What is about to happen is truly historic in scope. Pharmaceutical companies and distributors found accountable for contributing to the opioid crisis are expected to give states and municipalities more than $50 billion over the course of the next 15 to 18 years. The largest opioid-related settlement ever reached was the historic 2021 settlement alone, which extracted $26 billion from AmerisourceBergen, Cardinal Health, McKesson, and Janssen and distributed it across 46 states. The total has since increased due to further settlements with Teva, Allergan, CVS, and Walgreens. This wave of money was ultimately the result of over 3,000 civil lawsuits filed over about 20 years by both large and small jurisdictions. Even though it was slow and grinding, the legal machinery delivered. What comes next is the more difficult question.

Instead of waiting for state governments to make a decision, communities are attempting to provide their own answers. The city of Lexington, Kentucky, is organizing how to spend about $30 million over the course of 18 years, with treatment and recovery infrastructure being the main focus of their declared priorities. Researchers in Pennsylvania have been modeling fair allocation formulas in an effort to make sure that low-income communities and rural counties, which have continuously suffered disproportionately from the epidemic, aren’t left behind just because they don’t have the administrative capacity to compete with larger jurisdictions for funding. The research’s findings are striking: counties that are low-income, rural, or have poor health rankings receive lower fairness measures across all allocation strategies examined. Where there are already systems in place to receive it, the money tends to move more readily.

One of the main conflicts that are currently occurring in dozens of states is that gap between the communities that most need the funds and those who are best able to access them. The 2021 settlement agreement was created in response to the 1998 tobacco settlement’s shortcomings, as detractors claimed that insufficient funds were allocated directly to impacted communities and remained locally. According to the opioid agreement, states and local subdivisions must receive at least 85% of the funds directly, and spending must be allocated to abatement activities, or real services rather than general funds or budget gaps. That prerequisite has significance. However, meaningful requirements and meaningful outcomes are not the same thing, and there are many warning signs in the history of significant waves of public health funding.

The argument over how to use these funds is already becoming more intense along predictable lines. The Reason Foundation’s policy analysts have made the case that governments ought to give preference to outside service providers, such as community organizations, nonprofits, and for-profit businesses, over internal government initiatives that need ongoing public funding. The reasoning is practical: government employee-focused programs have nowhere to go when settlement payments eventually taper off and cease. In contrast, organizations that increase their capacity during the settlement period can continue to operate by switching to other sources of funding, such as Medicaid reimbursements, state contracts, or philanthropy. Here, Massachusetts provides an actual example. Launched in 2015, a performance-based supportive housing program eventually housed 1,055 people, with 85% staying in stable housing or leaving positively. At the same time, each participant’s average annual healthcare costs were reduced by more than $5,000. That is the kind of result that surpasses the initial investment.

Communities around the nation seem to be both hopeful and prepared as they watch this develop. I’m optimistic because, when used wisely, $50 billion can truly change the world. Braced because there is a real and recent history of large settlement funds being absorbed into general budget gaps, used for programs with little accountability, or taken by the person with the best grant writer rather than the most pressing need. The 1998 tobacco settlement serves as a warning that legal success and community benefit are not the same thing, and it frequently comes up in policy discussions surrounding opioid funds.

The desire for connection to care, family support, and recovery services expressed by residents in places like Bedford is also a subtle critique of the notion that professionals and authorities should create these programs in a vacuum. No policy recommendation is being made by those requesting a connection to care. The time between an overdose, a hospital discharge, a released prisoner returning home, and the next available treatment appointment is what they are describing—something they have seen their communities lack for years. People have died as a result of that gap. And if the appropriate voices are present when deciding where to send it, there is now money to close it.

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