Impactful ways to spend small opioid settlement allocations

By: Roxanne Saucier and Sara Whaley

We often read the headlines about the more than $55 billion flowing into states and local communities from the myriad legal settlements with opioid manufacturers, distributors, and marketers. But for some communities, the windfalls are smaller, especially on an annual basis. Recognizing the urgency of the moment, with opioid-related deaths still at historic levels, these towns and counties wonder how they can have an impact with small pots of settlement dollars – sometimes less than $5,000 a year. These allocations may not be enough to stand up new programs, but they can still offer critical support. Below, I offer 10 ideas for ways to spend small pots of money.

1. Purchase low-cost naloxone. With limited dollars, you’ll want to maximize how far those dollars go. Intramuscular naloxone – the original naloxone formulation – has been used by laypeople in the US since 1996 and costs a fraction of the price of the newer intranasal products. The nonprofit drug distributor, Remedy Alliance/For the People, offers the best price for this product, at under $5 a dose, to programs that distribute it directly to people who use drugs. “No locale is currently providing naloxone at the scale needed to be available whenever overdoses occur, and intramuscular naloxone, at less than a quarter of the price of intranasal, is our best hope of reaching ‘naloxone saturation.’ We already send injectable naloxone all over the country, so we know that people are comfortable using it,” says Maya Doe-Simkins, co-director of Remedy Alliance. You can get a sense of naloxone saturation in your area by asking organizations that distribute it directly to people who use drugs whether they ever need to ration their supply of naloxone, or if they have enough to give every person who asks for it as much as they want every time they need it. As with anything, local jurisdictions will want to coordinate with states since, in some cases, states are also making bulk purchases of naloxone to send to counties.
2. Purchase test strips. While people who use opioids – who know that fentanyl is now ubiquitous in the drug supply – may have limited interest in fentanyl test strips, these tools can be particularly useful when people who use stimulants –  who may not have a tolerance for opioids – are trained to use them. They’re inexpensive, at about a dollar apiece. Xylazine test strips can help people avoid this contaminant, which can cause extreme sedation and skin wounds. Studies show that people may modify their drug use behavior after receiving positive test results, taking steps to reduce their risk. Local harm reduction organizations, re-entry programs, shelters, drop-in centers, and health departments are all potential distribution sites. Offering test strips can also be a good way to draw people into programs that can provide them other tools and education for protecting their health.
3. Buy wound care supplies for people who use drugs. Supplies to treat xylazine wounds include soap and sterile water, petroleum jelly, gauze pads, and gauze wrap. Access to these basic materials can help avoid drastic amputations later. “We hear in the media graphic descriptions of wounds from injecting xylazine. The truth is the wounds can be treated with the right supplies, but programs that work with people who use drugs don’t always have a budget for them. Helping people treat their wounds using these basic methods can avoid life-altering and costly procedures later,” says Jordan Scott, Advocacy and Organizing Coordinator at the Pennsylvania Harm Reduction Network.
4. Provide transportation vouchers so people can get to treatment, job interviews, and other appointments. You could operationalize this by partnering with treatment programs, re-entry programs, or drop-in centers, for example. “There are other dollars that can cover medications for opioid use disorder, but often what’s missing is the money to get to appointments. This is where opioid settlements could fill a gap,” says Nancy Rosen Cohen, executive director of NCADD-Maryland.
5. Provide wifi for those who don’t have access to it, so they can take advantage of telehealth appointments, for example with a drug treatment provider. “Especially in rural areas, people may have to drive hours to reach a clinic. Telehealth has become an option for drug treatment, but in these same areas, internet access may be limited. Providing people with wifi access could enhance treatment uptake,” says Rollie Martinson, Senior Policy Advocate at Community Education Group.
6. Grant funds to your local syringe service program. These programs are natural on-ramps to care for people who don’t currently interface with the medical system. But they often run on a shoestring budget, limiting their potential reach. If your county doesn’t have a syringe service program, a program in a neighboring county may be able to partner with your county to provide mobile services to your residents “SSPs help protect against the spread of infections like HIV and hepatitis, and they are also a great way to get people engaged in broader healthcare. Unrestricted funds are so useful to be able to respond quickly to changing needs,” says Elizabeth Burke Beaty, Founding Executive Director of Sea Change Recovery Community Organization and Harm Reduction Center.
7. Use the funds to produce harm reduction-oriented educational materials and conduct trainings specifically for stimulant users about the risks of opioids and how to access naloxone. This could be done by a local health department or a local harm reduction program. Overdose rates are increasing amongst stimulant users and their needs often aren’t being adequately addressed by current programming. While in 2010 less than 1% of fatal fentanyl overdoses involved stimulants, by 2021 almost a third of those overdoses involved stimulants. “Some people call this the ‘fourth wave’ of the overdose epidemic, with combinations of fentanyl and either cocaine or methamphetamine contributing to overdose deaths across the country. But most programs that work with people who use drugs aren’t successfully reaching stimulant users. This is partly driving deaths amongst Black and Indigenous people,” says Hill Brown, Southern Director of Faith in Harm Reduction.
8. Fund trainings for maternity care and social service providers about best practices for working with pregnant and postpartum people who use drugs. There are major misconceptions when it comes to supporting pregnant people who use drugs and new parents. Treatment with opioid agonists like methadone or buprenorphine is best practice, but pregnant people are too often stigmatized and penalized for using these medicines. And many clinicians don’t know that best practice for neonatal opioid withdrawal syndrome involves rooming in – keeping parents and baby together. Groups like the Academy for Perinatal Harm Reduction provide trainings or may be able to connect you with local experts in your state.
9. Give the funds to your local health department to use on addressing overdose, prioritizing the high-impact interventions in the national settlement agreement. “We often find that local health departments know the current needs in their community. And sometimes even investing in their own staffing or infrastructure can be really helpful; they’re also well-placed to regrant to local organizations,” says Jeremy Saunders, co-executive director of VOCAL-NY. Just like other fund recipients, county health departments should be required to report on how they use opioid settlement funds, and to measure their impact. The Opioid Settlement Principles Resource and Indicators (OSPRI) offers helpful ideas for concrete metrics to track impact.
10. Fund better overdose data collection by a local university or your health department. This helps with understanding the crisis in real time to better focus resources. Rapid needs assessments of populations not represented in traditional health surveillance – for example health needs among unhoused people who use drugs, or barriers to treatment among pregnant people – can uncover critical gaps in care. “Focus on answering one limited and specific question. Go beyond focus groups and really listen to what individuals have to say. These could be good summer projects for interns or fellows,” says Nabarun Dasgupta, Senior Scientist at University of North Carolina at Chapel Hill.

