Opioid Settlement Funds Remain Unsettled

November 2023

By Nikki Tierney, JD,LPC,LCADC, CPRS
NCAAR Policy Analyst

“There comes a point where we need to stop just pulling people out of the river. We need to go upstream and find out why they’re falling in.” ― Desmond Tutu

New Jersey and its subdivisions will receive more than 1.1 billion dollars over the next two decades to combat the opioid epidemic through settlement agreements with various opioid manufacturers, distributors, and retailers.¹ According to the terms of the settlement agreements in those various cases, approximately half of the settlement dollars will go directly to the State to administer and, after payment of litigation expenses, the remainder will be distributed directly to 262 eligible subdivisions (comprising 21 counties and eligible municipalities that have populations over 10,000 or that filed related lawsuits).

On its face, this seems like welcoming news, especially considering the devastating toll opioid use disorders and opioid-related deaths had and are still having on the citizens of New Jersey and the State as a whole. However, due to cognitive distortions, stigma, and even some old fashioned “good intentions,” some individuals who wield unbridled power over deciding how those funds should be spent may actually exacerbate the enormous loss of life and suffering New Jersey is already experiencing from the opioid epidemic.

After over 50 years of evidence from the failed strategies of the War on Drugs, New Jersey and many other government entities have taken extraordinary steps to better understand substance use disorders, particularly opioid use disorders, and accordingly designed responses that address why people are falling in the river, not just pulling them out, as Desmond Tutu suggested. However, opioid use disorders have a multifactorial etiology, encompassing psychosocial and biological mechanisms as well as genetic influences. In addition, not only is the cause of opioid use disorder relevant to designing effective and efficacious responses to this crisis, but the factors that allow the disorders to continue must be addressed in any response. Amongst factors that allow opioid use disorders to continue are barriers to mental wellness and treatment, risk factors, and a lack of protective factors. All responses must also account for cultural considerations of each population they are intended to serve.

If responses to the opioid crisis are to be effective and efficacious, they must be evidence-based. Stated otherwise, the responses must be supported by data and science. The response to this historic loss of life and amount of suffering needs to work. New Jersey has taken many encouraging steps to move towards evidence-based strategies and away from the previous simplistic “Just Say No’ campaign and penal and punitive responses to a public medical emergency. However, according to the recent New Jersey Subdivision Annual Opioid Abatement Report, 2023, some troubling trends not only appear to be wasteful of settlement funds but have the tragic potential to increase harms and deaths from opioids.

Before addressing which evidence-based prevention, treatment, and support programs should be funded with settlement money, there is a critical threshold issue which must be resolved if New Jersey is to mitigate the damages from the opioid epidemic. That issue is capacity. According to New Jersey Drug and Alcohol Use Treatment – Statewide Substance Use Overview 2022 released by Department of Human Services, Division of Mental Health and Addiction Services, there is 62.7% Unmet Demand for Substance Use Treatment of the Adult Population.² Unfortunately, this disturbing trend is not unique to New Jersey and is exacerbating the damages from the opioid epidemic. All responses must include a component to increase capacity so not only are the responses successful, but people can access support. Next, counties and municipalities should invest in prevention and treatment programs that are evidence-based. For example, it is beyond question that harm reduction is an effective approach to reduce harm and death from drug use as people progress through the stages of change until they are able and ready to engage in services. New Jersey has made some innovative and lifesaving strides in this area, such as widespread, free distribution of Naloxone. However, there is room for additional improvement. More specifically, despite being considered the gold standard treatment by professionals, medication for opioid use disorder (MOUD) remains underfunded and underutilized.

Data Demonstrates Funding Needs

A recent study using New Jersey Medicaid data from 2014 to 2019, which included 4,898 NJ Medicaid enrollees, revealed that receipt of MOUD was associated with two-thirds (66%) reduction in repeat overdose risk.³ Despite such impressive outcomes, the study also revealed that only a minority of participants received MOUD during follow-up. More specifically only 18.9% of participants in 20152016 and 23.9% of participants in 2017–2018 received MOUD.⁴ These findings are similar to low rates of post-overdose MOUD found in studies in Medicaid populations in Pennsylvania, where 15% of Medicaid beneficiaries with prescription drug overdose and 33% with heroin overdose received MOUD in the six months after nonfatal overdose and in Massachusetts where 30% of individuals with medically treated opioid overdose received MOUD within 12 months.⁵

This study offers detailed, evidence-based strategies that can be used to reduce deaths and harm. These strategies include initiation of MOUD in the emergency department after overdose, assertive follow-up interventions, expanding community availability of MOUD, and improving integration of acute and general medical care. Additional evidence-based responses set forth in the study include naloxone prescribing and distribution; education on overdose risk and prevention and safe injection practices; and, as appropriate, referral to community-based harm reduction and syringe access programs, which have been proven to decrease risk of repeat overdose and mortality.⁶ Unfortunately, as explored in further detail below, very few of the counties or municipalities are following this roadmap to success in spending opioid settlement funds.

