potential lost opportunities.

In New Jersey, Elizabeth Burke Beaty, who is in recovery from substance use disorder, has noticed that most members of her state’s council represent urban enclaves near New York City and Philadelphia. She worries they’ll direct money to their home bases and exclude rural counties, which have the highest rates of overdose deaths and unique barriers to recovery, such as a lack of doctors to treat addiction and transportation to faraway clinics.

Natalie Hamilton, a spokesperson for New Jersey Gov. Phil Murphy, a Democrat who appointed the members, said the council represents “a wide geographic region,” including seven of the state’s 21 counties.

But only two of those represented — Burlington and Hunterdon counties — are considered rural by the state’s Office of Rural Health needs assessment. The state’s hardest-hit rural counties lack a seat at the table.

Now that most of the council seats nationwide are filled, worries about racial equity are growing.

Louisiana, where nearly a third of the population is Black, has no Black council members. In Ohio, where Black residents are dying of overdoses at the highest rates, only one of the 29 council members is Black.

“There’s this perception that this money is not for people who look like me,” said Philip Rutherford, who is chief operating officer of Faces & Voices of Recovery and is Black. His group organizes people in recovery to advocate on addiction issues.

Research shows Black Americans have the fastest-rising overdose death rates and face the most barriers to gold-standard treatments.

In several states, residents have lamented the lack of council members with firsthand knowledge of addiction, who can direct settlement dollars based on personal experiences with the treatment and criminal justice systems. Instead, councils are saturated with treatment providers and health care organizations.

And this, too, raises eyebrows.

“Service providers are going to have a monetary interest,” said Tracie M. Gardner, who leads policy advocacy at the New York-based Legal Action Center. Although most are good people running good treatment programs, they have an inherent conflict with the goal of making people well and stable, she said.

“That is work to put treatment programs out of business,” Gardner said. “We must never forget the business model. It was there for HIV, it was there for covid, and it’s there for the overdose epidemic.”

Councils in South Carolina and New York have already seen some controversy in this vein — when organizations associated with members pursued or were awarded funding. It’s not a particularly surprising occurrence, since the members are chosen for their prominent work in the field.

Both states’ councils have robust conflict-of-interest policies, requiring members to disclose professional and financial connections. New York also has a law precluding council members from using their position for financial gain, and South Carolina uses a rubric to objectively score applications.

That these situations cause alarm regardless shows how much hope and desperation is tied up in this money — and the decisions over who controls it.

“This is the biggest infusion of funding into the addiction treatment field in at least 50 years,” said Gardner. “It’s money coming into a starved system.”

Database Methodology

The list of council members’ names used to build the database was compiled by Johns Hopkins University’s Sara Whaley and Henry Larweh and Shatterproof’s Kristen Pendergrass and Eesha Kulkarni. All council members, even those without voting power, were listed.

Although many states have councils to address the opioid crisis generally, the database focused specifically on councils overseeing the opioid settlement funds. A council’s scope of power was classified as “decision-making” if it directly controls allocations. “Advisory” means the council provides recommendations to another body, which makes final funding decisions.

The data is current as of June 9, 2023.

KFF Health News’ Aneri Pattani, Colleen DeGuzman, and Megan Kalata analyzed the data to determine which categories council members represent, based on the following rules:

— Each council member can be counted in only one category. There is no duplication.

— People should be given the most descriptive categorization possible. For example, attorneys general are “elected officials,” but it is more specific to say they are “law enforcement and criminal justice” officials.

— A “government representative” is typically a government employee who is not elected and does not fit into any other descriptive category — for example, a non-elected county manager.

— People who provide direct services to patients or clients, such as physicians, nurses, therapists, and social workers, are classified as “medical and social service providers.” People with more administrative roles are typically classified as “public” or “private health and human services,” based on their organization’s public or private affiliation.

— “Lived or shared experience” refers to someone who has personally experienced a substance use disorder, has a family member with one, or has lost a loved one to the disease. Because people’s addiction experiences are not always public, only individuals explicitly appointed because of their firsthand connection or to fill a seat reserved for someone with that experience were categorized as such.

KFF Health News’ Colleen DeGuzman and Megan Kalata contributed to this report.

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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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Hasta ahora.

Después de más de un mes de comunicaciones con fiscales generales estatales, abogados privados que trabajan en el acuerdo y los administradores del acuerdo, KFF Health News ha obtenido documentos que muestran las cantidades exactas en dólares que se asignaron a los gobiernos locales para 2022 y 2023. Más de 200 hojas de cálculo detallan las cantidades pagadas por cuatro de las empresas implicadas en los acuerdos nacionales. (Otras empresas relacionadas con los opioides comenzarán a hacer pagos a finales de este año).

Por ejemplo, el condado de Jefferson, Kentucky —donde se encuentra Louisville— recibió $860,657.73 de tres distribuidores farmacéuticos este año, mientras que el condado de Knox, un condado rural de Kentucky en los Apalaches —la región que muchos consideran la zona cero de la crisis— recibió $45,395.33.

En California, el condado de Los Angeles recibió este año $6,3 millones de Janssen, la filial farmacéutica de Johnson & Johnson. El condado de Mendocino, que tiene una de las tasas de mortalidad por sobredosis de opioides más altas del estado, recibió unos $185,000.

El acceso a “esta información es revolucionario para las personas que se preocupan por cómo se utilizará este dinero”, dijo Dennis Cauchon, presidente de la organización sin fines de lucro Harm Reduction Ohio.

Algunos estados, como Carolina del Norte y  Colorado, han publicado en internet los detalles de su distribución. Pero en la mayoría de los lugares, el seguimiento de los importes de los pagos exige llamar por teléfono, enviar correos electrónicos y presentar solicitudes de registros públicos a todas las administraciones locales de las que se desee obtener información.

Por lo tanto, recopilar los datos de un estado puede suponer ponerse en contacto con cientos de instituciones. En todo el país, podrían ser miles.

Cauchon lleva buscando esta información para su estado desde abril de 2022. “El trabajo de compensación por los opioides se realiza a nivel local, a nivel individual, y ahora por primera vez, quienes trabajan a nivel local sabrán cuánto dinero está disponible en su comunidad”.

Los acuerdos nacionales sobre opioides son el segundo mayor acuerdo de salud pública de todos los tiempos, tras el acuerdo marco sobre el tabaco de la década de 1990. El dinero se destina a remediar el modo agresivo en que las empresas promocionaron los analgésicos opioides, alimentando una crisis de sobredosis que ahora se ha trasladado en gran medida a las drogas ilícitas, como el fentanilo. El año pasado murieron más de 105,000 estadounidenses por sobredosis.

Hasta ahora, los gobiernos estatales y locales han recibido más de $3,000 millones en conjunto, según un documento de resumen nacional creado por BrownGreer, una empresa de administración de acuerdos y gestión de litigios designada por la corte para gestionar la distribución de los pagos. En cada estado, los fondos del acuerdo se dividen en porcentajes variables entre las agencias estatales, los gobiernos locales y, en algunos casos, los consejos que supervisan los fondos de reducción de opioides. Los pagos comenzaron en 2022 y continuarán hasta 2038, estableciendo lo que los expertos en salud pública y los activistas denominan una oportunidad sin precedentes para avanzar contra una epidemia que ha asolado a Estados Unidos durante tres décadas. KFF Health News sigue de cerca el uso —y el mal uso— que los gobiernos hacen de este dinero en una investigación de un año de duración.

