Innovations in Opioid Settlement Fund Spending | CMAP Nexus Series

0:19 Well, good afternoon everyone. Thanks so much for joining us. Uh my name is Matthew Eisenberg and I'm the director of the Center for Mental Health and Addiction Policy. Uh we're excited to have you at today's event on Innovations in Opioid Settlement Funding. Um, this event is actually the capstone event to a year-long series the center has held here at the Bloomberg Center for a variety of different discussions on mental health and addiction policy issues capping off 10 years since the center was founded. Um, so we're happy to have you here. We saved the best for last. So, uh, uh, we're glad glad you're here for that. We want to thank the the Provos office, the Bloomberg American Health Initiative, and the Bloomberg Overdose Prevention Initiative for funding. We want to thank all of our um

1:04 uh faculty leads who helped organize this. Abby who you'll hear from momentarily and Sabria uh Linton and Suchini Bandaraa and of course none of this would be possible without uh Sam Rosenberg who is the excellent excellent excellent coordinator for for the center. So I will uh without further ado I'll pass it over to to Abby. Thanks so much. >> Okay. Um, someone else is controlling this. Okay, great. Hi everyone. I am Abby Wker. I'm the program director for the Bloomberg Overdose Prevention Initiative and I am so happy to be here to introduce you all to what is going to be

1:50 a wonderful discussion and panel and kick it off with some background on opioid settlement funds, the Hopkins settlement tracking project and the principles to guide uh expenditures from opioid litigation. So without further ado, I will dive into some background. So just a very big picture history. Um nationwide, states and local governments have brought litigation against companies along the opioid supply chain. That's pharmaceutical companies, distributors, and pharmacies alleging their blame in the first wave of the opioid crisis. In 2021, the first national settlements were reached. And to date, more than 56 billion dollars have been committed to

2:36 states, local, and tribal governments over an 18-year period. These funds are controlled by several distinct entities within each state, and they've been allocated based on an attempt to quantify the scope of the public health impact within each individual state. So, these funds are controlled by distinct shares within each state. Typically, this looks like a state share, a local share, and a settlement council or committee. In some cases, there is another third party share like an administrative subfund. On the right of the slide, you see an example from the state of New York, which just shows the breakdown of state, local, and settlement fund share, but this looks different across every state.

3:22 So in order to introduce the principles for the use of funds from settlement litigation, we need to go back in time and provide a little bit of history. And so we'll we'll think about the tobacco master settlement agreements of 1998. Um, this was an agreement reached between four major US tobacco companies and the majority of US states for the tobacco company's role in perpetuating smoking related illness and addiction through their misleading and harmful practices. Companies were ordered to pay over $200 billion across 25 years. Unfortunately, hardly any of this money, estimates suggest only around 3% ever went back to prevention, cessation, or tobacco risk reduction efforts. The rest

4:09 were absorbed into general funds. Uh, and without any mechanisms in place for accountability or tracking of where that money went, much of it, it's just unknown what it actually went or was invested in. Um, as opioid settlement funds have begun being allocated across states and communities, we have recognized in public health that there are few mechanisms in place to prevent similar misuse. This led a series of public health leaders to think about how we could avoid these settlement funds reaching a similar fate and that led to the development of the principles for the use of funds from the opioid litigation. This is a series of five

4:54 principles meant to guide opioid settlement investments. They were created by members of this team at Hopkins on the Bloomberg overdose prevention initiative and at this point have been endorsed by over 60 national organizations. These funds have this sorry these principles have come to be seen as sort of the gold standard to guide settlement fund expenditures and they're really looked at as kind of the the model for how to think about allocating these funds in a way that aligns with the intention of the settlements. So what are the principles? First and foremost is spending money to save lives. This one really, really serves as a reminder of the real intent of these funds, which is to abate the harms of the crisis. The goal is for

5:40 money to go straight to helping those most in need, reducing overdoses, and supporting those at the greatest risk of experiencing an overdose or a substance use disorder. The principles go on to encourage several other considerations to a guide effective spending. This includes investing in evidence. We know there are many programs along the continuum of care which have an evidence base to support individuals with a substance use disorder. And we also know that there are many programs that are not evidence-based or that run counter to evidence but that are receiving funding. So, it's super important to ensure that funding decisions are made in alignment with evidence or at least supported by existing research and um

6:26 data that shows which programs have an evidence base to be effective. We encourage focusing on prevention and the reduction of the onset of new cases of substance use substance use disorder. Again, it's super important to do so thoughtfully and ensure that funding going towards prevention is supporting programs that are in fact aligned with evidence and not those that are shown not to work. A priority on racial equity. This is particularly important in the context of new data that we've seen in the recent in recent years showing declines in rates of overdose across the country, which of course is fantastic to see and something all of us in public health are really pleased about. But we've also simultaneously seen disparities on the rise,

7:12 particularly among certain subpopuls, including people of color. And so it's more important than ever to ensure that these funds are reaching those most disproportionately impacted by the crisis, not just those that are easiest to target and find. And then finally, a focus on transparency. The public has a stake in how this funding is used. And it's impossible to assess the quality or the impact of expenditures without a clear record of how the money is being spent. And this applies as well to processes. So we encourage transparency not only in where money is going but also in how spending decisions are being made to ensure fair and transparent processes. So these principles were introduced and

7:58 what very wellreceived. My clicker is not progressing me. Is there another way to move forward? Thank you. Um but as um my predecessor in this role and others went about sort of introducing the principles and their scope, they received the question from a lot of audiences, well it's great to have these guiding principles in place, but where is the money actually going? So that led to the creation of the opioid settlement fund tracking project. That is a partnership between Aneri Patani whom you will hear from shortly at KFF Health News, Kristen Pendergrass of Shatterproof, who I believe is potentially here online, and my predecessor in this role at Hopkins,

