By Meg Wingerter
The Denver Post
DENVER 鈥� Hundreds of millions of dollars will flow into Colorado over the next 17 years to try to offset the societal damage from opioid addiction, but the governments and regional councils that control the money have little guidance on how best to spend it.
Colorado will receive at least $787.7 million through nearly a dozen multi-state legal settlements with , with $110.7 million of that total distributed since November 2022.
About 60% of Colorado鈥檚 share will go to 19 regional groupings of counties, with . The amount sent to municipalities, which still benefit from the regional allocations, depends on their populations and how hard the opioid crisis hit them.
So far, the regional distributions have ranged from $345,000, given to five counties in the northwest corner of the state, to $8.4 million for the region that includes only Adams County. Municipalities have received anywhere from just $121, sent to the town of Empire, to $3.9 million, which was Denver鈥檚 allocation.
鈥淚 think the money itself is significant,鈥� she said. 鈥淚t鈥檚 not going to be able to solve every issue.鈥�
And the pot of money could still grow. Purdue Pharma, which made OxyContin, and its former owners still haven鈥檛 finalized their settlement, which would pay about $6 billion over 18 years to state and local governments, as well as qualifying individuals. The U.S. Supreme Court threw that arrangement into question last month from lawsuits through Purdue鈥檚 bankruptcy.
The initial payments from the finalized agreements are supposed to be the largest, however, so unless more companies settle, communities will receive smaller amounts as the years pass, though the exact amount they鈥檒l receive in the future is uncertain. If the regions and local governments don鈥檛 have a plan for all of their allocated funds in a particular year, they can opt to have the state hold that money for them until a future year.
Communities have dozens of options to spend the settlement, and while the sums can be significant, they won鈥檛 cover every possibility, even in cities receiving millions. That forces regional councils and local governments to prioritize what needs to be tackled first and decide how best to do that, with only limited guidance.
Recipients may never be sure if they chose the absolute best use of their funds. But they鈥檒l know if they made a wrong choice by picking something without strong evidence it works, said Rhiannon Streight, senior behavioral health consultant at the Steadman Group, a consultancy that focuses on health care and is helping five regions sort through their options for the settlement money.
Multi-state opioid settlements
As part of multi-state settlements with companies that allegedly fueled the opioid crisis, Colorado will receive about:
- $312,857,251 from the three largest drug distributors
- $86,241,756 from Walgreens
- $79,293,082 million from CVS
- $72,335,953 from Johnson & Johnson
- $70 million from Kroger
- $65,040,485 from drugmaker Teva
- $44,906,208 from Walmart
- $35,831,849 from drugmaker Allergan, which is now part of AbbVie
- $9,926,054 from consulting firm McKinsey and Company
- $5,699,388 from the marketing company Publicis Health
- $5,533,225 from drugmaker Mallinckrodt
- Total: $787,665,251 over 18 years
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For example, Drug Abuse Resistance Education 鈥� 鈥� is a permitted expenditure, but hasn鈥檛 been shown to reduce youth drug use, she said.
鈥淚 do think there鈥檚 a wrong way to do it,鈥� Streight said. 鈥淭here are so many right ways.鈥�
Colorado requires the regions and 79 municipalities receiving settlement money directly to spend it on opioid- and addiction-related projects 鈥� no paving roads or cutting property taxes. Many towns and counties receiving smaller allocations decided to send their share to their region rather than administering it locally.
The 19 regional councils, largely made of elected officials, that oversee the spending have dozens of options to choose from within those bounds, though, and regions are taking very different approaches. A few are saving most of the money for one major project, such as building a treatment facility, while others are making grants to 10 or more organizations almost immediately.
The regions had to submit two-year plans for how they would spend their share of the settlement funds to the Colorado Attorney General鈥檚 Office, which is overseeing the settlements鈥� distribution. The Colorado Opioid Abatement Council must determine whether the planned spending is an , but can鈥檛 deny it if the members believe a different approved use would be better.
The opioid settlements, like the , carry some unusual challenges, said Glenn Sterner, an assistant professor of criminal justice at Penn State University who is involved with Pennsylvania鈥檚 settlement distribution. Typically, when a community wants to do something to address substance use, it submits an application to an agency, which determines if the idea seems sound. In this case, courts are distributing the money, and while communities are required to spend it on opioid-related items, no one is giving them much guidance on how best to do that, he said.
Another challenge is that stigma still surrounds some of the interventions with the most evidence, such as offering the medications methadone or buprenorphine to people in recovery, Sterner said. If decision-makers aren鈥檛 comfortable with proven strategies or think their communities won鈥檛 be, they may instead turn to ideas without track records, he said.
In a perfect world, every community would have a 鈥渂alanced portfolio鈥� of investments in prevention, treatment, harm reduction and recovery services, but the settlement sums are less impressive than they sound when spread out over 18 years, Sterner said. So each place will have to consider which needs are most pressing and how they can use other funding sources to achieve as much as possible, he said.
鈥淲e don鈥檛 really know what the right mix of programs and projects are鈥� for different situations, he said.
Denver goes in on harm reduction
Communities don鈥檛 lack options to spend their settlement dollars.