Los últimos documentos se han obtenido de BrownGreer. La empresa es una de las pocas entidades que sabe exactamente cuánto dinero recibe cada gobierno estatal y local y cuándo lo recibe, ya que supervisa cálculos complejos que implican los distintos términos y plazos de los acuerdos de cada empresa.

Aun así, hay lagunas en la información que ha compartido. Algunos estados optaron por no recibir sus pagos a través de BrownGreer. Algunos pidieron a la empresa que pagara una suma global al estado, que luego la distribuiría entre los gobiernos locales. En esos casos, BrownGreer no disponía de cifras sobre las asignaciones locales. Tampoco figuran en los datos de BrownGreer algunos estados que llegaron a acuerdos con empresas relacionadas con los opioides al margen de los acuerdos nacionales.

Roma Petkauskas, de BrownGreer, señaló que el acuerdo de conciliación exige que el bufete de abogados envíe notificaciones de los importes de los pagos a los gobiernos estatales y locales, así como a las empresas que llegaron a un acuerdo. El bufete compartió los documentos cuando KFF Health News se lo pidió, pero no está claro si seguirá haciéndolo.

Petkauskas escribió: “Los acuerdos de conciliación no prevén que tales notificaciones se hagan públicas”, indicando que tal divulgación no era un requisito.

Las personas perjudicadas por la crisis de los opioides reclaman más transparencia que la que ofrecen los requisitos mínimos. Dicen que, actualmente, no sólo es difícil determinar cuánto dinero reciben los gobiernos, sino también cómo se gastan esos dólares. Muchos se han puesto en contacto con funcionarios locales con preguntas o sugerencias, sólo para ser rechazadas o ignoradas.

Christine Minhee, fundadora de OpioidSettlementTracker.com, descubrió que, en marzo, sólo 12 estados se habían comprometido a informar públicamente sobre el uso del 100% del dinero de sus acuerdos. Desde entonces, sólo tres estados más han prometido compartir información detallada sobre el uso que hacen del dinero.

Los expertos jurídicos y políticos que observan los acuerdos dicen que la falta de transparencia puede tener que ver con la influencia política. En sus elogiosos comunicados de prensa, los fiscales generales de los estados se han jactado de los logros de estos acuerdos.

“El fiscal general [Daniel] Cameron ha cumplido hoy su promesa de luchar contra la epidemia de opioides anunciando un acuerdo de más de $53 millones con Walmart”, decía un comunicado de prensa emitido a finales del año pasado por el estado de Kentucky.

“Miles de nuestros vecinos han enterrado a sus seres queridos a lo largo de la epidemia de opioides” y “estoy orgulloso de haberles entregado este gran acuerdo”, declaró el fiscal general de Louisiana, Jeff Landry, en un anuncio de julio de 2021, cuando se cerró uno de los primeros acuerdos.

Una mayor transparencia, incluidos los importes de pago específicos para cada gobierno local, puede restar fuerza a algunos de esos comunicados de prensa, dijo Minhee. “Es difícil politizar las cosas cuando no puedes presentar las cifras en el vacío”.

Si una comunidad compara su reparto de varios cientos de dólares con el reparto de varios miles de dólares de otra comunidad, puede haber consecuencias políticas. En las zonas rurales más afectadas por la crisis ya ha surgido la preocupación de que la fórmula de reparto tenga demasiado en cuenta el número de habitantes y no reciban dinero suficiente para hacer frente a los daños sufridos durante décadas.

Aun así, los expertos afirman que hacer públicos estos datos es un paso crucial para garantizar que los acuerdos cumplan el objetivo de salvar vidas y remediar esta crisis.

Las soluciones tienen que estar lideradas por la comunidad, afirmó Regina LaBelle, directora de la iniciativa sobre adicción y política pública del Instituto O’Neill de la Universidad de Georgetown. “Para ello, las propias comunidades tienen que saber cuánto dinero reciben”.

Si su condado recibe $5,000 este año, no tendría sentido abogar por un centro de desintoxicación de $500,000. En su lugar, podrían centrarse en la compra de naloxona, un medicamento que revierte las sobredosis de opioides. Conocer el importe anual también permite hacer un seguimiento de los fondos y asegurarse de que no se malgastan, añadió LaBelle.

Para Cauchon, de Harm Reduction Ohio, los datos de los pagos a nivel local son fundamentales para garantizar que el dinero de los acuerdos se destina a un buen uso en cada condado de Ohio.

“El conocimiento es poder y, en este caso, es el poder de saber cuánto dinero está disponible para ser utilizado en la prevención de sobredosis”, señaló.

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"Distributors" refers to the pharmaceutical distributors AmerisourceBergen, Cardinal Health, and McKesson, which settled jointly with states. Distributors made their first payment in 2021. It was held in escrow and delivered to states in 2022. The distributors' second payment was made in 2022 as well. The distributors' third payment was made in 2023.

Janssen is the pharmaceutical subsidiary of Johnson & Johnson. Janssen made its first payment in 2022. Some states chose to accelerate their payouts and received a larger amount that first year, taken out of their allotments for future years. Janssen made its second payment in 2023.

Documents for some states are not available because those states were not part of national settlement agreements, had unique settlement terms, or opted not to have their payments distributed via BrownGreer. In some cases, BrownGreer combined the payments for multiple years into one document.

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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Until now.

After more than a month of communications with state attorneys general, private lawyers working on the settlement, and the settlement administrators, KFF Health News has obtained documents showing the exact dollar amounts — down to the cent — that local governments were allocated for 2022 and 2023. More than 200 spreadsheets detail the amounts paid by four of the companies involved in national settlements. (Several other opioid-related companies will start making payments later this year.)

For example, Jefferson County, Kentucky — home to Louisville — received $860,657.73 from three pharmaceutical distributors this year, while Knox County, a rural Kentucky county in Appalachia — the region many consider ground zero of the crisis — received $45,395.33.

In California, Los Angeles County was allocated $6.3 million from Janssen, the pharmaceutical subsidiary of Johnson & Johnson, this year. Mendocino County, which has one of the highest opioid overdose death rates in the state, was allocated about $185,000.

Access to “this information is revolutionary for people who care about how this money will be used,” said Dennis Cauchon, president of the nonprofit advocacy group Harm Reduction Ohio.

Some states, like North Carolina and Colorado, have posted their distribution specifics online. But in most other places, tracking payment amounts requires people to make phone calls, send emails, and file public records requests with every local government for which they want the information.

Thus, gathering the data across one state could mean contacting hundreds of places. For the country, that could translate to thousands.

Cauchon has been seeking this information for his state since April 2022. “Opioid remediation work is done at the local level, at the individual level, and, now, for the first time, local people working on the issues will know how much money is available in their community.”

The national opioid settlements are the second-largest public health settlement of all time, following the tobacco master settlement of the 1990s. The money is meant as remediation for the way corporations aggressively promoted opioid painkillers, fueling an overdose crisis that has now largely transitioned to illicit drugs, like fentanyl. More than 105,000 Americans died of drug overdoses last year.