There is also ample data to show what responses do not work, and are not only wasteful and ineffective, but may exacerbate deaths and suffering from opioid use disorder. Broadly, these tactics are described as supply side interventions. The theory is that by decreasing the amount of opioids available, the epidemic will just disappear with the supply. This theory is internally flawed and has little to no support that it improves outcomes for people with substance use disorders.

Here is but one example of the catastrophic results of supply-side interventions. In 2017, New Jersey became one of the first states in the country to impose a hard limit on initial opioid prescriptions, with patients allowed only a 5-day supply of opioid pain medication.⁷ Since their peak in 2015, when over 5,640,000 opioid prescriptions were filled in New Jersey, opioid prescribing has fallen over 35% in the state; however, that coincided with an alarming increase in overdose deaths as illicit fentanyl analogues began to flood New Jersey.⁸ This is a prime example of “good intentions” not being sufficient in addressing a public medical crisis. Drastically reducing supply of prescription medicine may have made the overdose crisis worse by forcing some patients to turn to increasingly dangerous street drugs.⁹ Although supply side interventions dominate drug policy, evidence of their effectiveness is dismal. Another relevant example is the prescription drug monitoring plans governments spent millions of dollars to implement, which has had no effect on aggregate opioid mortality for the period 1993-2017.¹⁰ A plethora of studies and data have made clear that if supply-side restrictions are implemented, they must be paired with policies to improve access to evidence-based treatment for opioid use disorder and related social service supports.¹¹

Annual Opioid Abatement Reports

The Annual Opioid Abatement Reports from all 21 counties and 242 municipalities revealed some very troubling trends in spending or plans to spend opioid settlement funds, which are based on outdated, ineffective supply-side interventions. The reports were filed at the end of June and released in September 2023. Only five of the state’s 21 counties (24%) had utilized any funds— Atlantic, Camden, Passaic, Salem, and Somerset. The vast majority of counties have not spent a single cent notwithstanding that over 2,100 people have died from drug-related deaths in 2023, including 54 during the second week of October alone.¹² Black men and older people of all races are disproportionately impacted by the rising death rate.¹³The number of municipalities that have spent funds is even more disheartening. Only 27 out of 242 municipalities listed in the report have spent funds. A mere 11% of our local governments have spent money to help save lives. Perhaps Desmond Tuta’s inquiry should be expanded to ponder when leaders will take action for the people who are falling into the river.

As if the 11% is not demoralizing enough, a more in-depth look reveals that some of this money is being spent on programs that have historically been shown to increase the harms and deaths from inhumanely utilizing punitive responses to substance use and mental health disorders. For example, Ramsey Borough received $16,076.60 and reports it spent $5,361.85 thus far on a narcotic detection dog. The total cost is “$19,440 initially and annual $4,140 (spent $5,361.85 as of 6/30/23)”. Similarly, Mahwah Township, although they have not yet spent any funds, has reported it plans to invest $20,000 on an “Opioid K-9”. They further disclosed that the “K-9 will be trained to uncover the presence of Opioids which will allow officers to get the drugs off of the streets” which they categorize as harm reduction. Franklin Township spent $689.98 to “buy a laptop onboard a police vehicle to run the Drug Testing for Impaired Drivers program” with the purported problem listed as “Getting impaired drivers off the road and possibly into treatment.” Mantua Township intends to spend their money to “Increase Police Department Staff.” One can almost see or hear the performative “we cannot arrest our way out of this problem” refrain while perusing this report.

Likely the most horrifying planned expenditure is from the Town of Clinton, which intends to spend $26,000 to “Purchase of equipment to help officers safely identify unknown drug substances they encounter.” The program’s target population is 13 people. This is likely based on the completely disproven myth that fentanyl analogues can cause overdoses to law enforcement agents because of transdermal contact. A recent study stressed the deadly consequences of this type of misinformation: “[t]his is an urgent ethical and public health imperative, as failure to effectively address the spread of misinformation can cost lives and resources. First responders and other witnesses may refuse or delay providing lifesaving help during overdoses. Professional responders report elevated levels of stress, vicarious trauma, and compassion fatigue; unfounded safety concerns can aggravate these occupational mental health challenges.”¹⁴

The Borough of Collingswood received $47,468.39 and spent $5,600 thus far on an Employee Assistance Program for 130 Township Employees and their families. Again, in theory increasing access to mental health and substance use disorder treatment seems well-intentioned, but Township employees likely already receive insurance benefits, and this has an appearance of conflict of interest. Ocean City plans on allocating $5,000 to Count on Comedy for a one-day Juneteenth Comedy event with the anticipated outcome being reported as “Deterrence And Knowledge”.

