“It took away the pain — all the pain,” said a doctor who fell victim to the charms of Oxycontin. “In the brain, in the heart, in the body. That’s what we’re up against.”

Every day in California, 20 people die of opioid-related overdoses, and many thousands more wrestle with the ravages of addiction. After years of legal wrangling, the companies that made and distributed the first waves of these super-addictive drugs — aggressively pushing doctors to prescribe them and insisting they weren’t addictive — are doing a financial penance that’s washing into most every neighborhood in America.

California and its counties will get about $3.5 billion over the next decade-plus from opioid settlements, according to the Attorney General’s office. The first waves of that money are arriving, and the lion’s share of it is in the control of local governments — primarily your county board of supervisors, but also cities.

To date, California’s state and local governments are owed $425 million from various opioid settlement funds, with $59.5 million for Los Angeles County and its cities, $22.7 million for Orange County and its cities, $17.7 million for Riverside County and its cities, and $12.7 million for San Bernardino County and its cities, according to data from Brown Greer, court-appointed funds administrator, and published by the Kaiser Family Foundation.

Hundreds of millions more will funnel to California governments over the next several years. This money is meant to ameliorate harm. Will it, can it, actually make a difference?

“Policymakers, community leaders, and all those affected, want to avoid the outcomes of the tobacco litigation, in which only 2.6% of litigation payouts actually went to smoking prevention and cessation programs,” said a blueprint for wise settlement spending compiled by experts from Harvard, Johns Hopkins, Yale, Stanford, RAND Corporation and others.

“State and local policymakers will, in many cases, have considerable discretion over how these lawsuit dollars will be spent in their communities — and they will need to weigh important trade-offs and make evidence-informed decisions to ensure the funds are well-spent.”

The money won’t come close to covering the $1 trillion in public and private costs of the opioid crisis, wrote Rebecca Lee Haffajee and Bradley D. Stein of RAND. But the infusion of dollars could quickly save lives and mitigate lifelong harms.

“It matters how this money is earmarked for use,” they wrote. “Settlement money should be spent in three areas that research shows will substantially reduce deaths and improve lives: preventing overdoses and other harms to those using opioids, providing evidence-based addiction treatment, and offering services for mothers and children affected by the crisis.”

Transparency is vital as these funds make their way into the world, said Stein, director of the NIH-funded RAND-USC Schaeffer Opioid Policy Center and senior physician policy researcher at RAND. But getting specifics from local governments is still very much a work in progress.

Destination: Still largely unclear

In giant Los Angeles County, which gets the biggest slice of the pie in Southern California, a county team is working on the final details of a multi-year spending plan that will be presented to the Board of Supervisors “as soon as possible,” officials said.

Officials are working with community-based service providers — who are on the ground and understand the most critical needs — to shape L.A. County’s plan, and the public will get to weigh in soon when it goes to the Board of Supervisors for approval. Expect to see proposals for harm reduction and overdose prevention programs, as well as recovery housing and youth education.

San Bernardino County is working on a plan. So is Riverside County, focusing on training, enhancing data collection, prevention, treatment, recovery efforts and a public education campaign. It’s expected to go to the Board of Supervisors this summer.

Costa Mesa hasn’t decided where to spend the money yet. Neither has the city of San Bernardino.

Annastasia Rose Beal of Harm Reduction Circle hands out Narcan and supplies in Santa Ana in April.(Photo by Jeff Gritchen, Orange County Register/SCNG)

Santa Ana plans to use the money for homeless-related services, to buy naloxone and train first responders. The Riverside city council will debate the same options in late August, and will also consider using the cash to fund new positions like substance use disorder counselor, social worker and/or behavioral health clinician.

More than a dozen cities’ shares are so small they’re forwarding it to the County of Orange. The County of Orange has launched a data dashboard tracking “Orange County Drug and Alcohol Misuse and Mortality trends” to better target services where they’re needed, to be funded with settlement funds, and plans to provide medication-assisted treatment to folks in jail, greater support for pregnant women and families, buy Narcan and fentanyl test strips and launch a public education campaign.

Newport Beach, though, is forging ahead. It plans to use $396,000 to make naloxone — the drug that can reverse overdoses and essentially bring people back from the dead — more readily available beyond police and firefighters, including training workers at bars, restaurants, hotels, gas stations and other common places people might overdose.

“We will also be developing a public outreach campaign aimed at educating the public on the availability of Narcan, how to use it, and encouraging people to use it when in doubt (no downside if a person isn’t overdosing),” said John Pope, spokesman for Newport Beach, by email.

“Our thought is that most people understand the risks at this point, so we won’t be repeating the ‘one pill can kill’ type messaging. Instead, we want to make Narcan distribution more of a public health resource, similar to having first aid kids handy and knowing the basics of how to use it.”