So far, state and local governments have received more than $3 billion combined, according to a national summary document created by BrownGreer, a settlement administration and litigation management firm that was court-appointed to handle the distribution of payments. In each state, settlement funds are divided in varying percentages among state agencies, local governments, and, in some cases, councils that oversee opioid abatement trusts. Payments began in 2022 and will continue through 2038, setting up what public health experts and advocates are calling an unprecedented opportunity to make progress against an epidemic that has ravaged America for three decades. KFF Health News is tracking how governments use — and misuse — this cash in a yearlong investigation.

The latest trove of documents was obtained from BrownGreer. The firm is one of the few entities that knows exactly how much money each state and local government receives and when, since it oversees complex calculations involving the varying terms and timelines of each company’s settlement.

Even so, there are gaps in the information it shared. A handful of states opted not to receive their payments via BrownGreer. Some directed the firm to pay a lump sum to the state, which would then distribute it to local governments. In those cases, BrownGreer did not have figures for local allocations. A few states that settled with the opioid-related companies separately from the national deals are not part of BrownGreer’s data, either.

Roma Petkauskas, a partner at BrownGreer, said the settlement agreement requires the firm to send notices of payment amounts to state and local governments, as well as to the companies that settled. It shared documents when KFF Health News asked, but it is not clear if the firm will continue doing so.

Petkauskas wrote, “Settlement Agreements do not provide that such notices be made public,” indicating such disclosure was not a requirement.

People harmed by the opioid crisis say they want more transparency than the bare minimum requirements. They say, currently, it’s not only difficult to determine how much money governments receive, but also how those dollars are spent. Many people have reached out to local officials with questions or suggestions only to be turned away or ignored.

Christine Minhee, founder of OpioidSettlementTracker.com, found that, as of March, only 12 states had committed to publicly reporting the use of 100% of their settlement dollars. Since then, just three more states have promised to share detailed information on their use of the money.

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Legal and political experts watching the settlements say the lack of transparency may have to do with political leverage. State attorneys general have touted these deals as achievements in glowing press releases.

“Attorney General [Daniel] Cameron today delivered on his promise to fight back against the opioid epidemic by announcing a more than $53 million agreement with Walmart,” read one press release issued late last year by the state of Kentucky.

“Thousands of our neighbors have buried their loved ones throughout the opioid epidemic” and “I am proud to have delivered this great agreement to them,” said Louisiana Attorney General Jeff Landry, in a July 2021 announcement when one of the earliest settlements was finalized.

Greater transparency, including the specific payment amounts for each local government, may take the wind out of some of those press releases, Minhee said. “It’s hard to politicize things when you can’t present the numbers in a vacuum.”

If one community compares its several-hundred-dollar payout to another community’s multi-thousand-dollar payout, there may be political fallout. Concerns have already arisen in rural areas hit hard by the crisis that the distribution formula weighs population numbers too heavily, and they will not receive enough money to address decades of harm.

Still, experts say making this data public is a crucial step in ensuring the settlements fulfill the goal of saving lives and remediating this crisis.

Solutions have to be community-led, said Regina LaBelle, director of the addiction and public policy initiative at Georgetown University’s O’Neill Institute. “In order to do that, the communities themselves need to know how much money they’re getting.”

If their county is receiving $5,000 this year, it wouldn’t make sense to advocate for a $500,000 detox facility. Instead, they might focus on purchasing naloxone, a medication that reverses opioid overdoses. Knowing the yearly amount also allows people to track the funds and ensure they’re not being misspent, LaBelle added.

For Cauchon, of Harm Reduction Ohio, the local-level payment data is key to ensuring settlement dollars are put to good use in each Ohio county.

“Knowledge is power and, in this case, it’s the power to know how much money is available to be used to prevent overdoses,” he said.

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They have put $2.4 million toward paying off the county’s debt and have directed another $1 million arriving over more than a decade into a capital projects fund. In March, they appropriated $50,000 from that fund to buy a “litter crew vehicle” — a pickup truck to drive inmates to collect trash along county roads.

“It’s astounding,” said Nancy Schneck, a retired nurse who has seen addiction infiltrate the community, where employers avoid drug testing for fear of losing too many employees and mental health crises and homelessness are rampant. She wants to see the money go toward mental health and addiction treatment. Why can’t county leaders “see treating some people and maybe getting them out of this cycle might be advantageous?” she said.

In 2021, the latest year for which comparable data is available, Greene County’s rate of drug overdose deaths topped state and national figures.

But Mayor Kevin Morrison said the county has borne the costs of the opioid epidemic for years: It has funded a beleaguered sheriff’s office, improved the jail — which is packed with people who’ve committed addiction-related crimes — and supported a drug court to divert some people to treatment. It has also suffered indirect costs of the crisis: people dropping out of the workforce due to addiction, schools and welfare services caring for more children who’ve experienced trauma, and some taxpayers leaving the county altogether. Addiction is not the sole reason for Greene County’s economic woes, but it has contributed to more than $30 million of debt.

“We’ve been dealing with this crisis for quite some time, but nobody wants to pay the bill as it comes,” Morrison said. “So when these funds are made available, then we are paying bills that have been due for quite some time.”

The debate in this Appalachian county is reverberating nationwide as state and local governments receive billions of dollars from companies that made, distributed, or sold opioid painkillers, like Johnson & Johnson, Cardinal Health, and CVS. The companies were accused of fueling the overdose epidemic, and the money is meant to remediate that harm. About $3 billion has already landed in state, county, and city coffers, and about $50 billion more is expected in the coming decade and beyond.

States are required to spend at least 85% of the money on opioid-related programs, but KFF Health News’ ongoing investigation into how the cash is used — and misused — shows there is wide interpretation of that standard and little oversight.

That restriction didn’t apply to the money Greene County moved to its capital projects fund.

In many rural communities, which have been struggling to pay addiction-related costs for decades, local officials justify using the settlement funds to reimburse past expenses. Most of Tennessee’s 95 counties are in significant debt, which can present difficult choices about how to use this money, said Robert Pack, co-director of East Tennessee State University’s Addiction Science Center.

Still, he and many advocates hope the settlement funds are spent on tackling the current crisis. After all, more than 200 people nationwide are dying of overdoses each day. Investing in treatment and prevention can save lives and protect future generations, they say.

“There is no good excuse to sit on the funds or put them into a general fund,” said Tricia Christensen, policy director for the nonprofit Community Education Group. The organization is tracking settlement spending across Appalachia, which Christensen called the epidemic’s ground zero. “These dollars should be used to support people who have been most impacted by the overdose crisis.”

Nationally, there has been little oversight of the settlement dollars. President Joe Biden’s administration pledged to ensure the funds went toward tackling the addiction crisis, but has taken little action. Accountability at the state level varies.

In Tennessee, 15% of the state’s opioid settlement funds are controlled by the legislature and another 15% by local governments. Those two buckets have few restrictions.

The other 70% is controlled by an Opioid Abatement Council, which has more rigorous standards. When the council, which must give 35% of its funds to local governments, recently distributed more than $31 million to counties, it required the funds be spent on a list of approved interventions, such as building recovery housing and increasing addiction treatment for uninsured people.

“I can guarantee we’re going to bird-dog” those funds, said Stephen Loyd, chair of the council and a physician in recovery from opioid addiction. If counties use them for unapproved purposes, the counties will not receive future payouts, he said.

Greene County’s reimbursement of its capital projects fund comes from its own pot — the 15% that is controlled entirely by local governments.