8:44 Sarah Whe. The goal of this project is to identify all publicly available expend expenditure data across all shares that is the state local council or committee and additional subshares. Compile that data into one comprehensive database which includes DC and all 50 states and characterize each individual expenditure by a coding scheme to make sense of where the money is actually going. This includes a series of buckets, core strategies, and then when relevant, special interest tags. So you can imagine this is a major endeavor that it is. But what have we learned so far? So project year 1, which you'll see in the middle column, encompasses calendar

9:30 years 2022 and 2023. This was done because the project began in 2024 when two years of settlement expenditures had already begun flowing and been allocated. Project year two spans calendar year 2024 and we are now in the process of collecting data for a third calendar year that's 2025. Some basic takeaways at a kind of high level. You can see that the largest bulk of funds in both project years have gone towards treatment than harm reduction and recovery services. We see a much lower proportion going to prevention. Uh I just want to caution that it's important to note that it's difficult to draw direct comparisons between these two years of data because there were

10:15 some methodological changes between the two years of data collection and um the combination of spending across two calendar years for the first project year makes it difficult to draw direct comparisons. Excuse me. As far as our core strategies and a note that these are not mutually exclusive. So something tagged in a bucket will also be tagged as a core strategy. Um we see the largest proportion in both years again going towards treatment recovery services and then nlloxxone medications with prevention reaching 8 to 9 or 10 10ish%. So we are currently as I mentioned underway with the third year of data collection. We hope that with the

11:00 passage of time, we'll be able to start doing some really interesting research to look at trends in spending across multiple years. We have some of our research assistants in the room today and online. And we are very grateful. It is, as I said, no small feat to identify what in the first project year was over 7,000 individual expenditures and in the second year over 10,500. So, where are we going from here? Those of us on this team and who are working in the settlement fund research and policy spaces are thinking about some key issues as nearly 15 years remain in settlement fund expenditures. First is to ensure as I mentioned racial equity and that these funds are actually reaching those populations at greatest

11:47 need and who are facing the greatest risk of either substance use disorder or overdose. That includes a focus on racial equity and identifying those populations that are really facing the greatest burden of this crisis. Improving transparency and reporting consistency, not only to make our jobs easier when we're tracking expenditures, but also to improve the public's ability to understand where this money is going and make sense of these trends in spending. avoiding misuse and supplementation or replacing an existing funding stream with settlement funds, particularly in the context of the federal funding cuts that we've been seeing in the very uncertain federal policy environment. We'll hear a little bit about that at

12:32 the end of this conversation. Certainly questions of monitoring and evaluation. We're thinking a lot about how to monitor and measure the impact of this spending. Are these dollars really going towards saving lives in communities? Assessing the actual quality of the investment across buckets. For example, if a community tells us that something is prevention, does that mean it's really going towards prevention? Is it that it's going to a prevention program that in fact does not have an evidence base? There's a lot of research to be done to understand whether trends in spending are actually aligned with evidence-based strategies. And then finally, segueing us into our fantastic conversation we're about to have today is identifying and raising

13:18 examples of best practices, positive use of spending, and of course, innovations and settlement fund expenditures. So, we're so thrilled to have a really excellent panel here to discuss some best practices and raise up some really interesting and unique work going on across the country with settlement fund spending. And without further ado, I will pass the microphone to Aner to bring up our guests. Thank you so much.

14:04 Okay. Hello everyone. Uh thank you all for coming here today. I'm uh Aneri Patani. I'm a reporter with uh KFF Health News where I've been doing a series of articles for I think this is my fourth year now covering uh how state and local governments are spending their opioid settlement money, how they're making decisions around this. And so I'm very excited to have this conversation. Um been talking to the folks up here about it, some of whom have been in my articles before. Um so I know that they'll have a lot of great stuff to share. Uh before I get started, I do want to let everyone know that in a few minutes there's going to be a QR code up on the slides. That is your way of sending in questions for us to ask panelists. So I'm the moderator and I get the privilege of asking my own questions first, but then I will uh get to yours. They'll come to my phone and

14:50 so I'll be looking at that and and asking them towards the end. So at any point whenever you want to scan that and send them in, um please go ahead and do that. To get started, I'm going to ask uh just our panelists to quickly introduce themselves, just give you their name and title. There's a lot more detail. These are really cool, accomplished folks. So, you can read their full um bios online and on the papers um you you have at your seat, but I'll ask them to just go through and give you their uh name and quick description of what they do. Tracy, you want to start us? >> Okay. Um do it. >> It should be on. >> Tracy Gardner. I'm the executive director of the National Black Harm Reduction Network. Our Gen Z folks make us say N and burn.

15:36 And uh it's a new organization barely three years old, but the concept of black harm reduction is definitely not new. >> Liz Al Countryside Public Health, which is Big Stone, Chipoa, Lacapar, Swift, and Yellow Medicine counties. I'm in southwest Minnesota and I am the administrator of the public health agency. >> Hey everybody, my name is Dalton Barrett. I work in Edgecom County, which is eastern North Carolina and I serve as opioid settlement program director as well as uh the post overdose response team manager. >> And hi everyone, my name is Alyssa Kitless. I'm the opioid settlement program manager in Wake County, North Carolina, which is where Raleigh is located. and I'm also a proud alumni of the Bloomberg School of Public Health.

