Opioid Settlement Funds: Let’s Avoid the Mistakes of the Tobacco Settlement - Drs. Braun and Rich

Opioid Settlement Funds: Let’s Avoid the Mistakes of the Tobacco Settlement - Drs. Braun and Rich

Rhode Island’s Attorney General, Peter Neronha recently negotiated a settlement valued at greater than $100 million against the drug makers Teva Pharmaceutical Industries and AbbVie for their roles in fueling our state’s opioid epidemic. The companies will deliver $28.5 million to Rhode Island over 10 years, along with 1 million doses of the life-saving rescue medication naloxone and 67,000 30-pill bottles of the treatment drug buprenorphine-naloxone. This brings the total settlement negotiated over the past year to over $250 million. As addiction medicine doctors, we know that these funds cannot erase prior harms. But, they may reduce future injuries, if they are used to fund evidence-based interventions that expand prevention and treatment services and reduce stigma, with careful monitoring and a focus on justice. 

The CDC has identified three waves of the opioid epidemic, beginning with deaths involving prescription opioids, followed by increases in heroin-involved deaths, and finally synthetic opioids such as fentanyl. The epidemic has rapidly evolved—the forces that fueled the start of this epidemic, such as an unprecedented marketing campaign from pharmaceuticals and overprescribing, are not the same as the forces that sustain it, especially as we enter a 4th wave characterized by polysubstance and stimulant use. Thus, strategies for multiple substances may be appropriate, rather than considering the impacts of opioid harms alone. These waves have profoundly impacted Black, Indigenous and people of color (BIPOC) communities, and the racism that led to mass incarceration, coupled with regulatory barriers that disproportionally limit addiction treatment for communities of color, contribute to the current increases in overdoses amongst Black populations.

We applaud the set of principles put forth by the coalition coordinated by Johns Hopkins faculty to avoid mistakes of the 1998 tobacco settlement, during which funds often went to a state’s general revenue and only a fraction of the funds went to health care. The Hopkins report provides 5 principles and call for focus on addiction treatment, on prevention, and on avoiding diversion of funds to close budget gaps. We urge Rhode Island to follow New York’s lead in requiring funds not replace or supplant existing funds; rather, these funds should work synergistically with existing programs to maximize impact and longevity. 

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Funds should be used for substance use disorder treatment, prevention, and harm reduction programs, and address the epidemic’s impact on the criminal justice system. Examples of immediate evidence-based interventions include: a)  establishing additional inpatient addiction consult services to more hospitals, b) opening the newly sanctioned overdose prevention sites (which can be expected to reduce overdose mortality, drug use, and infectious disease risk, and facilitate access to health and social services), and c) in the setting of an increasingly toxic illicit drug supply, expanded access to opioid reversal agents (i.e., naloxone) and drug-checking technology (i.e., fentanyl or methamphetamine test strips). Diversification of the addiction treatment workforce provides an additional path to improve care, as does training and career pathways for peer recovery coaches. Since tailored care such as street outreach improve perceptions of treatment, steps to combine street outreach and telemedicine offer promising opportunities to extend addiction providers’ reach. In addition to funding services, we should invest in a research and policy development fund and involve affected individuals and families, to avoid the mistakes that followed the tobacco settlement. We should follow Portugal's lead and develop humanistic and pragmatic policies that focus on treatment, not the failed policies of punishment and incarceration.

The development of the Opioid Settlement Advisory Committee is a good start. No single program or policy can address the complex opioid and polysubstance use crises in our communities. We hope the state can seize this opportunity to help develop a robust prevention and treatment landscape for patients with substance use disorder in Rhode Island. 

- Hannan M. Braun, MD, Addiction Medicine Fellow, Department of Medicine The Warren Alpert Medical School of Brown University and Josiah “Jody” Rich, MD, MPH, Professor of Medicine and Epidemiology at Brown University, Director and co-founder The Center for Health + Justice Transformation at The Miriam and Rhode Island Hospitals