In such cases, the public can hold officials accountable, Loyd said. “If you don’t like the way the money is being spent, you have the ability to vote.”

Local leaders are generally not being “nefarious” with these decisions, he said. They make hundreds of budgetary choices a month and simply don’t have experience with addiction or health policy to guide them in using the money.

Loyd and other local experts are trying to fill that gap. He meets with county officials and recommends they speak with their local anti-drug coalitions or hold listening sessions to hear from community members. Pack, from East Tennessee State, urges them to increase access to medications that have proven effective in treating opioid addiction.

Both men point counties to an online recovery ecosystem index, where leaders can see how their area’s resources for recovery compare with those of others.

In Greene County, for example, the index indicates there are no recovery residences and the number of treatment facilities and mental health providers per 100,000 residents is below state and national averages.

“That’s a great place to get started,” Loyd said.

Some Greene County residents want to see opioid settlement funds go to local initiatives that are already operating on the ground. The Greene County Anti-Drug Coalition, for instance, hosts presentations to educate young people and their parents on the risks of drug use. They meet with convenience store owners to reinforce the importance of not selling alcohol, cigarettes, or vaping devices to minors. In the future, the coalition hopes to offer classes on life skills, such as how to budget and make decisions under pressure.

“If we can do prevention work with kids, we can change the trajectory of their lives as adults,” said Wendy Peay, secretary of the anti-drug coalition and executive director of United Way of Greene County.

The coalition has asked the county for settlement funds but has not received any yet.

Nearby in Carter County, a new residential treatment facility is taking shape at the site of a former prison. At least seven counties, cities, and towns in the region have committed a combined $10 million in opioid settlement funds to support it, said Stacy Street, a criminal court judge who came up with the idea. Greene County is among the few local governments that did not contribute.

It will be part of the region’s drug recovery court system, in which people with addiction who have committed crimes are diverted to intensive treatment instead of prison.

Currently there are no long-term residential facilities in the area for such patients, Street said. Too often, people in his court receive treatment during the day but return home at night to “the same sandbox, playing with the same sand-mates,” increasing their risk of relapse.

Street said the new facility will not offer medications to treat opioid addiction — the gold standard of medical care — because of security concerns. But some patients may be taken to receive them off campus.

Morrison, the Greene County mayor, said he worried about contributing to the facility because it is a recurring cost and the settlement funds will stop flowing in 2038.

“There’s been great pressure put on local entities like Greene County to try to solve this problem with this limited amount of funding,” he said, when “the federal government, which has the ability to print money to solve these problems, is not in this business.”

The county is still deciding how to spend nearly $334,000 of settlement funds it recently received from the state’s Opioid Abatement Council. Morrison said they’re considering using it for the anti-drug coalition’s education efforts and the county drug court. Given the guidelines from the abatement council, these funds can’t be used to pay old debts.

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During the 2020 campaign, Biden had laid out a plan to appoint an “opioid crisis accountability coordinator” to support states in their lawsuits against companies accused of sparking the overdose epidemic. The following year, the White House convened a meeting about the soon-to-be finalized settlements, noted that the money could support drug policy priorities, and helped create a model law that states could adopt in anticipation of receiving funds.

But today, as billions of dollars actually start to flow and state and local leaders make crucial decisions on how to spend the more than $50 billion windfall to tackle this entrenched public health crisis, the federal government has gone mostly quiet.

No federal employee holds the title of opioid crisis accountability coordinator. The Office of National Drug Control Policy has not released public statements about the settlements in over a year. And the settlement funds are mentioned just twice in a 150-page national strategy to reduce drug trafficking and overdose deaths.

The federal government is not legally obligated to engage in the discussion. After all, states filed the lawsuits against companies that made, sold, or distributed opioid painkillers, including Johnson & Johnson, McKesson, and Walmart.

But there is an expectation that the federal government, including the nation’s leading agencies on mental health and addiction, should play a role. Public policy and health experts say a vacuum of federal leadership could lead to serious wasted opportunities and missteps in the use of the billions that will be paid out over nearly two decades — in what could be an unfortunate reprise of the multibillion-dollar 1998 settlement with tobacco companies.

“States get wide eyes when they get these huge pots of money,” said Bill Pierce, who served as spokesperson for the Department of Health and Human Services in the early 2000s. He was there when states began receiving cash from the tobacco settlement. Soon enough, money “starts to seep out to other areas that could be completely unrelated,” he said.

Back then, tobacco companies agreed to pay states billions annually for as long as they continued selling cigarettes. But there were no restrictions on the money’s use and much of it went to plugging state budget gaps, filling potholes, and even subsidizing tobacco farmers. Today, less than 3% of the annual payouts support anti-smoking programs.

Protecting the Opioid Cash

The opioid settlements have a built-in protection to address this concern. At least 85% of the money states receive must be spent on opioid-related expenses. But interpretations of qualifying expenses vary widely — often based on state politics. And oversight so far has been weak. The companies paying out the money are responsible for holding states to that threshold, but they’re unlikely to monitor closely, legal experts say.

Public vigilance could help, but most states have promised little to no public reporting, making it difficult to track their use of funds. KFF Health News is following how state and local governments use — or misuse — the cash through this year.

Some people hope the federal government can fill this gap in oversight.

“There are opportunities to incentivize” and support state and local governments “in the right direction,” said Michele Gilbert, a senior policy analyst with the think tank Bipartisan Policy Center. The Biden administration can issue official guidance, promote the findings of national research, or leverage the power of its purse strings. But so far, “there hasn’t been a lot of federal government action on the settlement.”

The Office of National Drug Control Policy told KFF Health News it regularly discusses the use of settlement dollars with governors, mayors, and other elected officials to ensure the money bolsters federal efforts already underway. Beating the opioid epidemic by disrupting drug trafficking and expanding access to treatment is one of the four pillars of Biden’s “unity agenda.”

“We know that expanding access to treatment for substance use disorder, lifesaving interventions like naloxone, and recovery support services will reduce the harms of addiction and the overdose epidemic,” said Rahul Gupta, director of national drug control policy.

That’s why the administration helped create a model law, as “a blueprint for states and communities on evidence-based ways to use opioid settlement funds,” he said. It’s been adopted, at least in part, by 11 state legislatures and is being considered by two others.

Lessons in Lax Oversight

But history suggests optional federal guidance may not be enough to ensure the money is used for its intended purpose.

Matthew Myers, president of the nonprofit Campaign for Tobacco-Free Kids, said it was a mistake for the federal government to take a back seat on the tobacco master settlement more than two decades ago.

Those lawsuits aimed, in part, to recover health care costs for smoking-related illnesses. Medicaid, a public insurance program for people with low incomes or disabilities, was a leading payer. Since Medicaid is jointly funded by the U.S. and state governments, federal authorities had a right to some of the settlement money.

States lobbied Congress to forgo that claim. Myers and other advocates asked legislators to do so only if they required states to spend at least 25% of the funds on anti-smoking efforts.

But Congress waived its right to the money unconditionally.

“It was a significant missed opportunity,” Myers said, “because it meant the federal government ended up having no say whatsoever in how the dollars were used.”

When it comes to the opioid settlements, it’s not clear if the federal government will try to claim repayment for Medicaid expenses linked to opioid addiction, which was estimated at $23 billion in 2019. Bruce Alexander, spokesperson for the Centers for Medicare & Medicaid Services, declined to answer specific questions and simply wrote, “CMS is currently reviewing the issue.”

