As payments from the National Opioid Settlement and other opioid-related lawsuits are distributed to local governments across the country, the question many communities are asking is, ‘How should we spend the funds?’ While the opioid settlements include a list of possible uses for the funds (often denoted as core strategies or high-impact opioid abatement strategies), local governments and states have major leeway in choosing which strategies to implement. ¹ The strategies communities are evaluating and choosing to fund range from the expansion of treatment services, recovery housing support, employment-related services, drug task force creation, naloxone (Narcan) distribution, new medical facility construction, syringe service programs, implementing mobile units to access remote populations, prison diversion programs, to funding various research projects, and more.² The challenge is that not every opioid abatement strategy aligns with the needs of the local communities; there is no one-size-fits-all strategy that will guarantee a best outcome. Instead, these decisions should be informed by local context and need, in conjunction with evidence-based research to support specific strategies known to generate positive impact. This requires local and state leaders to actively engage with community members in order to ensure that a community’s unique needs are being met. A strategy that works for an urban community may not work in a rural community, and vice-versa.

Entities seeking to provide recommendations on how to best use the settlement funds must grapple with the challenge that not every state or locality is allocating the funds the same way.^3,4,5 While the national agreement outlined overarching terms for how the funds can be used, the 46 participating states have significant autonomy in how they determine reporting requirements, percentage of funds allocated to local governments versus the state, advisory committee structures, and fund disbursement schedules. For example, Tennessee’s Opioid Abatement Council began direct payments from their Opioid Abatement Trust Fund to county governments in February 2023.⁶ Tennessee’s agreement states 35% of the settlement funds will go to the county governments, while the remaining 65% will be distributed, “through a competitive grant application process to be established by the Opioid Abatement Council.”⁶ This is in contrast to North Carolina, where local governments received initial payments in 2022 and will receive up to 85% of the settlement funds, and the remaining 15% will go to the state where the General Assembly can prioritize specific strategies.⁷ In addition to differing fund disbursement plans, various states are in different stages of readiness when it comes to determining how to spend the settlement funds. North Carolina has utilized the North Carolina Association of County Commissioners to prepare and discuss best use cases among local governments for years prior to the funds actually being received. This is to ensure settlement funds’ impact is maximized and ensures communities can effectively and expeditiously commit the funds to valuable resources for opioid abatement.⁸ However, many states and local governments have not done as extensive prep-work before funds started to arrive and are finding themselves in a rush to develop advisory committees and solicit community input. Others have not found use for the funds at all, remaining undecided. In North Carolina for example, out of 100 counties, more than 30 counties still had not decided on what to spend the funds on as of April 2024.⁹

In addition to the challenge of providing resources and recommendations to states and communities in different stages of readiness, there is the challenge of adapting recommendations to fit with local community beliefs and current stigma around the opioid crisis. While many harm-reduction programs have strong bodies of research and evidence to support their use, such as syringe service programs, many communities may have stark opposition to the use of settlement funds for such purposes given local political differences or belief structures. For example, in North Carolina’s 20 westernmost counties, only three have confirmed that they have allocated funds and all three neighboring counties chose different strategies. Buncombe County is prioritizing harm reduction, McDowell County counseling services and treatment, and Henderson County plans to train personnel and hire recovery staff.¹⁰ This demonstrates the differences in approaches and beliefs localities may have on settlement fund use even if they are in close proximity to one another. These differences are not only present across large geographic distances or urban versus rural environments. North Carolina has 100 counties, and each county will likely have its own opinion on what their community needs. Therefore, providing helpful recommendations to communities that may not have the resources to gather evidence or determine which abatement strategies have the best return on investment starts with having nuanced dialogues with diverse stakeholders present in said communities.

Recently, the UNC Center for the Business of Health (CBOH) and Acadia Healthcare partnered on the development of an opioid settlement fund playbook.¹¹ The project’s goal is to review the opioid epidemic’s deep impact, address challenges and opportunities counties have come across on making fund allocation decisions and develop best practice recommendations tailored to communities and stakeholders. A key objective of the playbook is to develop the most effective ways for communities to use opioid settlement funds based on these challenges and best practices observed through dialogue with communities. To accomplish the aims of the playbook, the CBOH has partnered with NCGrowth, a multistate economic development center, to conduct community dialogue sessions with diverse stakeholders across North Carolina. Starting in early 2024, CBOH and NCGrowth, in partnership with Acadia Healthcare, aim to hold four community immersive experiences across the state of NC to foster community engagement and provide insightful context for the recommendations being made for the playbook.

While each state and county have unique needs, comparisons can and should be drawn across regions and states as best practices emerge. By conducting community immersives in North Carolina to better understand local needs, the findings can serve as case studies and foundational best practices for other states. This approach will help states manage funds and address their populations’ needs over the next decade.

In addition to community dialogue insights, the playbook will compile the best toolkits and resources from both CBOH and external entities. As an online resource, it will include settlement trackers, research on common abatement strategies, and resources for decision-makers, policymakers, health service providers, and the general public. It will also provide grant and funding resources to help organizations submit proper proposals for settlement funds to local and state governments.