In September 2022, Denver for its $4.7 million initial payment. Some of the uses, such as medication-assisted treatment in jails, already had other sources of funding, and some weren鈥檛 feasible with the amount available, such as building a new treatment center. Denver received funds both as a city and as a one-county region.
Ultimately, the largest share of the $7.9 million Denver has received so far went to harm reduction, which accounted for at least $1.5 million, according to data from the attorney general鈥檚 office. Denver received allocations as both a city and as a one-county region.
Harm reduction includes tactics such as operating syringe exchanges to reduce the spread of infectious diseases and handing out naloxone to people who might need to reverse someone else鈥檚 overdose.
The Naloxone Project is using its share of the money, which has totaled about $400,000 so far, to fund and to distribute the overdose reversal drug, which it pays for with other grants and donations. In the past year, about 1,000 Denver Health paramedics, Denver Police Department officers, and Denver Fire Department personnel have taken training about naloxone, and many accepted free doses they can give out to at-risk people they encounter on their calls, Naloxone Project founder Dr. Don Stader said.
Part of the goal is to encourage first responders to think more broadly about who might be at risk. For example, police might be called to an encampment for a disturbance that doesn鈥檛 relate to opioids, but notice needles or other paraphernalia around that would lead them to believe that someone could overdose in the near future, and would have the option to leave naloxone, Stader said. Naloxone won鈥檛 solve the crisis alone, but it can prevent deaths, he said.
鈥淚t鈥檚 part of a holistic solution to the opioid crisis,鈥� Stader said.
The group also is hoping to get some state funding to expand its training beyond the 25 agencies that currently participate, , said Joshua Jacoves, pre-hospital project manager for the Naloxone Project. As of the end of June, the existing partners had given out about 450 naloxone kits to the public. While they don鈥檛 know how many people used them to reverse overdoses, a few recipients have volunteered that they used their first kit and were seeking a second one, he said.
Some of the money also went to diversify the group of people working in peer support in the city. Tonya Wheeler, executive director of Advocates for Recovery Colorado, said the $338,000 the group received from Denver this year allowed it to promote a recovery coach of American Indian and Spanish descent to the role of cultural program manager, and to hire a native Spanish speaker originally from Mexico as a recovery coach. People tend to have an easier time relating to coaches who share their background, and the peer recovery workforce is still disproportionately white, she said.
鈥淟et鈥檚 bring the proper services to the proper community using the proper support,鈥� she said.
Some of the Denver grant also will go toward translating some of their written materials into Spanish, hiring a contractor to train the recovery coaches on diversity and inclusion and paying stipends to people serving on an advisory council to help the group be more equitable, Wheeler said. The group isn鈥檛 guaranteed to get funds every year, but Wheeler said she鈥檚 hopeful that the opioid money will offer some longer-term stability for the people they hired and the diversity work they鈥檙e doing.
鈥淚t can be disruptive to a community when we put services in and have to yank them away,鈥� she said.
to connect more people to treatment through the Colorado Health Network, and the city plans to help the Harm Reduction Action Center purchase a facility; to expand capacity at 5280 High School, ; and to run a public education campaign about harm reduction, among other things, said Curran, the opioid abatement funds program coordinator for the city and county.
The regions have to balance how they鈥檙e going to address immediate needs with longer-term strategies, and have to think about how to collaborate with others working on addiction to do the most with the available funds, Curran said. Denver is talking to the other regions and the attorney general鈥檚 office to see what it can learn from different approaches, she said.
The council in Denver is trying to think 10 or 20 years out for its strategic plan, with the knowledge that it almost certainly will change within that time, Curran said. Twenty years ago, opioid addiction wasn鈥檛 on most people鈥檚 radar as a health problem, and 10 years ago, prescription pills were still the most salient threat. Since then, heroin displaced prescription pills as the top threat, before illicit fentanyl displaced it as the drug linked to the most overdose deaths.
鈥淲e don鈥檛 want to develop this plan, wipe our hands and say, 鈥榃e did it,鈥� 鈥� she said.
Construction, prevention and public messagesSome regions are betting the settlement funds are their opportunity to make a single big investment they couldn鈥檛 otherwise afford.
In its most recent report to the state, the Southwest Opioid Response District said it put 93% of the roughly $1.5 million it had received at that point toward saving up to build a 鈥渞ecovery campus,鈥� with the remaining $109,000 going to grants for community organizations working on addiction. The campus is still in the planning phases and doesn鈥檛 have a site yet.
Heather Otter, project manager for a five-county economic district and facilitator of the Southwest Opioid Response District, said SWORD accepted the first applications from community organizations in June and is still evaluating them. Both the include Archuleta, Dolores, La Plata, Montezuma and San Juan counties.