The agency has tried to recoup costs in at least one case.

In 2019, CMS sent a letter to Oklahoma asking for part of the state’s $270 million settlement with Purdue Pharma, maker of OxyContin. According to Phil Bacharach, spokesperson for the Oklahoma attorney general’s office, the state eventually reached an agreement to keep all its Purdue settlement but later pay $390,000 to the federal agency from a separate settlement with opioid manufacturer Endo.

Some states, like Arkansas and Oregon, have planned for similar possibilities in their public documents about the opioid settlements. But as of mid-March, neither state had received federal requests for their share.

A Carrot-and-Stick Approach

Health policy experts suggest the Biden administration could use the possibility of claiming those funds as leverage: In return for allowing states to keep the cash, it could require all of it be spent on addressing the opioid crisis or be used only for treatments backed by research.

Alternatively, it could attach conditions to the more than $6 billion in federal grants that is funneled to states each year to address addiction.

“The federal government is spending a lot of money on opioids,” said Pierce, the former HHS spokesperson. “If they want, they could try and tie that money to requirements that settlement money be spent on opioids.”

In the 1970s, the Nixon administration used a similar tactic, with federal transportation funding as the carrot. Given the energy crisis at the time, the administration wanted states to reduce oil consumption by imposing a maximum speed limit of 55 mph. But it couldn’t mandate states to do so. Instead, Nixon signed a law saying states could receive federal highway funding only if they lowered speed limits. In the end, all states complied.

Myers, of the Campaign for Tobacco-Free Kids, put it this way: “States will only listen to the federal government if there’s a financial reason to do so.”

The federal government also can suggest the settlements be used to augment, not duplicate, existing federal funding, said Gilbert, of the Bipartisan Policy Center.

For instance, the money could support grassroots organizations that don’t have the time or ability to apply for federal grants, she said. Or it could go to groups that provide sterile syringes and other supplies to people using drugs, which can’t be purchased with taxpayer dollars.

The federal government can emphasize the more flexible options for spending the settlement money compared with federal funds, Gilbert said.

The Biden administration has been the first to embrace grassroots programs and has called for sustainable funding for “harm reduction services” in its national overdose prevention strategy. But it has stopped short of explicitly recommending settlement funds for this purpose.

Such initiatives are designed to minimize the risks of using drugs but are politically fraught, with critics saying they encourage illegal activity and supporters saying they save lives. Local opposition often takes the form of “not-in-my-backyard” or questions about why certain neighborhoods bear the brunt of addiction and homelessness concerns.

In such turf disputes, the lack of federal leadership is acutely felt, say some advocates.

For example, in New York, Democratic Gov. Kathy Hochul rejected a recommendation to use opioid settlement funds to support two overdose prevention centers — places where people can use illicit drugs under supervision. She cited “various state and federal laws” that make such sites illegal. A similar conversation is taking place in San Francisco, with the mayor citing a lack of federal legal clarity on the issue.

Federal authorities haven’t acted to shut down any sites so far but haven’t publicly supported them either. The Office of National Drug Control Policy declined to comment, given ongoing litigation in a related case in Philadelphia.

Some people question whether the Biden administration’s weighing in would have much impact, given the deep political divisions in some states where local officials are eager to flout federal guidance. Earlier this year, Republican leaders in Tennessee rejected millions of dollars in federal funding for HIV prevention to push back on federal support for transgender and abortion rights.

But Regina LaBelle, who was acting director of national drug control policy during Biden’s early years and now works for Georgetown University’s O’Neill Institute, said the federal government has managed to guide state policy on controversial topics before.

In 2015, shortly after intravenous drug use sparked a major HIV outbreak in Scott County, Indiana, the Centers for Disease Control and Prevention published a study showing other counties were similarly vulnerable. Kentucky, identified as a hot spot, went on to implement policies that dramatically increased the number of syringe service programs, which are known to reduce HIV transmission.

Today, the Biden administration could provide data to similarly inform local decisions, LaBelle said. A national dashboard launched late last year to show nonfatal overdoses is a start. And there is time to build on that, since the opioid settlements will be stretched out over many years, she added.

“We have an opportunity to see what’s the appropriate role of the federal government,” LaBelle said. “It’s not too late.”

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Es una cantidad enorme de dinero: el doble del presupuesto de la NASA y cinco veces los ingresos de una temporada de la NBA.

Pero la forma en que se repartirá esa cantidad y cómo se gastará el dinero en el futuro parece estar rodeada de misterio. Los requisitos de información son escasos y los documentos presentados hasta ahora son, a menudo, tan vagos que resultan inútiles.

La mayoría de los acuerdos estipulan que los estados deben gastar al menos el 85% del dinero que recibirán, en los próximos 15 años, en el tratamiento y la prevención de adicciones. Pero la definición de estos conceptos depende de las opiniones de las partes interesadas y de la política estatal. Para algunos, puede significar abrir más centros de tratamiento. Para otros, comprar autos patrulla para la policía.

Los afectados por la epidemia de opioides y quienes trabajan para combatirla tienen ideas muy diversas. Para Marianne Sinisi, que perdió a su hijo Shawn, de 26 años, por sobredosis en el oeste de Pennsylvania, los fondos del acuerdo son “dinero manchado de sangre” que podría evitar a otros padres sufrir un dolor similar. Para Steve Alsum, que trabaja con consumidores de drogas en Grand Rapids, Michigan, es una oportunidad de llegar por fin a todos los necesitados. Y para David Garbark, que se recupera de una adicción a los opioides, es una forma de darles una segunda oportunidad a otras personas de su comunidad del este de Carolina del Norte.

Gastar el dinero de forma eficaz y equitativa es complicado, dada la persistencia y complejidad de la adicción, que afecta a individuos y comunidades y es objeto de acalorados debates en la investigación científica, los servicios sociales, la política, la justicia penal e incluso en los hogares.

Es más, muchos estados no son transparentes sobre el destino de los fondos ni sobre quién se beneficiará de ellos. Una investigación realizada por KHN y Christine Minhee, fundadora de OpioidSettlementTracker.com, concluyó que sólo 12 estados se han comprometido a informar públicamente y con detalle de todos sus gastos.

El análisis consistió en examinar cientos de documentos legales, leyes y declaraciones públicas para determinar cómo reparte cada estado el dinero de los acuerdos entre las agencias estatales, los gobiernos de ciudades y condados, y los consejos que supervisan los fideicomisos (trusts) dedicados al tema. El siguiente paso fue determinar el nivel y el detalle de los informes públicos requeridos. El resultado: Pocos estados prometen informar de forma accesible para el ciudadano, y muchos guardan silencio sobre la cuestión de la transparencia.

Hasta ahora se han entregado más de $3,000 millones a los gobiernos estatales y locales. KHN seguirá de cerca cómo se utiliza ese dinero y los miles de millones que llegarán en los próximos años.

Según la mayoría de los acuerdos, los gobiernos sólo están obligados a informar sobre el 15% del dinero que puede utilizarse para asuntos no relacionados con la epidemia, como compensar déficits presupuestarios o arreglar carreteras viejas. Hasta el 28 de marzo, sólo tres estados y condados habían presentado dichos informes. Aunque indicaban las cantidades en dólares, ninguno precisaba cómo se había gastado el dinero.