Galloway Township received $35,593.62 and spent $8,499.00 for a one-year Cops in Schools Program. They also reported that in the future they plan to fund a 2 to 3-year program to “halt the diversion and abuse of prescription drugs”. Similarly, Elmwood Park has reported investing $15,210.00 on Community Policing “Get the Word Out” and describes the program as “Simply teaching that over-the counter medicines can lead to opioid addiction.” Marlboro Township reports planning to spend $82,236.82 on “Education of police officers.” See also Franklin Township and Sparta Township. Finally, Manville reports planning to spend $5,997.18 on D.A.R.E. While community policing, relationship building and safe disposal are laudable goals, these programs are simply not needed in light of the preferred evidence-based responses available. Based on the severity of the current crisis, these expenditures will not improve outcomes for people impacted, directly or indirectly by opioid use disorders. These interventions are neither evidence-based nor likely to reduce harm or death.

Conversely, some counties and municipalities are utilizing, or plan to utilize these funds on evidence-based principles that will not only save lives, but also improve the quality of life for people with mental health and substance use disorders, increase treatment and prevention capacity, and reduce costs to the State resulting from the current opioid crisis. Amongst the most encouraging expenditures are the following:

• Montclair is using the money to purchase fentanyl and xylazine test strips to distribute to its citizens. In addition, they are entering into a Memorandum of Understanding with a local treatment provider to provide opioid use disorder treatment to residents;
• Southampton intends to distribute naloxone and build an informational website for its citizens (see also New Providence, West Deptford, Randolph Township, Warren Township, Plainfield City, and West New York);
• South Orange Village and Maplewood Township are collaborating and hiring a part-time Crisis Intervention Social Worker and supporting their Municipal Alliance, inter alia;
• Harrison Town plans to spend $30,000 to facilitate treatment for residents in need and
  $13,5000 to create a welcoming “Drop In Center” to support residents in “treatment and recovery”;
• Jersey City plans to spend $200,000 to support people in treatment and recovery by providing wrap around services primarily in Wards A & F;
• Weehawken Township reports the following plan: “Our social workers, EMS, and law enforcement officers will be further trained in sensitivity and harm reduction practices to let those suffering from this disease retain their dignity while also providing the resources that will assist those who choose to partake in programs to overcome their addiction, with medical assistance if necessary. Ensure our social workers, EMS, and law enforcement are fully trained in administering overdose-prevention drugs”;
• Readington Township plans to utilize their funds on “Community Outreach Team blending the Police Department and Social Services”;
• Perth Amboy City plans to use its funds on “Drug Prevention Awareness through Digital Advertisements”;
• Robbinsville Township has developed Community Addiction Recovery Effort (C.A.R.E.) which will provide diversion and Peer Recovery Coaches to its citizens with opioid use disorder;
• The City of Trenton Opioid and Overdose Mapping will focus on expanding capacity for treatment and created an “Opioid Response Team office in the Department, and hold monthly community outreaches where we offer direct pathways to treatment, STD and HIV testing, Narcan distribution, and open access to housing services”;
• Carteret Borough will use its funds to reduce stigma and “Harm Reduction: Implementing strategies such as needle exchange programs and supervised injection sites to reduce the negative health consequences of opioid addiction”;
• Asbury Park City has spent money to provide residents access to no cost identification so that they can gain access to necessary social services and enter treatment; Freehold Township will be utilizing funds to provide treatment for residents who are uninsured (see also Manchester Township);
• Long Branch City plans on opening a Wellness Center; Middletown Township plans on utilizing funds for a Crisis Intervention Team (see also Bound Brook Borough);
• Red Bank Borough reports awarding a contract to professional social worker services; Chatham Township plans to spend money on NARCAN kit education and giveaway; Ocean Township will devote $7,500 to “Trauma, Addiction and Men: Create Connection, Increase Vulnerability and Improve Treatment Outcomes with the Male Client” and address mental health professional capacity and competency by planning to spend $16,750.00 on a complimentary 2 Day Seminar, “EMDR: A Rapid, Safe and proven Treatment for Trauma”;
• Paterson City will be providing MOUD and explained it plans to spend funds on “ORT (opioid response team), our ‘RealFix’ program providing MAT (medication assisted treatment) in real time, and our community court” (see also Union City);
• and Elizabeth City will be implementing a comprehensive program called Project Recover that will, among other things, “Train First Responders and local stakeholders in stigma language” and offer peer support and harm reduction.

The list above not only implements evidence-based practices but is also driven by local and individual needs assessment for each municipality. These interventions are also culturally competent and are most likely to prevent deaths and further destruction from the opioid epidemic. While no value can be put on a person’s life or wellness, 1.1 billion dollars has tremendous value and if used correctly, it could save lives and increases the quality of people’s lives. Conversely, it also has negative potential to only exacerbate and worsen the current epidemic we are facing. Counties and municipalities should not delay implementing proven responses immediately. The people of New Jersey deserve better than to drown in the river.