Approved uses for opioid settlement money
Authorized uses of the money received from the multi-state opioid settlements include but aren鈥檛 limited to:
- Treatment for opioid use disorder
- Supportive housing for people in recovery
- Mental health treatment for people with opioid use disorder and their families
- Drug courts
- Treatment within correctional facilities
- Support for mothers with opioid use disorder
- Stigma reduction programs
- Naloxone distribution
- Syringe exchange programs
- HIV and hepatitis C testing
- Research on addiction prevention and treatment
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The recovery campus won鈥檛 be ready for several years, at least, but it could represent a 鈥済enerational solution鈥� to the problem that people in the area don鈥檛 have anywhere to go after treatment if they don鈥檛 feel ready to return to their normal lives, Otter said. The plan is eventually to build a continuum of recovery services, ranging from supportive groups through sober living homes and the recovery campus, which will have a curriculum that residents complete, she said.
鈥淭he recovery piece is something that can endure long after we鈥檙e doing the work,鈥� she said.
Other regions concluded that building new infrastructure didn鈥檛 make sense for them.
Broomfield, which has received a combined $725,000 as a city and a region, doesn鈥檛 have a treatment center within its borders, but in a geographically compact community, people don鈥檛 find it a great hardship to go to one of the surrounding counties for care, said Jason Vahling, director of the city and county鈥檚 Department of Public Health and Environment.
Broomfield had recently completed a community health assessment, which gave some general areas to explore, Vahling said. It then convened an advisory group, which determined the biggest priorities were preventing substance misuse, harm reduction, linking people to treatment and setting up an infrastructure to oversee the groups using the funds, he said.
Some of the strategies they鈥檙e pursuing include preventing drug use by giving young people scholarships for activities so they have less unsupervised time, training community members to recognize when someone needs help, distributing naloxone to anyone who wants it and hiring someone to help in the justice system get treatment and meet their other basic needs, Vahling said.
鈥淲e believe we need to be able to address all of those community factors,鈥� he said.
Generally, prevention programs are most successful when they teach kids communication skills, how to make good decisions and how to handle their emotions and control their behavior, said Nathaniel Riggs, executive director of the Colorado State University Prevention Research Center.
Family programs that teach how to talk to kids and monitor their behavior in a way that doesn鈥檛 feel punitive also can help, he said. The center is working with four Colorado regions to develop their prevention plans.
鈥淚t really is about promoting the good,鈥� because people who feel their lives are going well are less likely to engage in dangerous behavior, he said.
In contrast, evidence has shown that 鈥渟care tactics鈥� and programs that just present information about the negative effects of drugs rarely succeed in reducing youth use, Riggs said. Bringing in one-time speakers also isn鈥檛 a good use of money, he said.
鈥淲e know those approaches don鈥檛 work, mainly because they don鈥檛 build skills,鈥� he said. 鈥淩aising knowledge of substances and the effect that they have on the human body鈥� is important, but it鈥檚 not enough.鈥�
Prevention can look different from region to region.
Karina Schorr, opioid abatement council coordinator for the mountainous Region 5, said their anti-stigma campaign has an element of encouraging people to think about how they can still enjoy themselves and be part of their communities without substances. They plan to feature local people in recovery from a variety of substances, not just opioids, since people who are struggling with one drug may use others, she said.
鈥淎s a region, we鈥檙e somewhat characterized by the mountain resort towns,鈥� she said. 鈥淚t kind of comes along with a lot of substance use and so-called party culture.鈥� Region 5 includes Summit, Eagle, Pitkin, Garfield and Lake counties.
The Region 5 council also contracted with a local group, High Rockies Harm Reduction, to distribute naloxone in places where people feel comfortable coming to pick it up, Schorr said. As is, most of the free naloxone in the area sits in county health departments, and people who use drugs may not want to advertise that fact to a government agency, she said. The group also offers peer support and help finding care to people who want to stop using drugs.
鈥淎ccess isn鈥檛 (as) strong up here鈥� as it is in the metro area, she said.
Most funding sources last only a year or two, so the councils have to shift their thinking to best use the opioid settlement funding, Schorr said.
鈥淲e鈥檙e still trying, I think, to wrap our heads around what it means to have funding for 18 years,鈥� she said. 鈥淲e鈥檙e just trying to make sure we build a long-term vision and strategy.鈥�
Initially, the attorney general鈥檚 office asked the councils to submit two-year plans, but now they can go one year at a time, said Streight, the consultant working with regions on plans to use their settlement money. Increasingly, though, councils are looking to make plans for three to five years, so they don鈥檛 have to go through the process of redetermining their priorities annually, she said.
鈥淐ouncils are getting 鈥� 鈥榝atigued鈥� maybe is the right term 鈥� and want some longer-term planning,鈥� she said. 鈥淧rograms require a little bit of time to determine if they鈥檙e working or not.鈥�
Streight said she and the other consultants in the firm choose a handful of the available tools to help the regions they鈥檙e working with to make their decisions. Most have come in without a clear idea of what goals they want to pursue, which isn鈥檛 surprising since the elected officials on the regional councils aren鈥檛 experts on substance use disorders, she said.
The settlement came with an appendix highlighting the strategies that have the most evidence behind them, but even those may not be right for every community, which makes it vital to talk to people in recovery and those working in addiction locally, Streight said.
They also compile data to get an idea of what resources a community has and what gaps are most important to fill, she said.
鈥淭he people who have lived this in their communities, they know what to do,鈥� she said.
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