Tanto gobiernos estatales como locales pueden promulgar protocolos de información más rigurosos —por ejemplo, exigir una lista pública de todos los lugares que reciben dinero y con qué fin—, pero pocos lo han hecho hasta ahora.

A oscuras, desinformados

Más de 250,000 estadounidenses han muerto por sobredosis de opioides con receta, promocionados agresivamente como analgésicos y distribuidos por una serie de empresas, como Johnson & Johnson, AmerisourceBergen, McKesson y Walmart. Los acuerdos pretenden compensar y remediar los efectos de ese comportamiento empresarial.

Pero muchas personas a las que se les ha destrozado la vida, vuelven a sentirse traumatizadas.

Sinisi dijo que a ella y a otros padres que han perdido a sus hijos a causa de la adicción se les ha dejado en la oscuridad, desinformados o, peor aún, tratados como una molestia por los funcionarios responsables del dinero.

“Te ven como un padre enfadado que ha perdido a su hijo”, afirmó, “en lugar de como un ciudadano preocupado que quiere que las cosas cambien para otras madres, padres y sus hijos”.

En Michigan, incluso la Opioid Advisory Commission (OAC) del estado, encargada de evaluar el uso del dinero de los acuerdos, ha tenido problemas para hacer un seguimiento del dinero.

Durante los seis meses posteriores a que la legislatura estatal asignara $39 millones de los fondos del acuerdo al departamento de salud, el verano pasado, se hizo pública muy poca información sobre cómo se gastaría ese dinero. No hubo comunicados de prensa. No hubo forma de que las organizaciones solicitaran fondos.

“No podemos identificar realmente el impacto de esos fondos si no sabemos cómo se están utilizando”, señaló la doctora Cara Poland, presidenta de la OAC y médico especialista en adicciones.

Con la escasa supervisión a nivel nacional, muchos temen que el dinero se destine a iniciativas que, según las investigaciones, son en su mayoría inútiles, pero que encajan con la tendencia política local, como detener a los consumidores de drogas, ampliar las cárceles y favorecer la recuperación basada únicamente en la abstinencia en lugar de la medicación. Es posible que se destinen al postor más ruidoso, como a empresas que prometen encontrar el próximo tratamiento innovador y a centros de rehabilitación —algunos de ellos con un historial deficiente— que aspiran al dinero.

Por no hablar de la preocupación de que el dinero vaya a parar a actividades que poco o nada tienen que ver con el tratamiento de los opioides: la construcción de nuevos estadios o escuelas públicas. En los años 90, estas prioridades presupuestarias domésticas consumieron la mayor parte de lo que los estados obtuvieron de las empresas tabaqueras en el acuerdo nacional sobre el tabaco, dejando poco para los programas antitabaco.

Los fondos del acuerdo sobre opioides serán diferentes, aseguraron los fiscales generales que lucharon por ellos. Además de exigir que al menos el 85% del dinero se utilice en gastos relacionados con los opioides, la mayoría de los acuerdos incluye una lista de intervenciones, como el aumento del tratamiento de la adicción para las personas sin seguro y la ampliación de las viviendas para la recuperación.

“Queríamos dar a los estados flexibilidad en cuanto a los enfoques que querían adoptar”, garantizando al mismo tiempo que el dinero no se destinara a “aliviar el impuesto de sociedades”, como ocurrió con el dinero del tabaco, explicó el fiscal general de Carolina del Norte, Josh Stein, que dirigió las negociaciones de los acuerdos nacionales.

Pero la aplicación de la norma del 85% se deja, curiosamente, en manos de las empresas que pagaron el dinero. Según expertos jurídicos, es poco probable que se mantengan vigilantes.

El dinero ya está comprometido y, para muchas de estas empresas multimillonarias, los acuerdos son calderilla, morralla, suelto (o cualquiera de las palabras con que cuenta el español para designar a una cantidad de dinero insignificante). Por ejemplo, Johnson & Johnson deberá pagar $5,000 millones en nueve años; pero la empresa registró ventas de casi $95,000 millones sólo el año pasado.

El nuevo panorama

A medida que empiezan a llegar los cheques, unos estados se comprometen con la transparencia, mientras que otros parecen quedarse cortos. Missouri ha prometido informar de todos sus gastos en internet para que cualquiera pueda ver quién recibe dinero, cuánto y para qué programas. New Hampshire ya ha publicado informes en línea, y Colorado ha creado un tablero de control público para saber cómo se utilizan los fondos.

Otros estados, como Nevada, han adoptado un enfoque intermedio, exigiendo que los beneficiarios informen al poder legislativo o a otro organismo de supervisión, pero sin garantizar que los informes se hagan públicos. Algunos estados exigen auditorías, pero no se comprometen a enumerar gastos específicos. Otros permiten que el público solicite los informes, pero no los facilitan automáticamente.

También hay estados muy afectados por la epidemia de opioides, como Michigan y Ohio, donde ya están surgiendo problemas de transparencia. Cada estado espera recibir al menos $1,000 millones.

Cuando Poland, de la OAC de Michigan, se dio cuenta de que recibía poca información sobre cómo se gastaban los fondos del estado, su comisión decidió utilizar su primer informe anual —publicado este mes— para exigir mejoras. “La presentación de informes oportunos y transparentes” al público es “una responsabilidad ética”, dijo, pidiéndoles a los legisladores una mayor supervisión de los beneficiarios y crear un panel público para realizar un seguimiento de los gastos.

KHN entrevistó a casi una docena de personas y presentó una solicitud de registros públicos para conocer cómo el departamento de salud del estado está gastando la asignación inicial de los fondos de liquidación de $39 millones.

Un documento presupuestario, obtenido por KHN, muestra que desde el 9 de enero, el Departamento de Salud y Servicios Humanos de Michigan había asignado $3,9 millones en fondos de liquidación a 35 beneficiarios. La mayoría son departamentos de salud locales o programas de servicios de jeringuillas que el departamento de salud del estado ha financiado previamente.

Otros $27 millones se destinan a intervenciones concretas, como el aumento de la mano de obra para el tratamiento de adicciones, la ampliación de las viviendas de recuperación y la mitigación de los daños del consumo de opioides con medicamentos como la naloxona.

Y, tras las preguntas de KHN, el departamento emitió un comunicado en el que enumeraba prioridades similares.

Esas iniciativas tienen sentido para Jonathan Stoltman, director del Opioid Policy Institute, con sede en Michigan, que investiga el estigma y la privacidad digital en el tratamiento de la adicción. Pero le habría gustado conocerlas de antemano y que se hubiera establecido un proceso claro para que los grupos pudieran solicitar los fondos. De lo contrario, organizaciones capacitadas para utilizar el dinero, para ayudar a los más necesitados, podrían perder una oportunidad única de ampliar su trabajo y salvar vidas.

El verano pasado, cuando Stoltman preguntó si podía solicitar los fondos, el departamento de salud le dijo que presentara una “propuesta de alto nivel” para “compartirla”, según los correos electrónicos revisados por KHN.

“Todo lo que sea entrar por la puerta de atrás me asusta”, dijo Stoltman. “Tuve suerte de encontrar con quién hablar, aunque no llegara a ninguna parte”.