In some cases, locales receiving smaller pots of opioid settlement dollars may want to pool their money with others. For example, some cities have decided to contribute their dollars to their county’s pot; in other cases, counties may want to collaborate with neighboring counties or joint health districts. For instance, by pooling funds, a few counties may be able to equip a mobile harm reduction unit to cover their catchment area or hire a shared data analyst. You may be able to bring people from multiple neighboring counties together for a training. 

If you’re interested in more ideas for impactful ways to spend opioid settlement dollars, HEAL Ohio produced a beautiful deck of cards with options for opioid settlement spending. You can see those at https://www.healoh.org/deal-us-in. A group of nearly 200 organizations from across the country also produced a Roadmap for Opioid Settlement Funds that offers guidance on spending priorities, cautions against counterproductive expenditures, and reviews some noteworthy spending to date. 

While we’re starting to see some results from approaches that treat drug use as a health issue rather than a crime – with overdose mortality down 12.7% in the past year – we are still losing more than 100,000 people in the US to overdose each year with Black and Indigenous people particularly at risk. This underscores the urgency of supporting proven interventions to respond to the crisis – and every dollar helps.

Roxanne Saucier, MPH is a consultant with Open Society Foundations’ Global Drug Policy Reform team, where she works to advance drug policies grounded in human rights and public health. She serves on the board of directors of Remedy Alliance/For the People, a nonprofit that ensures that harm reduction programs have sustainable and equitable access to low-cost naloxone, as well as on the board of directors of Forward Justice, a nonpartisan law, policy, and strategy center dedicated to advancing racial, social, and economic justice in the U.S. South.