Tension around best ways to spend opioid settlement money
By Taylor Knopf
The first payments from a $26 billion, multi-state opioid lawsuit settlement are set to arrive in the states later this spring, and in North Carolina, there are already disagreements over which groups are most qualified to receive the money.
Over the course of 18 years, North Carolina will receive $750 million of the opioid settlement funds from the agreement reached with drug companies for their alleged roles in fueling the opioid epidemic. Most of the money will be sent to North Carolina’s county governments to help people and communities impacted by the overdose crisis.
The NC Attorney General’s Office and the state health department created very specific guidelines for how each county can use its share of the money. Nonetheless, there’s growing tension around what interventions and treatments should be funded, and some approaches are backed by more scientific evidence for treating opioid addiction than others.
For example, a recently formed group called Bridge to 100 aims to help secure opioid settlement funds for “faith-based rehabilitation centers” in all 100 North Carolina counties. The group was founded by former state GOP leader Robin Hayes, who pleaded guilty to lying to the FBI in 2019 and was pardoned by Donald Trump in January 2021.
Now, Hayes is turning his attention to the opioid settlement, and helping him is former businessman Daniel Williford who was convicted of a multi-million dollar Ponzi scheme and is still serving time in federal prison, according to the federal inmate database. Hayes said Williford — who is finishing the remainder of his sentence at home — has been an “outstanding” help. Hayes said he plans to put Williford on the Bridge to 100’s board of directors, saying “everybody deserves another chance.”
“I’ve been in the public service business for well over 40 years now. I think this is another way that I can use the contacts that I have, the experience and knowledge to continue to help people,” said Hayes, who is also a former NC congressman.
“This is an extremely important issue, and there are a number of different tools and assets and people and organizations that can and should be at the table.”
Faith groups and medical experts at odds
Most of the faith-based groups Hayes said he’s partnering with use a 12-step approach to treating addiction, meaning they do not use medications. One addiction treatment program in Stanley County emphasizes its use of abstinence-only treatment, incorrectly claiming on its website that medication for opioid use disorder “DOESN’T WORK.”
Another addiction treatment group in Brunswick County includes “regular church attendance” in its definition of addiction recovery and its treatment model includes “a relationship with Jesus Christ.” Hayes said he’s also visited Hope Alive’s new addiction treatment facility in Robeson County and talked with the pastor who founded the group, a nonprofit NC Health News previously reported received $10 million from the latest state budget despite having no experience in substance use treatment.
Medical experts say that faith communities can provide valuable support to a person recovering from addiction, but religious activities should not be conflated with medical treatment for opioid use disorder.
“I have no interest in imposing personal faith on folks,” Hayes said when asked about the focus on Christian groups. “But through experience, I’ve seen so many instances where the belief in God as a higher power has a very transformative effect on folks that were suffering some catastrophic circumstances.”
“Gold standard” opioid addiction treatment
It’s been well-documented that medication to treat opioid use disorder — such as methadone and buprenorphine — greatly reduces the risk of overdose death.
At a time when overdose deaths have reached record numbers, addiction medicine experts are pressing for treatment programs to embrace the FDA-approved drugs for opioid use disorder that have come to be considered the “gold standard.” In fact, there’s so much consensus in the medical community about the effectiveness of these medications that President Joe Biden called for universal access to them by 2025.
Meanwhile, the widespread presence of fentanyl in the street drug supply — an opioid 50 times stronger than heroin — has “changed the game,” said Eric Morse, an addiction psychiatrist in Raleigh and CEO of Morse Clinics which provides medications for opioid use disorder.
“Now the death rate is so high that if you’re not providing the best care at the very beginning, you’re letting people die,” he said. “And in no other field of medicine would that be permitted.”
During a recent discussion about opioid settlement funds, Morse took aim at residential addiction programs that don’t allow participants to take buprenorphine and methadone.
Upset in Wake County
The Raleigh-based doctor told members of the Wake County Drug Overdose Prevention Coalition in October that programs such as Healing Transitions in Raleigh and Fellowship Hall in Greensboro shouldn’t receive settlement funds unless they allow participants access to all FDA-approved medications for opioid use disorder.
“I just am tired of the discrimination against our patients,” Morse told NC Health News in an interview. “They should not be discriminated against just because they’re on a lifesaving, FDA-approved medicine to treat their chronic medical illness.”
Patients on medication for opioid use disorder are stuck at a crossroads, with few residential addiction programs in North Carolina that will take them. Morse estimated that around 10 percent of his patients on buprenorphine or methadone would like to go to a residential program. He said these patients are on medications but still in “chaotic” living situations where they’re around people using illegal drugs or they’re involved in illegal activity to support themselves.
“It would be nice to be able to go to Healing Transitions and remain on your methadone or buprenorphine or be able to go to TROSA in Durham,” he said.
At Greensboro-based Fellowship Hall, buprenorphine is only used for substance use detoxification treatment. Director Mike Yow said his program is not licensed to prescribe the medication long term. And because people have shorter stays at Fellowship Hall — an average of 25 days — he said it would be difficult to initiate someone on these medications and then find them somewhere to go.
Yow also called long-term use of methadone and buprenorphine “drug replacement therapy” and said it may keep someone alive in the short-term but that it “ultimately doesn’t help” people long-term.