Steve Alsum, director ejecutivo del Red Project de Grand Rapids, al que se concedieron unos $266,000 para mejorar la salud de las personas que consumen drogas, señaló que esperaba que el estado dispusiera de un proceso de solicitud con criterios de puntuación que explicaran por qué se elegía a determinados grupos. Pero, dijo, “no ha quedado claro quién toma la decisión y cómo se toma”.

Jared Welehodsky, que dirige los esfuerzos del departamento relacionados con el acuerdo, contó que pronto hará públicas varias solicitudes de subvenciones competitivas para la mayor parte del dinero. No se hizo antes porque la mayoría de los pagos no llegaron hasta finales de 2022 y “no queríamos hacer comentarios sobre cómo iba a salir el dinero cuando no teníamos dinero para repartir”, añadió.

Cómo mantener el público al margen

En Newark (Ohio), Linda Mossholder, de 75 años, lleva preguntando por los dólares del acuerdo en las reuniones del ayuntamiento desde el verano pasado. Como voluntaria de Newark Homeless Outreach, que sirve almuerzos gratuitos semanalmente, trabaja con muchas personas que consumen drogas y quiere que el dinero les ayude.

Mossholder viste con orgullo una camiseta en la que se lee: “Tu primer error es pensar que sólo soy una señora mayor”. Ha hecho un seguimiento con correos electrónicos, mensajes de voz y solicitudes de registros públicos; pero no ha obtenido una respuesta clara sobre cómo piensa utilizar la ciudad los casi $50,000 que ya ha recibido.

En enero, según Mossholder, el director de servicios públicos de la ciudad finalmente le dijo que el plan era asignar dinero a quienes intervienen con la naloxona. Pero cuando KHN presentó solicitudes de registros públicos para confirmarlo, el auditor de la ciudad Ryan Bubb escribió: “No se han asignado ni gastado fondos”.

Mientras tanto, en el noreste de Ohio, una junta regional que controlará millones de dólares del acuerdo se pasó una reunión, en febrero, debatiendo si se debe permitir al público acceder a las grabaciones de las reuniones.

“Yo no lo abriría al público, sinceramente”, dijo Judy Moran, miembro de la junta que representa a Eastlake, según una grabación de la reunión obtenida por KHN. Otros miembros preguntaron si sus reuniones estaban sujetas a las leyes de reuniones abiertas del estado.

Moran declaró posteriormente a KHN: “Por supuesto que el público tiene derecho a saber cómo se desembolsan estos fondos”, pero añadió que le preocupaba que las grabaciones permitieran que se interpretasen palabras “fuera de contexto”.

Al menos en Ohio, puede que eso no sea una opción durante mucho más tiempo.

Una demanda interpuesta por Harm Reduction Ohio para que se facilite el acceso al público a las reuniones de otra junta —la OneOhio Recovery Foundation, que supervisa la mayor parte de los $1,000 millones previstos por el estado— está abriéndose camino en los tribunales. Un juez local rechazó este mes la petición de la fundación de desestimar la demanda, escribiendo que “el público merece transparencia”.

Pero Connie Luck, portavoz de OneOhio, dijo que la fundación es una “organización privada sin fines de lucro, y no una agencia gubernamental”. Hasta ahora ha permitido la asistencia del público a las reuniones, pero ha dicho que no está obligada a hacerlo.

La sentencia final en este pleito, que es el primero de este tipo para los fondos de los acuerdos sobre opioides, sentará un precedente en los derechos del público a la información a nivel nacional.

En algunas partes del país, la perspectiva de contar con dinero para tratar una epidemia que lleva mucho tiempo sin financiación suficiente trae esperanza, aseguró Tricia Christensen, que trabaja en una organización sin fines de lucro que hace un seguimiento de los fondos en los Apalaches. Cuando la gente sabe lo que está ocurriendo, no sólo se disuade del uso indebido, sino que puede revelar éxitos sorprendentes, dijo.

Ese conocimiento da poder

“Estos fondos son como la llegada de la caballería. Por fin obtienes alivio después de sufrir en soledad durante tanto tiempo”, comentó Crystal Glass, del suroeste de Virginia, que se está recuperando del consumo de opioides y metanfetaminas, y que ahora trabaja como especialista en recuperación entre iguales.

Espera que los funcionarios impliquen en sus decisiones a las personas afectadas por la adicción.

Como ella dice: La transparencia “es dejar que todo el mundo —repito, todo el mundo— sepa que puede formar parte de esto”.

Colleen DEGuzman y Megan Kalata de KHN colaboraron con este informe.

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 an enormous amount of money — double NASA’s budget and five times the revenue of an NBA season.

But how that massive windfall is being deployed and how future dollars will be spent seem to be shrouded in mystery. Reporting requirements are scant, and documents filed so far are often so vague as to be useless.

Most of the settlements stipulate that states must spend at least 85% of the money they will receive over the next 15 years on addiction treatment and prevention. But defining those concepts depends on stakeholders’ views — and state politics. To some, it might mean opening more treatment sites. To others, buying police cruisers.

Those affected by the opioid epidemic and those working to fight it have an array of ideas: To Marianne Sinisi, who lost her 26-year-old son, Shawn, to overdose in western Pennsylvania, the settlement funds are “blood money” that she hopes can spare other parents similar grief. To Steve Alsum, who works with people who use drugs in Grand Rapids, Michigan, it’s a chance to finally reach all those in need. And to David Garbark, who is in recovery from opioid addiction, it’s a way to give others in his eastern North Carolina community a second chance, too.

Spending the money effectively and equitably is a tall order, given the persistence and complexity of addiction, which affects individuals and communities, and is the topic of heated debates in scientific research, social services, politics, criminal justice, and even at kitchen tables.

What’s more, many states are not being transparent about where the funds are going and who will benefit. An investigation by KHN and Christine Minhee, founder of OpioidSettlementTracker.com, concluded only 12 states have committed to detailed public reporting of all their spending.

The analysis involved scouring hundreds of legal documents, laws, and public statements to determine how each state is divvying up its settlement money among state agencies, city and county governments, and councils that oversee dedicated trusts. The next step was to determine the level and detail of public reporting required. The finding: Few states promise to report in ways that are accessible to the average person, and many are silent on the issue of transparency altogether.

More than $3 billion has gone out to state and local governments so far. KHN will be following how that cash — and the billions set to arrive in coming years — is used.

Per most of the settlements, governments are required to report only on the 15% of the money that can be used for things unrelated to the epidemic, like offsetting budget shortfalls or fixing old roads. As of March 28, only three states and counties had filed such reports. Although they listed dollar amounts, none said precisely how the money was spent.

State and local governments can enact more rigorous reporting protocols — for example, requiring a publicly available list of every place that receives money and for what purpose — but few have so far.

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Left in the Dark

More than 250,000 Americans have died of overdoses from prescription opioids, which were aggressively promoted as painkillers and distributed by a host of health care companies, including Johnson & Johnson, AmerisourceBergen, McKesson, and Walmart. The settlements are meant to compensate and remediate the effects of that corporate behavior.

But many people whose lives have been upended are again feeling traumatized.

Sinisi said she and other parents who’ve lost kids to addiction have been left in the dark or, worse, treated like nuisances by officials in charge of the money.

“They want to look at you as this angry parent who lost a child,” she said, “rather than a concerned citizen who wants to see a difference made for other mothers, fathers, and their children.”