16:23 Uh so the theme of today is innovations and spending. Um the folks up here could talk about lots of different innovations. In the interest of time, we've asked them each to focus on one. Um so I'm going to start off by asking each of them to kind of talk a little bit about one of the innovations that they've seen and they've worked on uh in the spending of opioid settlement funds. Uh Tracy, can I start with you? >> Okay. Fortunately, you should have in your chair a nice one pager um that we prepared about next DRO. And um in full disclosure, I am the board chair. I have been on the board since its inception. It's barely six years old. Um it

17:10 basically is mail order harm reduction and um I think the innovation part of it is really about the fact that um from the time it started um woman named Jamie Favaro who was working with the National Harm Reduction Coalition um and as the harm reduction coalition has been around since our shortly after our first opioid epidemic heroin and HIV. And so um this really she saw the need to develop this because of the stigma that persists around drug use around access to um storage exchange programs and um the

17:58 fact that traditional public health and what I call the mental hygiene system in which substance use disorder and addiction live have been generally hostile to people who are using drugs or in some stage of their own defined recovery that is not abstinence only. Um this became I mean syringe exchange and other harm reduction strategies were developed to address the harms from HIV and other bloodborne diseases. injection drug users were almost 60% of the um HIV um cases and um after a lot of Tomaltton controversy we were able to demonstrate uh

18:44 dramatically that the harm reduction strategies were were key in driving down HIV transmission. So this is the pot in which the um idea of next destro developed and this idea that you are still going to get harassed if you're trying to buy syringes from a drugstore if your state allows that. We're still dealing with some states who um think that nlloxxone is illegal. Test strips are contraband and all of the other barriers that I think we know a lot about. So this idea of mail order for example in Tennessee we have 600 requests. Let me just say overall there is a weight

19:29 list of o over a thousand. Um so in Tennessee there are 600 requests that really signal unressed needs. A lot of folks who um use Next Distro are folks of color. they are in rural communities but often they're also in places where there are other SSPs and they simply don't feel comfortable or safe in going to them. Um so there is a DRO side which is the distribution network working with organizations across the country to facilitate the distribution of the harm reduction supplies that include Nlloxxone test strips and then um the

20:14 onetoone work which is really critical because these are relationships through email where we know everyone that we're dealing with and we tailor what they need based on what they tell us. And um it's just an ongoing email relationship that puts their privacy and confidentiality at the height. And I'm going to just close in terms of the overview. Happy to answer more questions about how it works. But in some places, we're working with state health officials in um getting the supplies um to community organizations and individuals. Um but a lot of the interaction that Next Distro has with its clientele is

21:03 through email and through the websites. And um this is a model that should be not just replicated but the capacity for this kind of engagement with people who are alienated from these systems we assumed would work for the opioid settlement funds. Um we need to really think out of outside of the box. So thanks >> uh Liz. Yep. Go for it. >> Can you hear me? Yeah. Yeah. My Minnesota's coming out. Uh thank you for coming. What I wanted to touch on my innovation I was told is the pooling of resources. Now I'm definitely going to age myself because there was a slide out there about tobacco settlement and I vividly remember that going into the general

21:48 fund so that they could take care of a budget deficit. So when this opioid settlement fund came out, I was like a bulldog. I'm just going to tell you I really my innovation was pulling the resources. So when you have five tiny tiny counties, they're going to get a pittance. Each little county is going to get nothing. But together we get $2.7 million over 18 years. So we really got 25 commissioners, five county administrators, five family service directors, got them all in a room and said, "How do we pull this money to provide innovative funding?" So there's two buckets. I'm also a farm girl. There's a feed bucket that's evidence-based programming for third grade, fifth grade, seventh

22:34 grade with longitudinal studies being done on third grade, fifth grade, seventh grade. And the second bucket, which I'm in farmland, is crop communities response to opioid program. I figured I'd get people to remember it by telling talking about crops. And that hands out grants every spring and fall to really look at secondary and tertiary prevention. So that's my innovation was really wrangling everyone in a room and convincing them that this was a great great idea and we've had some really good success. >> I love that. Uh and as someone who has uh interviewed many like county officials sometimes in small places that are like we're not getting enough on our own. What do we do? That is a great response. >> The last thing is really the counties really commissioners got in a room and

23:21 they got rid of the county lines. And you know, that's that's the conversation you have to say is like, how do we get rid of the county lines because the greater good is bigger if we drop the lines? And so like $90,000 goes for evidence-based programming. We've done over a thousand kids in 11 school districts. We travel to every county. We're just crossing the county lines. And the grants are crossing the county lines as well. And the commissioners could see that. I mean, they just could see that it was going to be a bigger bang than getting, oh, we got 14,000 this year. What do we do with 14,000? So, it they really did see that benefit, but it took a little bit of wrangling to make that happen. >> Thank you, Dalton. >> Sure. >> Uh that's a hard one to follow up. Uh but >> not if you're Dalton, that's

24:07 >> in in in Edgecomb County, so rural eastern North Carolina. Uh we have a county based EMS system there. And I am a paramedic by trade. So, I grew up uh one of the streets, right? So, I've been out uh doing EMS in the Twin Counties for 13 years. And about four years ago, I had no idea what is. Um fast forward the next year, I was hired to manage the post overdose response team, right? Um so, I took that job. I come off the streets and started to design a program uh that obviously everybody, you know, knows the term, meet people where they need um and then also to fill the gap because we had no harm reduction agency in the area. Um, we had no OTP in our county. So, you know, citizens couldn't get methodone in the county. And of

24:54 50,000 residents, we had two providers that were doing buprenorphine. So, early on, we knew there was a lot of gaps when it when it come to harm reduction as well, but also when it came to treatment. Um, so we did uh field initiations of buprenorphine uh through EMS uh through the port team and that was something somewhat new in North Carolina. There were two other counties kind of on the western side of the state already doing that that had a lot more resources than us. But as we started getting people appointments with treatment, we knew that we didn't want to see them being withdrawal while they're trying to wait on the appointment. So we started BU you know sometimes you know intra overdose a lot of you know there's post overdose response scenes is a common term but a lot of those teams are doing intra