Newport Beach has an internal working group that will keep tabs on the program and make adjustments. “One thing we’ll learn is how much Narcan to buy, how much gets used, and how we plan for that,” Pope said. “There’s an expiration date attached so we don’t want to buy less than we need, but also don’t want to buy a whole lot more. I could see some of the training components living past the grant, like the school presentations.”

Blueprints for wise spending

The opioid settlement agreements have taken pains to be specific about how the money can be spent, and how it will be reported, in an effort to not repeat past mistakes.

File photo.

Back in 1998, state governments reached an enormous, 25-year, $246 billion deal with the nation’s largest tobacco companies. It was to be penance for lies about the lethal effects of smoking and fund anti-tobacco programs. But what happened has been the source of debate, discouragement and disappointment, said Harvard University’s Allan M. Brandt in the Harvard Gazette.

“The $246 billion was used to fill budget gaps, build roads, and for other purposes; only very rarely was it used for any form of public health, let alone reducing tobacco use, treating those who were addicted, and protecting kids from becoming smokers,” he said. “It’s become a notorious example of collecting a lot of funds through litigation, but not getting those funds to those who most need or deserve them. I think a lot of people have watched the emergence of the opioid litigation with the tobacco settlement cloud hanging over the proceedings.”

To dispel that cloud, experts have been working for years on blueprints for wise spending.

RAND says that distributing naloxone, detecting fentanyl, providing sterile syringes and connecting people to adequate housing are the quickest routes to immediately and effectively reduce overdose rates.

Experts at Johns Hopkins offer five basic principles:

• Spend money to save lives (not fill budget holes);

• Use evidence to guide spending (fund treatment that offers medication to curb opioid abuse — not simply AA-style 12-step programs so ubiquitous in California);

• Invest in youth prevention (not simply school campaigns warning about drug danger, but real support for families struggling with addiction, as those kids are most at risk);

• Focus on racial equity;

• And develop a fair and transparent process for deciding where to spend the money (“guided by public health leaders with the active engagement of people and families with lived experience, clinicians, as well as other key groups.”)

Taken under advisement

With all that in mind, California’s Department of Health Care Services has issued a 17-page “allowable expenditures” bulletin to guide local governments as they wrestle with spending decisions right now.

Settlement money should be spent on “creating new or expanded substance use disorder treatment infrastructure,” interventions to prevent addiction in vulnerable youth, diverting people from the justice system to effective treatment, buying naloxone and addressing the needs of communities of color. And there’s an emphasis on medication-assisted treatment, still rejected by 41% of California’s licensed and certified treatment centers.

Josh Page holds a picture of his friend Timmy Solomon who died of an apparent drug overdose Sept. 2 at age 31. Solomon’s struggle was depicted in SCNG’s Rehab Riviera coverage. (Photo by Mindy Schauer, Orange County Register/SCNG)

It’s still very early, but RAND’s Stein is cautiously optimistic.

“Overall, my sense is that, with the guardrails the states and others have set up, we’ll be able to avoid some of the worst things we saw in the tobacco settlement,” he said.

“We want to see the money flowing toward what works. Harm reduction. Treatment with medication. We know there’s a solid evidence base there, and that’s good.

“Where you see some concerns is in communities where funds go to treatment facilities that provide no medication treatment at all. While it isn’t going to work for everyone, it should certainly be an option.”

The singular focus on overdose deaths — overlooking those who use and remain very much alive and struggling — dearly needs attention, he said. “We have much poorer data on the range of harms that aren’t fatal overdoses. That heavily impact families and children.”

Transparency and inclusion are concerns of Susan G. Sherman of Johns Hopkins.

“Every context and community is different and is going to have different needs. But one thing that’s vital no matter where you are is: Who do you have in the process? Who is helping draw up these plans? Officials? People actively using? Family members?” she said. “You’re cutting yourself off at the knees when you’re not including a whole range of people. It’s often easier to have family members rather than people who are using, but the services serve them and they know what their needs are. That also provides meaning, and we know that having meaning in their lives allows them to make different choices.”

The public will get input when plans go to boards and city councils for approval, officials said. It’s a rare opportunity.

“For a generation or more, the U.S. has made little investment in building the capacity of the substance use disorder treatment system,” a coalition of experts said. “That system ….has not been subject to the requirements of modern health care, including the critical need to promote evidence-based treatment. As a result, a range of practices have been allowed to co-exist, leaving to chance whether consumers receive treatments that work or treatments that may be ineffective or even harmful.

“Abatement funds from opioid-related litigation offer an opportunity for a significant resetting of how we will deliver care for opioid use disorder in the future. …Thus, promoting ‘what works’ is of critical import.”

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Staff writer Laylan Connelly contributed to this report.