Meet the people who decide how to spend $50 billion in opioid settlement money

As more than $50 billion makes its way to state and local governments to offset the opioid epidemic, those with high hopes for the money are already fighting over a little-known bureaucratic arm of the process: state boards that wield enormous power over how it’s spent cash.

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

The data show that councils are as unique as states are from each other. They differ in size, power and the amount of funds they control. Members range from doctors, researchers and county health directors to law enforcement officials, city managers and business owners, as well as people in recovery and parents who have lost children to addiction.

“The overdose crisis is incredibly complex, and it takes more than money,” said Rollie Martinson, a policy associate at Community Education Group, a nonprofit that tracks spending on Appalachian settlements. “We also need the right people to be in charge of that money.”

It’s the $50 billion question: Are the right people driving the decisions? Criticism of the councils is now widespread, with stakeholders pointing out flaws ranging from over-representation to under-representation and many issues in between. For example:

• Council membership does not always reflect states’ most affected populations—by race or geography.
• The strong presence of specific professional groups—for example, treatment providers, health care managers, or law enforcement officials—may mean that money goes to those particular interests at the expense of others.
• Few places are reserved for people who have dealt with a substance use disorder themselves or supported a family member with one.

Of course, no one can create a perfect board. There is no agreement on what this would look like. But when there’s such a big pile of money at stake, everyone wants in on the action.

More than $3 billion in opioid settlement funds has already landed in the state treasury, with installments to be paid out through 2038. The money is intended to compensate hundreds of thousands of Americans who have died of drug overdoses in recent decades.

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

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

And it can cause arm wringing.

In many parts of the country, for example, people who support syringe service programs or similar interventions worry that municipalities with large numbers of police officers and sheriffs will instead direct large chunks of the money to buy police cars and body armor. And vice versa.

In most states, however, law enforcement and criminal justice officials make up less than one-fifth of the board’s membership. In Alaska and Pennsylvania, for example, they are not represented at all.

Outliers exist, of course. Tennessee’s 15-member board has two sheriffs, one current and one former attorney general, a criminal court judge and a special agent with the state Bureau of Investigation. But like many other councils, it has not yet awarded funds to specific groups, so it is too early to tell how the composition of the council will affect those decisions.

Pendergrass and Johns Hopkins researcher Sarah Whaley, who together compiled the list of council members, say criticism of councils that are based too much on one district, geographic area or race is not just a matter of political correctness, but of practicality.

“Having diverse representation in the chamber will ensure that there is balance in how funds are spent,” Pendergrass said.

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

“I’m convinced that if those six people weren’t on the council, harm reduction wouldn’t have gotten a single dollar,” she said.

Others begin to focus on potentially missed opportunities.

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

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

But only two of those featured — Burlington and Hunterdon counties — are considered rural by the state’s Office of Rural Health Needs Assessment. The state’s hardest-hit rural counties have no seat at the table.

But only two of those featured — Burlington and Hunterdon counties — are considered rural by the state’s Office of Rural Health Needs Assessment. The state’s hardest-hit rural counties have no seat at the table.

Now that most of the council seats across the country are filled, concerns about racial equality are growing.

Louisiana, where nearly a third of the population is black, has no black council members. In Ohio, where black residents die of overdoses at the highest rate, only one of the 29 council members is black.

“There’s this perception that this money isn’t 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 that black Americans have the fastest growing overdose death rates and face the most barriers to gold standard treatment.

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

And that raises eyebrows too.

“The service providers will have a pecuniary interest,” said Tracy M. Gardner, who directs policy advocacy at the New York-based Center for Legal Action. While most are good people running good treatment programs, they have an inherent conflict with the goal of getting people healthy and stable, she said.

“It’s a job to stop treatment programs,” Gardner said. “We must never forget the business model. There was it for HIV, there was it for covid and there is it for the overdose epidemic.”

Councils in South Carolina and New York have already seen some controversy along these lines — when member-affiliated organizations have pursued or received funding. This is not a particularly surprising development, as the members were chosen for their distinguished work in the field.

Both state boards have robust conflict-of-interest policies requiring members to disclose professional and financial relationships. New York also has a law that prohibits council members from using their position for financial gain, and South Carolina uses a rubric to objectively evaluate applications.

The fact that these situations are causing alarm shows how much hope and desperation are tied to this money – and the decisions about who controls it.

“This is the largest infusion of funding into addiction treatment in at least 50 years,” Gardner said. “That’s money coming into a hungry system.”

Database methodology

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

While many states have councils to address the opioid crisis in general, the database focuses specifically on councils that oversee opioid settlement funds. A council’s scope of authority was classified as “decision-making” if it directly controlled distribution. “Advisory” means that the board makes recommendations to another body that makes final funding decisions.

Data is current as of June 9, 2023.

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

— Each member of the council can be counted in only one category. No duplication.

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

— “Government official” is usually a government official who is not elected and does not fit into any other descriptive category — such as an unelected county manager.

— People who provide direct services to patients or clients, such as doctors, nurses, therapists, and social workers, are classified as “medical and social service providers.” People in more administrative roles are usually classified as “public” or “private health and human services” based on the public or private affiliation of their organization.

— “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 the experiences of people with addiction are not always public, only individuals specifically designated because of their first-hand connection or to fill a space reserved for someone with this experience were categorized as such.

Colleen DeGuzman and Megan Calata of KFF Health News contributed to this report.