25:40 overdose response so starting bup as soon as somebody wakes up is is been a great way to get people into treatment and really it's great to give them that even if they don't want to get into treatment just to humanize withdrawal and to keep them safe for at least 24 hours. So I think there's a case to be made on the public health side of things. Um, but in North Carolina today, I just checked my numbers a little bit earlier, we have 23 different counties doing EMS, but so in North Carolina there's 100 counties, so about 23%. And over the last 12 months, uh, around those 23 counties, there have been 4,000 uh, individual administrations. Um, and and I'm not sure if it was 8 milligrams or 32 milligrams, but that's a lot. Um, but we have much work to do. Um, but

26:26 we're really excited about that innovation and and everything that we've we've done has been patient centered. You know, kind of getting away from those silos of this countyy's doing this, this county is doing that. Yes, every community is different, but um, at the heart of it, it has to be patient centered and that's our innovation. >> Thanks, Dalton. Melissa, >> great. Um, so I was told to focus on one innovation and an area I'm going to ask you to hold me on track because I get excited about this work and might go down rabbit holes. I'm like we're doing be uh in the field as well. But the innovation I'm going to be talking about today is in Wake County. Um we really wanted to make sure these funds could make a difference. We um we were not wanting to start from scratch, reinvent

27:13 the wheel. We have a coalition that's been meeting coming together for over a decade. And so one of the things we started was asking our partners what they wanted to see in the community. And one of the things that came up was my innovation. Um I'm looking at Abby because I forgot to mention what that is is comprehensive wraparound services. We know that in particular peers and people lived experience who can walk alongside folks is are just critical to navigating systems. Dalton mentioned his county. My county is the opposite. We're about 1.2 million. It's a large county. We're resourceri, but most people don't know how to access services, including myself. It's really confusing. It's hard to know what's out there. And so, we've really focused on investing in programs that f traditional funding streams like

27:58 mechanism uh Medicaid don't support as easily. You know, there are limitations such as 15 minutes to visits with peer support. And so we wanted the settlement dollars to really allow folks to do the work they needed to do in the places where they are to support the people that they're working with and walking alongside. And so one of the programs I wanted to highlight is our partner Arise Collective. They provide re-entry support for women released from incarceration. In North Carolina in the two weeks following incarceration, people released from um our prisons and jails are 50 times more likely to die of a fatal overdose. And so this is a really critical population for all of us. And so we have been supporting our partners at Arise Collective. It's an organization that is primarily run and led by women with histories of

28:44 incarceration and substance use. And with the settlement funds, it allowed them to open a center where folks, it it is the hub where people can come to access um they're supported through transitional housing. They can access treatment and recovery support. They can connect with peers, do education. And so we're bringing all those services together in one place and allowing the folks that work there to spend maybe it's hours um talking to people, asking them about their needs, being really patient centered, um spending the time to take them to visits and and go with them to to jail or to the doctors. And so really trying to use these funds to allow people to do the work that we know works and that they need to do and really meet um that human side walk alongside folks um in a way that traditional funding streams can't

29:31 support. >> Thanks Elsa. And one of the things I love about all the innovations you all heard about and never spoke about here is that I think a lot of times when we hear the word innovation we're sort of you know uh attuned to like technology or some sort of new gadget and it doesn't have to be that right every person here I think said people and relationships and human and that is often the innovation it's something it's a different way of thinking about it. Um so thank you all for highlighting that. Uh I will reiterate now that you all have heard about their innovations. If you have questions for them, um scan the QR code and send those in and I will start asking those as well. Uh but I want to start off with some common themes that you I heard among you all. So all of you, but I'm going to have uh

30:16 Tracy and Alyssa weigh in on this. Um, both of you talked about kind of centering folks who are most impacted, who have lived experience. And we know historically that has not been the case in public health work and not just historically continues today to to often not be the case in addiction policy and programs, but both of the innovations you described really center that. Can you talk a little bit about how, you know, centering folks who have been marginalized and folks who have lived experience is key to the success of of the program? How how does the program um incorporate those voices and how does that help? >> Okay. And I neglected to say so next DRO is getting settlement dollars through New York but we have something like 16 state partners and they are also

31:03 leveraging settlement dollars to participate in this. But I think the the key to point out here is the how deep the marginalization is and the fact that we continue to talk about race, racial equity and the funding and that's not possible when we have systems that are at their core or embedded inequitable. And despite what this administration may want us or let us talk about, the reality is the reality. So next is especially um help crucial, critical to people because it is outside of all of the pathways that have been established. You

31:49 can start with the war on drugs, but it certainly predates that that have been the primary funnels through which money flows. And so to expect that new money will flow through the pathways created by punitive carceral law enforcement responses is purposely delusional. And so the people who are using Next Distro have been hurt by those systems through which funding has traveled. whether it's the addiction treatment system and again there are different worlds when we talk about public health and mental hygiene Shellyley we do know that that's different mental hygiene law and me

32:34 public health law in almost every state in this country are different and that has been the system that has been institutional carceral and hurtful and also very close to mandates and um legal forcible actions. So, anything that gives people an ability to be autonomous in getting their care without being penalized for it is something that I think people um will will gather to. Next is also made up of staff with lived and living experience. and that idea of living. Yes, that means that people are active in their drug use and they're still able

33:22 to do they are able to do this work. So I think that that is really the people engine can never be replaced by technology and the more that we connect people with people um outside of just we are now recognizing people's humanity we are now not narrowing people down through this one behavior that they do which is their drug use and ignore everything else. We are holistic. We are integrated and we're listening to people who are doing this. So I think for us that is the issue. We listen and we're gathering information from people who are willing to talk to us. >> Awesome. And Alyssa, I'll let you take this how you want with the Arise Collective or broader in Wake County.