In Michigan, even the state’s Opioid Advisory Commission, which is tasked with evaluating the use of settlement money, has struggled to track the cash.

For six months after the state legislature allotted $39 million of settlement funds to the health department last summer, little information was made public about how that money would be spent. No news releases. No way for organizations to apply for funds.

“We can’t really identify the impact of those dollars if we don’t know how they’re being used,” said Dr. Cara Poland, the commission’s chair and an addiction-medicine doctor.

With scant oversight nationwide, many people fear dollars may flow to efforts that research has proven mostly useless but jibe with the local political bent, like arresting people who use drugs, expanding jails, and favoring abstinence-only recovery over medications. They may go to the loudest bidder, with companies promising to find the next groundbreaking treatment and rehab facilities — some with shoddy track records — eyeing the cash.

Not to mention concerns that money will flow to activities that have little to nothing to do with opioid treatment: building new stadiums or public schools. Back in the ’90s, these day-to-day budget priorities consumed most of what states won from cigarette companies in the national tobacco settlement, leaving little for anti-smoking programs.

The opioid settlement funds will be different, say state attorneys general who fought for them. In addition to requiring at least 85% of the money be used on opioid-related expenses, most agreements include a list of suggested interventions like increasing addiction treatment for the uninsured and expanding recovery housing.

“We wanted to give states flexibility on what approaches they wanted to adopt,” while ensuring money didn’t go to “provide corporate tax relief” as the tobacco dollars did, said North Carolina Attorney General Josh Stein, who led negotiations for the national settlements.

But enforcement of the 85% standard is, oddly, left to the companies that paid out the money. They are unlikely to be vigilant, legal experts say. The money is committed already and, for many of these multibillion-dollar companies, the settlements are chump change. For example, Johnson & Johnson is set to pay $5 billion over nine years, but the company reported sales of nearly $95 billion in the past year alone.

An Emerging Picture

As the checks start to trickle in, a handful of states are committed to transparency while others seem to be falling short. Missouri has promised to report all its spending in online reports so that anyone can see who receives money, how much, and for what programs. New Hampshire already has posted reports online, and Colorado has created a public dashboard to track how funds are used.

Other states, like Nevada, have taken a middle-of-the-road approach, requiring that recipients report to the legislature or another oversight body, but not ensuring the reports will go public. Some states require audits but don’t promise to list specific expenses. And others allow the public to request records but won’t provide them automatically.

Then there are states hit hard by the opioid epidemic like Michigan and Ohio, where problems with transparency are already emerging. Each state is expecting to receive at least $1 billion.

When Poland, of Michigan’s Opioid Advisory Commission, realized she was getting little information on how the state’s funds were being spent, her commission decided to use its first annual report — published this month — to demand better. “Timely and transparent reporting” to the public is “an ethical responsibility,” it said, calling on lawmakers to enact greater oversight for settlement cash recipients and create a public dashboard to track spending.

KHN interviewed nearly a dozen people and filed a public records request to uncover how the state health department is spending the initial settlement funds allocation of $39 million.

A budget document obtained by KHN shows that as of Jan. 9, the Michigan Department of Health and Human Services had contracted $3.9 million in settlement funds to 35 grantees. Most are local health departments or syringe service programs that the state health department has previously funded.

An additional $27 million is set aside for particular interventions, such as growing the addiction treatment workforce, expanding recovery housing, and mitigating the harms of opioid use with medications like naloxone.

And, after KHN’s inquiries, the department released a statement that listed similar priorities.

Those initiatives make sense to Jonathan Stoltman, director of the Michigan-based Opioid Policy Institute, which researches stigma and digital privacy in addiction treatment. But he would have liked to have known about them in advance and to have had a clear process laid out for groups to apply for the funds. Otherwise, organizations that are well positioned to use the money to help those most in need may miss a once-in-a-lifetime chance to scale up their work and save lives.

Last summer, when Stoltman inquired about applying for the funds, the health department told him to submit a “high level proposal” to “share around,” according to emails reviewed by KHN.

“Anything that is backdoor scares me,” said Stoltman. “I got lucky that I found who to talk to, even if it didn’t go anywhere.”

Steve Alsum, executive director of the Grand Rapids Red Project, which was awarded about $266,000 to improve the health of people who use drugs, said he expected the state to have an application process with scoring criteria to explain why certain groups were chosen. But, he said, “it hasn’t been clear who is making the decision and how it’s made.”

Jared Welehodsky, who leads the department’s efforts related to the settlement, said it is in the process of releasing several competitive grant applications for the bulk of the money. That didn’t happen sooner because most payments didn’t arrive until the end of 2022 and “we didn’t want to comment on how the money was going out when we didn’t have money to go out,” he said.

Talk of Keeping the Public Out

In Newark, Ohio, Linda Mossholder, 75, has been inquiring about the settlement dollars at City Council meetings since last summer. As a volunteer with Newark Homeless Outreach, which serves weekly free lunches, she encounters many people who use drugs and wants to see the money help them.

The proud owner of a T-shirt that reads, “Your first mistake is thinking I’m just an old lady,” Mossholder has followed up with emails, voicemails, and public records requests. But she hasn’t gotten a clear answer about how the city plans to use the nearly $50,000 it’s already received.

In January, Mossholder said, the city’s director of public service finally told her the plan was to allocate settlement cash to first responders for naloxone. But when KHN filed public records requests to confirm, City Auditor Ryan Bubb wrote, “No funds have been allocated or spent.”

Meanwhile, in northeastern Ohio, a regional board that will control millions of settlement dollars spent a February meeting discussing whether the public should be allowed to access meeting recordings at all.

“I wouldn’t open it up to the public, honestly,” said Judy Moran, a board member who represents Eastlake, according to a recording of the meeting obtained by KHN. Other board members asked if their gatherings were subject to the state’s open-meeting laws.

Moran later told KHN, “Of course the public has a right to know how these funds are disbursed,” but she said she worried recordings would allow people to take words “out of context.”

In Ohio at least, that may not be a choice for much longer.

A lawsuit brought by Harm Reduction Ohio to open the meetings of a separate board — the OneOhio Recovery Foundation, which oversees the lion’s share of the state’s expected $1 billion — is working its way through the courts. A local judge this month rejected the foundation’s request to dismiss the lawsuit, writing that “the public deserves transparency.”

But OneOhio spokesperson Connie Luck said the foundation is a “private, nonprofit organization, and not a government agency.” It has so far allowed public attendance at meetings, but has said it is not required to do so.

The final ruling in this lawsuit, which is the first of its kind on opioid settlement funds, will set a precedent for the public’s right to information nationally.

In some parts of the country, the prospect of dollars to treat a long-underfunded epidemic brings hope, said Tricia Christensen, who works at a nonprofit tracking settlement funds across Appalachia. When people know what’s happening, it not only deters misuse but can reveal surprising successes, she said.

That knowledge is empowering.

“These funds are the cavalry coming in. You’re finally getting relief after suffering alone for so long,” said Crystal Glass, of southwestern Virginia, who is in recovery from opioid and meth use and now works as a peer recovery specialist.

She hopes officials will involve people affected by addiction in their decisions.

As she put it: Transparency “is letting everyone — I mean everyone — know they can be part of this.”

KHN’s Colleen DeGuzman and Megan Kalata 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.

USE OUR CONTENT

This story can be republished for free (details).