Can Opioid Settlement Funds End the Crisis?

Opioid makers and distributors are paying over $50 billion to settle lawsuits with states and cities.

But how is this settlement money being spent?

And is the opioid crisis nearing an end?

In this episode of CareTalk, David E. Williams and John Driscoll explore the impacts of recent opioid lawsuits and whether they could finally put an end to the crisis.

TOPICS
(0:30) Examining the Opioid Settlement
(2:50) The Difference Between the Opioid and Tobacco Settlements
(4:47) What Are the Settlement Funds Being Used For?
(7:09) What's the Impact of the Opioid Settlement?
(8:40) What Should States Do With Their Settlement Money?
(9:06) The Waves of the Opioid Epidemic
(12:50) Combating Waves of Fentanyl and Stimulants
(13:53) The Pitfalls in Opioid Addiction Treatment
(16:08) Preventing Opioid Addiction
(18:27) The Role of Mental Health in Opioid Addiction
(20:44) Avoiding Fentanyl With Test Strips

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CareTalk is a weekly podcast that provides an incisive, no B.S. view of the US healthcare industry. Join co-hosts John Driscoll (President U.S. Healthcare and EVP, Walgreens Boots Alliance) and David Williams (President, Health Business Group) as they debate the latest in US healthcare news, business and policy.