34:08 How have you all incorporated lived experience in decisions around settlement money and how has that contributed to the success? >> Thank you. I'm going to talk broadly about our settlement work in Wake County. And I will just say something that's really important is that you to do this well. I think it's critical to incorporate lived and living experience throughout the work. In North Carolina, as part of our legal framework, we're required to have a public meeting every year. We were talking about it before we came down. And some counties have uh their board of commissioner meetings as their public meeting, which is great. You know, that is a public meeting, but that is not where people always go. And so we've been really thinking about how do we get feedback in all the places we can get feedback. And so we've had those

34:54 big community meetings. I'm planning one for June if anyone's in Raleigh. Um but we also have surveys. We work closely with many organizations that are led by people with lived and living experience. I think that living experience is really critical because the drug supply changes rapidly. The current context we're in changes. So we need to be talking to people who are currently using drugs as well as with lived experience of substance use. And so um also I think so key to that is establishing real relationships and in doing so um you know making sure that you're listening to folks and showing up and delivering on those promises. When I started in my role, one of the big things I heard was um we do not have very much access to an lock zone in Wake County. We're a county of 1.2 million people and our budget for

35:40 an aloxx zone was $13,000. Um, and I did the math and at today's rate that's about under 600 nlloxxone kits for interasal nlloxxone. And so I see lots of shaking heads clearly nowhere near enough. And so one of the first things we did was delivered on that promise and showed people you we don't want anyone to ration this life-saving medication. And so I think building relationships, establishing ongoing channels for communication, um, and then really delivering on the promises and and, um, as and if you can't, letting people know why. But I think that's been really powerful. And I'll wrap it up to say that one thing that has been really cool, we have a program called healing transitions. They have a rapid responder program, a post overdose response team, and they

36:26 actually have it built into their program to do quarterly roundrobins where they bring folks like me, funders, leadership at the state level to hear directly from participants in their program. And we had one of those roundrobins a couple months ago for um with our state division of mental health director to hear from the folks receiving mobile opioid treatment program um services. So getting their medication for buponorphine and methadone daily to tell the director of mental health how that's working and what they need. And so I think um we have to go beyond having one big community meeting or putting out a survey in our strategic planning. We need to do it often establish real relationships and show up for people. Thank you. All right. So in addition to incorporating lived experience, the other thing I heard uh from several of

37:13 you was kind of working across silos, breaking down, you know, people in their own little areas. Um so Liz, I want to start with you. You mentioned, you know, getting all these counties to come together, work together, and you know, ignore the county borders. I imagine that's hard. Like it's awesome, but it's also lots of places have a hard time doing that. Funding streams are not set up for that. Governance is not set up for that. and the opioid settlement money is coming for a long time. So, you might have turnover in who sits on those uh in those seats. How have you been able to get people to come together and and how are you thinking about sustaining that? >> Thank you. Some of that um is relationshipbased. I have to say that we've had some

37:58 success in my five counties, my five tiny five tiny counties of really uh bringing down the county lines with success of a nurse family partnership home visiting program that is 30 counties. And so we brought down those county lines uh an imu immunization registry. So we we really developed things throughout my career that really brought the county lines down. What I would tell you uh regarding the county lines, some of the challenges is like you just said, who will still be there? One of the things that we do in Minnesota, Minnesota. I just I love when my accent comes out. Minnesota and I, you know, and then I'm from North Dakota. Um is joint powers agreements. And so

38:46 really a joint powers agreement allows you to really bring a group together. And so I function under a joint powers agreement. And boy, I'll tell you that's that's handy because that joint powers agreement really allows you to be that fiscal host, bring the money to one location. So, you know, the money wasn't siloed out. It really went into one spot. So, those joint joint powers agreements, if you have that ability, a compact, you know, something where you can bring that together, um, that has really helped us. And then I'm going to be really, you know, it it's all about relationships, being truthful, holding yourself to being accountable if you don't know the answer. I mean, all of those things as you're going along are so important or the county lines come back up, you know? So, if you don't keep

39:32 your word or if you don't follow through on something, the county lines will want to come back up. And so, you really have to really follow through and really and then report a lot of data. You know, if you've done a thousand kids that have had evidence-based education, well, I'm not going to lie to you. Do you think that county actually wants to know how many kids happened at their schools? Yes, they do. They also though hear from me. How many kids total? You know, because we're we're really it's a total. What impact can we make with evidence-based? If you looked at the principles, use evidence to guide spending and invest in our youth. I'm 8% of that budget of the slide. I got a thousand kids. I need them to not need Dalton's harm reduction. So, if

40:19 I can convince those people in that room to get those county lines down and find a mechanism to do that, which is a compact, a joint powers, some type of agreement, um you can really make those things happen. And so, the funding will stay with with that joint powers agreement, um even though the hands of people will change throughout the years. >> That's great. So you all have systematized it. Um Dalton, I imagine the silos that you're working across are, you know, somewhat same in the counties, but also fields, right? You have folks in treatment, folks in emergency response, and and you're kind of, you know, asking people to work together and take on some roles that they may not traditionally have had. Um talk to us a little bit about how you've made that work and maybe some of the barriers you encountered along the way. >> Sure. And that's that's a great point

41:06 because I mean if anybody in the room has been a paramedic or been a firefighter or something like that, public safety people are very territorial. Like you're not coming to my city and and doing this or whatever. Um and the interesting thing is that on the west side of our county is a large town, Rocky Mount, uh that split between the county lines, like runs right through the like the railroad tracks split it. So the old phrase, you're on the wrong side of the tracks, like that was very like, you know, it was us, you know. So, um, as we started like building out services for people, um, it's almost like we had to figure out what relationships that would take and start talking to those people before we needed them, if that makes sense. So,

41:51 like you talked about with with harm reduction, well, nobody was at the table there. Uh, so we just kind of had to do that on our own. But when it came to treatment, uh when it came to, you know, referring patients to care, uh we had to know who those people were first. And then the uh the local hospital system in our area was extremely difficult to work with. Um they were very um not evidence-based at all and they would kick people out of the ED and just kind of say, "Don't use drugs." and and and that happens a lot around the nation, but you know, now we've got a workflow established with them and they will literally call us to come to the ED to meet someone in their room because that's the easy button for them and we're all about it because, you know, it makes sense for us and we can we can meet that person right then. Um, so it