“Our experience is that when someone’s engaged in an addictive process, it’s very difficult to make any positive headway if they’re continuing to take addictive substances,” Yow said. “So people seek us out here, knowing what our treatment modality is — it’s well stated — and they come in on their own volition and say, ‘I want to come off this medicine because it’s killing me or it is too hard or it makes me feel like crap.’”
Chris Budnick, the director of Healing Transitions, clarified that his facility isn’t a clinical treatment program, but a “peer-run recovery program in a homeless shelter setting,” meaning people with their own experiences of addiction and homelessness support one another. People who complete the program at Healing Transitions typically stay between 14 to 16 months.
The barriers to allowing medications for opioid use disorder for Healing Transitions’ residents are complicated and include capacity issues, Budnick added. His staff and resources are stretched thin across different initiatives. He said there’s not a safe, responsible way to store and distribute the medications — which are classified as controlled substances — on site. And taking residents to a clinic daily to get the medications poses logistical challenges.
Budnick said there are a handful of people who have come back to Healing Transitions after returning to drug use, and now they are trying medication for opioid use disorder. He said staff drive some of these participants each day to receive methadone or buprenorphine. Sometimes Healing Transitions refers people to a program that will suit them better.
“Our goal is for somebody who comes in here is to find the solution that’s going to ultimately make them feel happy, satisfied and have a meaningful life,” Budnick said.
NC Health News reached out to the Wake County board of commissioners for a comment — since the board will ultimately approve each opioid settlement expenditure for organizations within Wake County — and a spokesperson said the county is still receiving “input on funding scenarios from community partners.”
Spending the settlement money
In an effort not to repeat the mistakes made with the 1998 tobacco settlement money — where only a small portion of the billions sent to states was put toward smoking cessation — there are clear guidelines for how the opioid settlement money must be spent. State lawmakers will be in charge of distributing 15 percent of North Carolina’s opioid settlement funds, but the rest will go directly to the counties.
All but a handful of North Carolina’s 100 counties have signed an agreement with the Attorney General Josh Stein’s office on how the funds will be used. Stein’s office has estimated the amount each county will receive from the settlement which will be doled out over close to two decades.
The settlement money must be used on opioid abatement strategies that address the harms of the opioid epidemic. In North Carolina, the different options are detailed under two lists (A and B) in the agreement between county leaders and the Attorney General’s Office.
In a series of virtual meetings with county commissioners — who will approve each settlement expenditure in their respective communities — staff from the Attorney General’s Office and the state health department highly encouraged local leaders to choose from the 11 strategies defined under list A. Some of these options include evidence-based addiction treatment, recovery housing support, post-overdose response teams, syringe service programs and criminal justice diversion programs.
County commissioners can fund other strategies under list B, but those must go through extra approval steps.
The strategies in list A are “so fundamental and there is such a broad consensus about the effectiveness of those strategies of addressing the opioid epidemic,” said Steve Mange, senior policy and strategy counsel to the NC Attorney General, during a virtual meeting with county leaders.
What is “evidence-based” addiction treatment?
If county leaders decide to fund addiction treatment, it’s defined as “evidence-based treatment consistent with the American Society of Addiction Medicine’s national practice guidelines for the treatment of opioid use disorder – including Medication-Assisted Treatment,” according to the settlement agreement.
During two virtual meetings, state leaders and medical experts highly encouraged county commissioners to fund addiction treatment that incorporates medications for opioid use disorder.
“The number one way that we treat opioid use disorder in the United States and in North Carolina is detox and abstinence,” said Blake Fagan, a family physician at Mountain Area Health Education Center in Asheville who oversees the organization’s office-based treatment program for substance use disorders.
During a virtual presentation, Fagan explained to county commissioners how roughly 90 percent of people who go through a 90-day abstinence program for addiction — participating in therapy and learning coping skills — return to use within six months to a year.
“It’s not the withdrawal, but the cravings that will get them,” Fagan said.
“For the 10 percent of people in long-term recovery who don’t need medication, that’s awesome for them,” he continued. “But the evidence-based answer to helping people with opioid use disorder are these three medications — buprenorphine, methadone and naltrexone.”
Fagan told the commissions that 56 percent of his patients on these medications are continuing and doing well.
Under the state settlement agreement, North Carolina counties will be required to report how they plan to spend their share of the money, where it is actually spent and what impact it has on the community.
The state developed a series of online dashboards where this information will be available. In addition to reporting requirements, there will be annual financial audits of the settlement spending.
Compared to other states, North Carolina is very prepared to account for its settlement money.
“Of all the government-promulgated materials created to explain this complicated national settlement process, North Carolina’s are the clear par exemplar,” wrote Christine Minhee, a Seattle-based attorney who created an opioid settlement tracker.
“To enrich localities’ abatement spending decision making processes, county-specific data related to opioid-related overdoses and relevant social determinants of health (e.g., unemployment, homelessness), the state has published a rather impressive set of statewide opioid settlement dashboards,” Minhee wrote. “Other states will be well advised to take heed of NC’s leadership on the data and public education fronts.”
North Carolina counties are required to set up a special revenue fund for the settlement money so it’s not mixed with other loans and projects, and each expenditure will need to be added as a budget item and voted on by the commissioners.
“There shouldn’t be any secrecy or cloak and dagger type arrangements about how the money will be spent,” Mange, of the Attorney General’s office, told county commissioners during a virtual meeting. “When 18 years has passed and we’re all looking back on how North Carolina spent the opioid money, it will all be reported.”
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