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Transcript

0:00

Opioid makers and distributors are paying over $50 billion to settle lawsuits with states and cities. How is that money being spent? And is the opioid crisis finally over? Welcome to Care Talk, America's home for incisive debate about healthcare business and policy. I'm David Williams, president of Health Business Group. And I'm John Driscoll, the chairman of Waystar. John, we're talking about $50 billion. I mean, what are these settlement funds and what does it all add up to? Billions. Well, you know, we have in the United States a tort, sort of a plaintiffs bar. that is extremely effective at suing big companies and getting big, big, big settlements, particularly when public health is involved. I think if memory serves, there was a tobacco settlement added up to almost a quarter of a trillion dollars, like 200 plus billion dollars. And this is not uncommon. What's different this time is this isn't a retrospective settlement after a lot of the harm has been done. We're in the midst of a real opioid crisis. So the lawsuits relating to where plaintiffs' attorneys sued pharmaceutical manufacturers, distributors, retailers, anyone in the pharmacy supply chain to get these settlements that were then consolidated, and they're really, they're standing in for the states, the state's attorney general who sued all of these entities and have gotten a succession of settlements where the companies over a period of time are paying these dollars out, well, we're in the midst of a real addiction crisis, particularly post-COVID. And so it's really interesting time to review what's happening to these dollars because while the increases in opioid deaths have gone down, we still lost, I think, 90,000 people in overdoses last year. So we're in the midst of an addiction crisis, David. So I think it's an opportune time to say, where's the money? Well, John, know, I mentioned over 50 billion and it's, this is still ongoing, including these settlements and it's likely to hit toward a hundred billion. I think the categories of the spending are meant to be in prevention, treatment and harm reduction, which as you say, is different from tobacco where it was really, hey, we incurred all these medical expenses because of people smoking in the past, as opposed to there's this crisis that, you know, those who being sued are, uh, you know, accused of participating in, and now we need prevention, treatment, harm, uh, reduction. So, all right. So now, John, we've got the money going out and it's going to states. And then I think some of them may allocate it to cities and counties and it's being spent at different levels. And one thing that's happening is, um, Kaiser family foundation as a public service has started keeping track of what the expenditures actually are. And at least for the first couple of years, 2022 and 2023, they counted up over 7,000 different expenditures. What are the sort of things that we're seeing being funded? Well, before you go there, the reason why that's so important is, David, do you know the percentage of the tobacco settlements that actually went to tobacco, like smoking cessation and harm reduction and avoidance in programs relating to tobacco for those $200 billion that went to the States? Do know what percentage of those dollars that were supposed to be, I think, they were awarded to the states related to tobacco, how much actually has gone to tobacco, which is still one of the leading causes, preventable causes of death in America in terms of heart attacks and cancer. What percentage of that 200 plus billion dollars went towards tobacco harm reduction or avoidance, David? Well, John, I read ahead in our research. As of 2018, it was about 2.6%. 2.6%. That's not even a tip. That's a joke. so I think that's why this Kaiser hat really is stepping up with some of the advocacy groups to look at, OK, we won again. Let's maybe this time actually use those winnings, which will come in over time, and are going to be north of $50 billion, to your point, to actually try to use those dollars in the fight to sort of solve this big public health crisis, but let's start with it being a public accountability crisis too. So where is the money going right now, David? Well, it is going to things like addiction treatment programs. That I think is front and center. Harm reduction. Now, harm reduction we talk about means that someone's going to do something to themselves anyway. So what can you do to prevent the problem or what can you do to mitigate it? And that is mostly Narcan or Naloxone distribution. So that's the product that can reverse opioid addiction. Yeah. And that's actually a revolutionary. it doesn't actually reverse an overdose. Yeah. So that's right. it will be, when someone is about to die from an overdose, it can reverse it. And it's an amazing product. And honestly, there's a pretty strong argument given that we lost 90,000 people last year to put that in every cop car, every first responders kit and frankly, every area easy to access like the cardiac defilibrators you see in any large public, highly trafficked area. So that's a great drug for someone who's about to die of an OD, but what else? John, if those who are watching on video and can see my background, right behind the Father's Day card is actually Narcan prescription right there. I keep it around, not because I know of anything specifically happening here, but just to be ready to do something. So you can get it at the pharmacy. It's actually covered by insurance. So anyway, that's there. But the settlement didn't pay for it, John. I think my insurance company paid for it. There's also mental health services and workforce training is another category where we're seeing this because mental health separate from addiction treatment is something that can be helpful in terms of keeping people off drugs and then training the workforce to be able to handle those patients. And then there's some other things that are somewhat more controversial like law enforcement equipment. That's another category loosely tied to. They're pretty well funded, as I recall. So, I mean, these categories sound pretty good. And I say there's more accountability and there's specific areas that it has to go into. It's not like in a sense, the tobacco settlement was like the lottery. The states won the lottery and they can put the funds toward general use or reducing taxes or buying, you know, armored personnel carriers for the police or whatever. And this is supposed to be a little bit different from that. I think there's still a question about where are the funds actually going to be spent and what's the impact going to be? Because some of these things that sound good are not necessarily evidence-based. Well, I'm just happy that they're actually