42:37 was all about relationship building and not taking no for an answer. So every time that we dealt with a situation with a patient, I didn't want to deal with that same hurdle for the next patient. So when it came to, you know, doing bup, you know, that was a thing when it came to uh trying to get somebody's blood tested. We would just refer out for that. Was like, why can't we do it? Um so we started doing that and then that was always a two-e turnaround. So we're like, this is not good enough. So now we have uh point of care hepatitis C testing. So we do that. Um and then we couldn't get blood work on somebody. So now we have ultrasound. So, it's just always, you know, it's it's blossomed into this beautiful thing three years from now, but really, uh, you know, three years ago, it was just a guy who was out there with a heart to serve and,

43:23 you know, they didn't know much. Uh, but he was good at building relationships and, um, you know, I get guess kind of figured it out. And I think that's important because every community is different. So, you have to have people at the table. You got to be creative and don't take no for an answer because it'll work out eventually. >> Can we can we interrogate two terms that I'm hearing a lot? It may not be for this, but harm reduction because we might have different um definitions and I bet we do. And then evidence-based. I call it the oppression, the tyranny of evidence-based because evidence-based then dismisses evidence informed which

44:09 is people centered. And again, when we're living in a world of data and and metrics that we need to meet, it just comes back, it's just another phrase that I know I like to use that says you don't throw away anecdotal. If real people are experiencing it, then it's evidence. So again, I think that's a whole other symposium. And again, not to knock the gold standard, double placebo, evidence-based, but there's other there are other metrics that we need to look at to know that we're impacting people. >> And I think that uh comes up a lot when we talk about innovation broadly, right, across all different fields where to innovate to some degree, you're going to have to try something new that we don't

44:54 know. But can we build it off of, you know, just a hunch or or something that suggests this is going to work? Uh, and so I think, you know, in my own reporting, I've come across this a lot where the question is, you know, is this a good use of settlement money because some people feel it is or is there some evidence to work off of? And and it's a it's not always a clear answer. So, I think that's a great point. Um, well, everyone is doing a great job sending in questions because I already probably have more than I can get to, but I will do my best. Um, and keep them coming if if you can, and then we can always chat about them uh afterwards during the reception. Um, but I wanted to start with someone who picked a question that I was already going to ask, so thank you. Um, great minds and whatnot. Uh, they asked basically, um, how do you all think about sustainability of programs

45:41 that are started with the opioid settlement funds? um the settlement money is sort of front-loaded for folks who don't know there's more coming to counties and states in the early years and the amount gets smaller over time and then of course at a certain point they will stop flowing. Um so how are you all thinking about sustaining the work that you started? Um I'll open it to a free-for-all whoever wants to jump in. >> Well, I'll cheat and say that I'm retiring in 12 working days. So it's not my it's not my problem. This may be the best answer, but someone try to compete. >> It it matters. Um what I would what we've really looked at is how can we eventually look at some billing options

46:29 um with with some of our prevention educators that are in the schools. I don't think we have it completely figured out. I that's just going to be honest. You know, Minnesota got tobacco settlement funds. We had actually Governor Ventur, if you heard of it, him and he literally believed in prevention and we got to do it for about four or five years. We all got bought in and then the next governor came and took it. So, you know, I think it takes a Dalton, you hit it. It's it's building the relationships and the trust and really building credibility with with your people so that they will want to continue it in some way. And I think that's going to take some work um for the new successor that is um taking my position. That's going to take some

47:15 real work to to make that happen. And and I think that um we have no guar let's be honest you guys waking up. We have no guarantee of funding period. I mean public health has been somewhat um rattled back and forth in the last year with funding. And so I think you you do your best work, you build your relationships, you try to really make that happen. Um, I do want to touch on my second bucket of funding because I I would be remiss without telling you that that is a group of individuals that have lived in live lived experience, a high school student, the me mental health provider, a hospital, social workers. They're making the decisions on the grants, not me. And it really gets to touch on what you just said. Has nothing

48:01 to do with evidence. I wanted a second bucket that was no evidence because you do get tied in with evidence. But I knew that I wouldn't get the money if I didn't have one bucket of evidence. So I just I appreciate what you said and so I really wanted to share because I felt like the person with lived experience in that room needed to tell us what grants came in and what really would work. Not not us but but the lived experience or high school students saying do you even know what you're talking about? I mean that's not even a word we use. So, I don't have an answer. I I I think this was my moment to cheat and say I'm leaving in 12 days and and heading into the sunset, but I it's going to be relationships and work. Dalton said that and we and you just keep grinding. You just keep grinding. >> Anyone else want to weigh in on the

48:46 question of sustainability? >> Go ahead, Tracy. Go ahead. >> Yeah. I mean, Edgecom County, we've got $5 million to go over 18 years. So, we don't have a lot either. I mean, it sounds like a lot, but really at the end of the day, it's not. Um, so I think there's a lot that needs to happen when it comes to like Medicaid reform and and like funding uh EMS or or mobile integrated healthcare or community paramedic programs that do that type of post overdose work or treatment navigation or or you know even more funding for peer support um you know types of programs that have you know port implications and all that. But I think that needs to happen. But I think in the meantime, we can really um try to figure out how to create our own evidence in the meantime while we do have the funds. Um and then on an administrator's side, knowing that I

