Opioid Settlement Money: will we treat or not treat addiction?

Overdose deaths involving opioids took 176,639 American lives in the 5-year period from 2013 through 2017. We know it. Walk into a college class, a rural town, a synagogue, a factory, an evangelical church or a jail and you are going to bump into someone who lost a family member or a friend. A tragedy of these proportions will require a serious commitment, not just of the heart, but of cash, which some experts imagine will require upwards of $100 billion. But I have a concern, which is what we’ll do with any money we get. The trigger for that worry is report of Oklahoma’s plans for $270 million it will obtain in a recently announced settlement with Purdue Pharma. Unless Oklahoma makes precedent-busting adjustments to plans it has announced (or has key provisions under wraps), the most important element of a humane policy response to the opioid crisis is poised to receive relatively little support.

To offer the briefest possible background: one central, if contentious, plank of the policy response to today’s opioid crisis is litigation. There is room to debate how much blame to apportion to drug manufacturers who extolled liberal opioid prescribing in response to complex forms of human distress involving pain. I number among those see a web of failures, rather than just one or two bad actors. But litigation is here. It is overwhelmingly likely that money will come to states, counties, tribes and municipalities. It will come either through court judgment, jury trial, or settlement. We should care what happens to that money.

What Oklahoma announced, as reported in the AP and New York Times, does not necessarily add up to $270 million, so let’s assume the details are yet to come, but here is what we know:

$12.5 million to help counties and cities recover costs they have incurred from the crisis.

$20 million (7.3% of $270 million) “in addiction medicine” for treatment of addiction.

$60 million to reimburse the state for litigation costs. I assume these are attorney fees, and they are (effectively) the price of doing business.

A large amount (“more than $100 million” or $200 million, depending whether you read the New York Times or the Associated Press) will establish “a new National Center for Addiction Studies and Treatment at Oklahoma State University in Tulsa.” What does a university-based center mean for treatment?

At its very best, a University-based Center can serve as a nidus for addiction training, research, and in some instances, delivery of care.

The Grayken Center at Boston Medical Center (my former stomping grounds until 2002, long before it was the Grayken Center) supports experts, researchers, and clinical endeavors that sometimes reach out across the state. Leaders like Colleen LaBelle direct the expansion of Office Based Addiction Treatment across Boston, and lead programs that affect the entire state. Overdose experts like Alexander Walley conduct research and spearhead research to show the nation would could make a difference. With $100 million or more, a Center can establish several endowed Chairs, hire clinicians who might otherwise have taken jobs in more generous environments, and set up programs to train medical students, pharmacists and psychologists.

But this is the crucial problem: What university centers typically do not do is pay for the health care of people who lack insurance.

University centers usually do not make grants to community-based treatment agencies, certainly not across an entire state. They don’t usually hire peer support workers, or distribute naloxone, unless they have received targeted dollars for exactly that activity.

All these limitations are not a problem if a university center operates in a state with a wide range of funding streams for the treatment of poor or underinsured populations with addiction (i.e. New York, Massachusetts, California, etc.).

But for states like Oklahoma, or my own (Alabama), the question of how to actually pay for care is pressingly real.

We need money for treatment, if we want to treat addiction. And the folks we plan to help will need psychotherapy, job training, and medical care too. It’s going to cost a lot.

So Oklahoma, like many states to come, has to make a serious choice. And on face, most of its declared money is not going to treatment, unless the state itself demands something very innovative. Oklahoma could do that, but only if they break the mold for what state-funded university centers ordinarily do.

There is nothing to stop Oklahoma from demanding that its new, to-be-established Center at Oklahoma State go beyond the boundaries of traditional university centers. In fact, it could be pathbreaking. But that requires daring leadership and accountability.

On the other hand… if billions of dollars in litigation wind up cushioning endowed chairs for senior faculty (and of course, sure, I would love one of those) and their research teams, eyes ever fixed on the next federal research grant, then a lot of money that could make a difference, won’t. That means Oklahomans who have addiction, very much the injured parties, not getting help.

This is a time for choosing. And what Oklahoma chooses will influence many more states to come. Let’s make sure we choose to treat addiction.

Stefan G. Kertesz, MD, MSc

Views expressed here are my own and do not represent positions of any of my employers including the United States Department of Veterans Affairs or the State of Alabama. I serve as consultant to precisely zero parties involved in the ongoing opioid litigation.