now as part of the settlement, the rules were set up a little bit more aggressively this time. So the states can use up to 15 % of their dollars for whatever general purpose funds, but the rest of it really is supposed to be used for some sort of treatment prevention alternative support for folks with addiction. And I think about a third of the money is allocated for stuff, sort of activities and programs now. Some of it's close to a third is being set aside. But I think the final third is people are, it's kind of opaque. But as you look at the dollars that are being spent, David, at least this time, most of them are going in the general direction. of addiction and prevention and care. We're in the middle of this right now. What's your recommendation to the states? If you're the opioid and addiction czar of a state that was like really hard hit like West Virginia, what should they do with the money? John, you mentioned a couple of times that we're in the midst of it. And also, I think that we want to be a bit evidence-based of how it's done. Let's talk about what it means to be in the midst of it. And maybe that will then help to drive some of the conversation. So we talk about the opioid epidemic occurring in waves and we're talking about the fourth wave now. Well, what were the original waves? First wave was prescription opioid abuse, right? People were prescribed opioids. You went and you got your wisdom teeth out and they gave you, you know, two months supply and this is all over and that's what people were doing. Now what happened was after people ran out of their prescription and they were addicted and they found out it's $25 a pill on the black market to get it. Then they went to heroin, which was reasonably inexpensive. so you had people that you didn't think about would be heroin addicts became heroin addicts. I mean, to put kind of context on that, heroin is cheaper than a six pack of beer. It went from being an expensive high to being a really inexpensive high in the context of drug and alcohol abuse. That's right. So anyway, despite the taboo about being a heroin addict as opposed to, I just take some pills, that was a second wave, John, heroin. Then the third wave, basically the basic story is things get worse and worse. third wave, John, is the fentanyl. So you have essentially synthetic heroin, very cheap and easy to add, sprinkle around in different places. So a lot of the overdoses, but in fentanyl where it's just unbelievably potent and it could be somebody's, you usually get a second chance after you screw up. I won't say for you, John, but for me, first time going out drinking as a teenager, you come back. you have a headache, maybe bad hangover, but you usually get a second chance. And with fentanyl, that's not necessarily the case. So these synthetic products like fentanyl, that's been the third wave. And I think we both know people who've been- And just, we know people who've died. mean, the thing about fentanyl is that its primary ingredients are the same that are used for a number of agricultural products. And so from a supply perspective, In some cases, the ingredients to make it are being brought into the States legally where they're then combined in an illegal way to distribute. it's very cheap to manufacture those and relatively cheap to purchase and then cheap to manufacture and obviously relatively cheap to distribute. You've also got fentanyl coming in ready-made across the border and that fentanyl the very highly, addictive, highly impactful, and, in, in many ways is deadly substance is a problem in every community in America. And you don't have to, you don't have to deal with much of it, but if it's at the right dosage, you know, it can be a contact. I could just touch it and you can get very, very sick or even, or even OD. So we are in the midst of a lower cost, easy to distribute drug wave. that honestly, Dave, these dollars would be really helpful at every level to help us get at that because it's killing lots of kids and adults. So John, they talk about now a fourth wave, which is related to the third, and that's fentanyl plus stimulants. So that's people taking something like cocaine plus a fentanyl. And it's sometimes intentional and it's sometimes not. it's polysubstance abuse is the term. that's used now back in the day, John, back in your day, at least, you know, they had things like speed ball heroin and cocaine together. So it's not a new concept of mixing the drugs either to, you know, balance the effect of the high and the lower to enhance it. but now it's happening intentionally and unintentionally and there's a lot of fentanyl out there. So to answer your question, John, I've been long winded in getting to the answer, but it should be focused on how do you combat this wave of fentanyl and then the fentanyl plus stimulants. That's what we should be focusing on. Yeah. And the reason why this is so important, David, is almost 14 % of all Americans have used illicit drugs in the past month or so. And of that number, close to a quarter of them will be drug dependent. And they can accelerate that into a situation where they can kill themselves because of these third and fourth waves of drugs. This is a large and growing problem of a drugged America. And these dollars could actually be quite powerful if we can target them at addiction and support for those who want to beat it. So John, just to give a couple of specific examples, so one of the things that's effective of weaning somebody from heroin is methadone. But if you have somebody that's actually has a polysubstance issue, methadone doesn't actually do the job. You can't go from taking fentanyl together with cocaine and just going on methadone. That doesn't work. There's a higher risk of overdose. And you basically need a more holistic approach to treat. And there are also some things that get in the way from a moralistic standpoint. So I'm not going to give somebody treatment unless they stop smoking marijuana. for example. And that sounds good because it's about personal accountability, but the impact is going to be you're to have more people die. So first level, we need to be aware of this as a public health crisis. I it's just under a billion dollars of associated costs when you add up health care, crime, lost workplace productivity, and it's growing as a challenge for the United States. This is a public health problem. And I think we ought to use the tools of public health to determine what works and what doesn't and apply it to as many people as possible. mean, David, have a mental, you know, we've talked a lot about mental illness on this show and, 50 % of all people with mental illness have had at some point, use of illicit drugs or substance abuse problems. There's two, two million plus people in the United States who are qualify