49:33 just can't have 20 dudes on this team and pay for them, you know, because we're going to run out of money and I and the last thing I want to do is have something around for three years just to shut it down. and then everybody had that hope and and it was things were going well and then all of a sudden um it fell away. But on the flip side of that, I also would caution any county that has not utilized opioid settlement funds because we see them around North Carolina too. Um because we do have a problem and there are services that need to happen now and and what what better time than now, right? If we do have some ways to to do even small things, we should be doing those, but we should do them in a sustainable way as well. So, not just to go all in at the jackpot,

50:19 but you have to you have to build some some things into that. Where where should you start? Where should you go? What things already exist? You don't need to duplicate resources. There's I mean there's we could talk about this for a long time. >> And just to um on Dalton's point, it's not just North Carolina. all over the country there are places that have not spent the money yet. Um, tons uh I wrote a story about that first or an article about that first I think three years ago or two and a half years ago and then every year I've had someone ask me to write the same story because there are still lots of counties and cities that are are are sitting on the money while there is an urgent need. Um, and some there are complex reasons for that which we can discuss. Um, but I think that's a great point and something that is a

51:05 national trend as well. >> Um, in terms of sustainability, one of the things that I get push back on and again to the issue about what do we you what do you mean? What do I mean when I say harm reduction? When I say harm reduction, I mean housing. Period. Point blank. Full stop. the fact that we are not providing housing that is so crucial to the kind of health and well-being that we want in people and what better use of opioid settlement dollars for things that will be around later. I hate that phrase, building the plane while we fly it. That means you're not planning. That means that you're it's a it's a it's a busted plane. And so I was just reminded the other day of an article that someone I'm a fan girl of, Eric

51:52 Gdora wrote in the Washington Post when we were in the midst of COVID. And he's like, "We respond to everything like an emergency. If people in harm reduction, and I've been doing this for 36 years, we run into the fire to save people and we don't know how to get out and we don't get a chance to figure out how the fire got started or how to fireproof ourselves. So I think in many ways the times that we're in are a chance for us to build capital projects that embody and reflect what we know should be that do not perpetuate harm in

52:40 helping people that don't extract um and make people silo themselves to get what they need. and that it's informed by what people say. This is what's most important, which is almost always housing. So, um I'm really a big fan of people using opioid settlement funds for housing or other kinds of durable things that will be here after the settlement money runs out. And I just want to say this is not I love lawyers. I'm not one. But letting lawyers develop a strategy for addressing a health emergency, we got what we got. For some of us who are old enough in the room to remember

53:27 HIV, Ryan White Care, some folks have heard me say this and I want to retire so bad. So bad. I want to go off into the sunset. I really want to. Um Ryan >> welcome to come with >> Ryan White care and HIV prevention planning from the CDC required government and community concurrence and the money could not flow unless there was an agreement about what the needs were. We're not done with HIV and I say that as National Black Harm Reduction Network. We still have a bunch of work to do on the inequities. But did I think I'd live long enough to see something damn near close to a vaccine? That's where we were with HIV. For me, we're

54:13 still in the 70s in many ways and how we're approaching people who use substances. >> Uh Alyssa, I have a different question for you if you don't mind. Um just there there was one that came in um where someone was talking about using opioid settlement money for prevention and is it possible or not? there's some confusion around that and we were some of us were chatting about this uh before we came on here. So, um I was wondering if you could start and talk a little bit about kind of how you're allowed to spend the money um in North Carolina and how prevention fits into that or where it fits in and then I'll ask others to weigh in as well. >> Yeah, thank you. I do have thoughts on sustainability. So, if you want to hear my thoughts, we can talk at the reception. Um, but prevention is a

54:59 little bit my Achilles heel because in North Carolina we actually cannot directly use settlement funds for prevention. Our continuum of care starts at early intervention. Um, and I'm not going to go down the weeds in explaining all these details, but we have two options of lists we can choose from. One being a short list of high impact um, evidence-based and evidence informed. They're not all evidence-based. I think that's a really important point. strategies um that we can choose from and most counties are using that list and it doesn't include prevention because there was a lot of fear from lawyers and others in North Carolina that these funds would just go to programs like DARE and you know before I

55:44 was in my role I was all on board for that approach and realizing our community wants prevention they want education and not being able to directly use these funds for that has been challenging because I don't want to hear this need um from our community and not be able to address it. So, we thankfully also are receiving other settlement funds like McKenzie and company which um follows the exhibit E list. For most other states, that's your guiding framework and that has a longer list that includes prevention. And so, um in North Carolina, it's complicated, but in other states, there are a lot more options. Um, but like any of the settlement funds, it requires a lot of creativity irregardless of the context. >> Okay. >> Yeah. No, that was great. And, uh,

56:30 Alyssa simplified a very complex process in North Carolina. So, kudos to her on that. Um, but the one point I wanted to add is that what she already said. It's different in every state. So, uh, your state may have, um, more allowable uses that fall under the prevention bucket. Um, your state may have passed additional laws. your county may have passed additional restrictions. So, it's it's one thing with the opioid settlement money is that it's different in every place. There are some overarching guidelines for everyone, but it really is locality by locality, what you're allowed to do with it, and how you can navigate that. Um, did anyone else want to weigh in on prevention spending though? >> Again, I'm sorry. I talk about this stuff so much. I cannot wait to stop talking about opioid settlement funds.