for opioid use disorder, which is overuse of the opioids that are the substance that actually got us this settlement. We need to take the tools and the metrics. Public health is really metric driven around what works and what doesn't in terms of return on investment and make sure that we're putting the dollars towards those things, particularly at a time when state budgets are sort of creaky, limited post-COVID. This is a looming public health crisis. And if we don't solve it at the addiction level, as you're suggesting, we're going to pay for it in terms of public health, in terms of all of our health care expenses. John, when you look at some things like when you're talking about prevention of a chronic illness like diabetes or high blood pressure, the challenge is you may do things upfront that are effective, but you don't get the savings or the impact until decades later. Here, what we're talking about is If you can stop somebody from, you know, using these substances and becoming addicted, you can prevent an overdose and a death in a short timeframe. And then we're talking about people that could be young, 20s, 30s, 40s, whatever, we're cutting many decades off of their life. So the downside is like very clear and close. And so that means that if you have programs that are evidence-based that work on preventing people from becoming addicted in the first place, that can be pretty successful. Because once addiction grabs you, it's pretty difficult. So the equation is more straightforward. This isn't so subtle, but we need to work on things that actually will have an impact. So David, when you look at where the dollars are spending, again, about a quarter of the dollars out there, it's really unclear where they're going. And in some cases where we know where they're going, they're going to, to your point, some weird things, whether it's an anti-abortion clinic, or heart screening for first responders. mean, the first thing we need to do is be responsible about where this money is because there are places where we could use it right now. I there aren't enough slots for addiction and mental health for all of those people who want to get the help that they need. They're very expensive. They're often not fully covered by insurance. people who are suffering from substance abuse disorder, who want to get help, who are in the criminal justice system, who are incarcerated, all of those clinics are underfunded. While we don't know everything about addiction treatment and mental health and disorder, we can at least, we should at least be willing to get people the care they want when they need it, because we do have some modalities that show that we can do it. But in terms of the prevention side, David, where would you invest there? if you had the opportunity to invest those dollars right now? I think on the mental health, because there's a lot of, you know, we've talked about a lot of people suffer from anxiety and depression, and many are self-medicating. And it usually starts with cannabis. And that works a little bit, you know, but then it doesn't. And then people go on, you know, from there. So I guess I'm giving my gateway drug argument, but. I would say mental health and addressing these widespread anxiety and depression. Well, no, it's not an unreasonable point. And the other thing to realize is today's cannabis is not your grandfather's cannabis. Are you a grandfather yet, David? It's not, I'm old enough for it, John. My kids are old enough, but I don't know. You don't know? Well, that's a separate I'm not supporting any grandchildren, so I'm going to say, yeah. The point you're making is really an important one. and I just don't want to jump over it. We are suffering from the anxious generation as Jonathan Hyde talks about it. And as that generation ages, the easiest way to stabilize for many people is alcohol, cannabis or other things. if they become addicted to that and they don't tend to work, then the challenge we have is we've gotten a massive easy access illegal drug market. And so if we can rip it out at the root, at least not rip it out, but at least manage it at the root, I suspect that would lower the amount of folks who would be prone to addiction. The other place I would really look to invest is black and brown communities, Native American communities, communities that have historically been the targets of some of the illegal and legal, use of substances, whether it's alcohol, tobacco, or illegal drugs, and really invest in prevention, education, support, and alternatives in those communities. It's not that we're running out of places to put these dollars because we do have an increasing addiction crisis in the United States. John, I have the fear a little bit that some of our suggestions are a little bit broad and vague and hard to act on. Let me also give a specific one, which is related to fentanyl. So a lot of times people don't realize they're getting fentanyl, but it's out there as previously described. And there are test strips that you can use basically to detect whether there's fentanyl or not. So for those that are trying to avoid fentanyl specifically, whether that's in a club or wherever, making those test strips broadly available is a good idea. Now, they don't detect the concentration. So some people who are trying to do like this polysubstance use They want some fentanyl and there's no way to tell how much it is. So it can have a downside as well if you say, okay, good, it has fentanyl in it. Yeah, well, let's be very clear that any use of fentanyl is potentially- Will kill you. Yeah, yeah. Is potentially fatal. Well, John, that seems like a good enough place to wrap it up. I thought we were gonna be getting onto the more optimistic side, but I'm glad we're covering these things from a clear face standpoint and hope that the drug- I don't know. here's the optimistic view. We now have dollars to put into these programs that have been underfunded for a generation. We're suffering from a generational wave of addiction and illegal drug and legal drug abuse disorders. Now we've got the dollars to do something about it. Let's for goodness sake this time actually spend it where it matters and where it's relevant. So I know, think this is a good time to... to make this point. Let's keep tracking and let's find out where every dollar is going and make sure that every dollar goes towards solving this real public health crisis and stock up on Narcan. Well, that's it for another episode of Care Talk. We've been talking about the use of the opioid settlement funds and the fourth wave of the opioid epidemic. I'm David Williams, president of Health Business Group. I'm John Driscoll, the chairman of Waster. If you liked what you heard or you didn't, we'd love you to subscribe on your favorite service. Please leave us a review.