57:17 Um, what do we mean by prevention? Harm reduction is pathway to harm elimination. That's prevention. These are weird. My 25-year-old always says, "Mom, you're so weird." These are weird distinctions that we need to be able to push back on. We have a lot of allowable uses, but we don't have a very robust list of things we shouldn't be spending settlement dollars on. And that to me is a little obscene that you can't use settlement dollars for prevention because clearly the belief is prevention is abstinence, treatment is abstinence. And we know better, right? Like we know better. So >> yeah, I think this

58:03 >> I am such a public health nerd. So bear with me. There are three levels to prevention. There's primary prevention, secondary prevention, and tertiary prevention. And we are doing I mean look at the grid. We are doing tertiary prevention which could be housing. It can be harm reduction. Where we fall down is in primary prevention. We just plain fall down. And we are really hurting our young people, our little ones. The little ones need the education and the support and the guidance to help them make decisions for the secondary and tertiary prevention that you all need to do. We all need to be doing it. Everybody needs to be doing it. We we are we have three

58:50 grants that are going into our incarcerated jails. That's tertiary prevention. They're struggling there. They need grant dollars to be there. But boy, I I got that third grader and I am hoping that they're never going to go there. So, >> how do you gauge that? That's part of the struggle for primary prevention. How do we measure? And the fact that you're doing longitudinal is so smart, but most people think prevention primary is there. >> No, but primary prevention, you you just you just nailed it with the primary prevention is um it is hard to measure. That's why that's why people don't want to fund it is because it's hard to measure. And then I go back to your line that I want to use is you better have good anod. Anecdotal doodle doodle

59:36 anodal anecdotal. You you could have the data but then put the story with it. Let me show you the third grader that went home at parent teachers conferences and literally said my prefrontal cortex I know how to regulate it now. And the the parents like what the I won't swear. What the blankety blank. And the mom said they're talking about how to manage their emotions with their prefrontal cortex. That's prevent. Take the anecdotal story with primary prevention and you will sell it. But you have to have both. When we when we cut ourselves off at the knees, what the heck am I going to do in 12 days, you guys? I'm like just woo. get

1:00:23 me going. Anyway, I just want to make sure you hear there's three levels of prevention. I'm probably speaking to the choir, but we cannot forget about primary prevention. We just can't. >> Sorry. >> Stay. Don't leave us. >> No, I'm I'm done. Uh, Dalton, I have a specific question that came in for you. Um, how is North Carolina or Edgeham County or both tracking the number of individuals who receive EMS delivered BUP? uh was this a partnership with medical systems uh or to create the care navigation or was it housed within EMS community paramedic programs? I guess those are two questions. Sorry. >> Yeah. So, um I would say that most counties that are performing EMS BUP,

1:01:08 probably about three4ers of those are through community paramedic programs. There are some counties like Wake, I believe they have it on the ambulance. Um so, it's a little bit different. Um but I mentioned earlier about some of the statistics and the um the dosing that we've seen over the last 12 months that is tracked. We have a data team at the North Carolina Office of EMS and when you submit data uh you have to have all these NISS validations and such which you know I mean everything's a data point now. So basically they just pulled out BUP and it doesn't matter if it was a ESO platform which is very common for PCR systems in EMS or if it was image trends or if it was EMS charts it was that Nyus data point of buprenorphine administration that was what was pulled out over the last 12

1:01:54 months. >> And they also asked this which I think is a great question. How can a member of the public find out which counties are offering EMS bup? That's a harder question um because I don't have a great answer for them. But what I would say is contact the North Carolina office or contact your office of EMS and and ask them um or your county. But each county is different because it may be county based EMS. It may be like in DC fire. It could be AMR and each one of those agencies may have a different protocol list. And it takes a really progressive EMS system to deliver bup. And not everybody is is is bought in yet. We we have some early adapters. Uh but then we have some folks that well we've never we're not doing it that way because we

1:02:40 you know 20 years ago we didn't do it that way either. You know we have some of that too. Um so I think slowly we're heading in the right direction but I think it's so different county to county. It's hard to say. >> Wonderful. Uh an interesting question that came in uh for all of you. I think anyone who wants to answer it. Have you experienced pressure to allocate funds in ways that do not align with opioid remediation? Um, and one thing that came to my mind that I know I've uh reported on a little bit is there has been um companies that make products are aware that this money is flowing to counties and cities and states and there's a flood of marketing to try to get the money for their product. Um, so that doesn't have to be the the angle that you all talk about, but that came to mind. I'm curious if if you all have felt pressure to use it in ways that

1:03:27 didn't feel like they matched the purpose. >> I'll say this uh if four milligrams of Nlloxxone is good then 8 milligrams is not goodter if that makes sense. And I'm sure that some of you all know which company I'm talking about and uh I did turn them into the FDA and there have been some things that have happened from that but that yes I mean that the marketing is real uh and they're coming after you. anybody that does opioid settlement program management, they're coming after you with their hand out. Um, so we've had we've we've had the same subreient come up to us like give us 3,000 or $300,000. We've had the pharmaceutical companies. We've seen companies um try to bolster EMS N boxes where we keep controlled substances.

1:04:13 That's not going to help somebody uh with an addiction, right? That's just there to, like you say, take some of the budget strain off of the EMS budget. like it's not going to benefit patients. Um, so I've seen that so much. Um, does anybody else have something? >> I up until recently I was on our state settlement board and that's another conversation if you want to have it with me. But I swear on LinkedIn, people are hitting me up like I'm carrying around settlement dollars in my pocket and they're disgusting. And they almost always are hitting me up for innovative strategies to reach underserved black communities. And it's disgusting and it's gross. But if we disrupt this idea that people cannot

1:05:00 gain sustained health and wellness from addiction treatment and other interventions, then we're going to remain very vulnerable to the for-profit mandate because some would argue that is what is driving this is that we don't get people well enough to not have to come back. >> Yeah. Melissa. Um I'm gonna be careful because I know this is being recorded so we can chat more later about the um Dalton and I get a lot of the same emails. Um but a couple things I just wanted to say. I think someone mentioned earlier that the importance of systemizing and building process. And I know it's not the sexiest of topics, but I think really building um guard rails

1:05:46 is important because I I might retire from this role. I don't know. I still have a while left in my career, but who knows? I could win the lottery or my husband could win Jeopardy or something and I might not be here. Um, and I want to have these systems in place to make sure the funds are going to where we know they need to go. And so I think that's an really important part is as you're building if you're in a role like

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