Missourians differ on how to spend millions in opioid settlement payouts

The Bridge of Hope crisis shelter near Highway 61 in Lincoln County still smells like new construction materials. The shelter and drop-in center, which has been open for about six months, offers people a place to stay and helps them meet housing deposits, rent and other needs.

"You're trying to alleviate the stress of not knowing what your everyday life is going to be," Chairman Chris Schieffer said. "So Bridge of Hope is able to bring you in, kind of calm things down, help you find the resources you need and keep you from buying that next drug."

Lincoln County commissioners used around $30,000 from settlements with drug companies to build the center. Rules laid out in the settlements and in state laws require the money be spent on addiction reduction, treatment and education. But local governments have differing views of how to spend the once-in-a-lifetime windfall.

Drug overdoses have killed more than 24,000 Missourians in the past 20 years, and the majority of those deaths were from opioids. States, local governments and cities have sued drug companies and manufacturers, alleging that they downplayed the addictiveness of opioids, among other claims. As those lawsuits are settled, hundreds of millions of dollars will be sent to the State of Missouri and other municipalities.

In a community room at Bridge of Hope, the operators hung pictures on the wall of local homeless people and their living arrangements — mattresses on the ground, shoes stacked along the windowsills of a run-down hotel in town.

Director Dan Colbert said that in the eastern Missouri county, drug use and housing instability are problems that perpetuate each other.

"Addiction is a terrible thing. It doesn't just affect the person who's taking the drugs. It affects everyone around them," he said. "And we have people here that we're helping along the recovery process.

"All the stories, if you stick with it, have a sad ending," he added. "And we're here to kind of change that storyline around and have some successes with it."

The center isn't a traditional addiction treatment facility. For the most part, its owners don't allow people on substances of any kind to stay there. It doesn't offer medical addiction help, and it's not specifically for people who have suffered from drug use, although its operators say it ultimately benefits people in recovery and prevents them from relapsing.

"We're not set up to be a detox hospital. We treat the other things that go along with the actual drug addiction," Colbert said. "The day you quit using, your life doesn't instantly turn around. There's a whole process."

He explained that residents who have been prescribed the addiction medications methodone or suboxone are eligible to stay. "But sadly, we don't see many with prescriptions," Colbert said.

A once-in-a-generation windfall

Drug companies have already sent $100 million to Missouri to settle lawsuits for their role in the crisis. The state will receive hundreds of millions as Teva, Walgreens and other companies start paying out their settlements with state and local governments.

Millions of settlement dollars from McKesson, Mallinckrodt and other drug companies are split — 60% goes to a state fund and 40% directly to Missouri municipalities. State officials estimate the state could receive around $900 million over the next two decades.

The settlement funds do have guardrails. By law, most of the funds must be used to treat and prevent opioid addiction and pay for related health care and law enforcement. But within those parameters, there's a lot of flexibility. Municipalities have used settlement funds for everything from drug diversion courts to T-shirts for anti-drug summits .

St. Louis has used some of its funds to set up a behavioral health bureau . Several local governments have not yet spent any of the funds.

Twelve states — including Missouri — have committed to publicly reporting how states spend their payouts. But KFF News has found that those state reports can be difficult to find and read . Missouri released its first spending report earlier this year.

A generation ago, states enjoyed a similar payout from the tobacco industry, said Rikki Wright, deputy director of the Missouri Department of Mental Health, the agency that distributes the state's share of the funds.

But not much of that money went to tobacco prevention and cessation efforts, she said.

"The opioid settlement is one of the largest settlements that the U.S. has had nationally since the tobacco settlements," Wright said. "And if folks remember from the tobacco settlements, when the funds came into the states, there were not any restrictions on them, and states use them to plug a lot of holes in their budgets."

This time, there are more rules, she said. So far, agency officials have been focusing on medically based treatment models. The state has spent a lot of its own share on distributing the overdose-reversal drug naloxone . It's also funded a pilot project among emergency responders that initiates addiction treatment immediately after workers revive someone from an overdose.

The department distributes state grants based on evidence-based treatment models, she said, but is not in charge of enforcing how localities spend their settlements. It also has been training municipalities about allowable and productive uses of the funds.

"We're not directly mandating how the money is spent," Wright said. "But we're trying to make sure that everyone knows what's available and to help them understand what the expectations are."

That can be important because small municipalities may not have experience treating addiction, said Shelly Weizman, associate director of the Center on Addiction and Public Policy at the O'Neill Institute at Georgetown University.

Weizman said it's up to states to make sure the money is spent on effective and proven treatment and prevention. While the settlement agreements have stipulations, it's not likely that the companies will enforce them.

"The recourse is the defendants, which are the manufacturers and distributors that were sued, have to go to the judge and say, 'Hey, we think this money isn't being spent according to the settlement agreement.' And then they're back in the papers," she said. "The chances of that happening are not going to be very high."

Who should decide?

Public health advocates say current or formerly addicted people and their families should have a say in how the settlements are spent. Some states have set up committees that include people with lived experience to weigh in.

"Effective collaboration with people with lived experience, particularly from racial and ethnic groups that have borne disproportionate harms from the opioid epidemic, can lead to the development of services that more closely meet the needs of those impacted," wrote Rebekah Falkner of the National Institute for State Health Policy earlier this year.

There are plenty of people in St. Louis who have opinions on what would help the most.

"You know that parents tell their children to stay away from so and so? I was so and so," said Burton Barr, a former cocaine and heroin user who's now a St. Louis minister. He teaches overdose response classes and works with addicted people in prison.

He's also a board member of the CENTER project at the University of Missouri-St. Louis , which aims to reduce overdoses and trauma among Black people affected by addiction and drug use.

Barr said based on what he hears from the people he works with, there's a need for more accessible treatment locations.

"There's just not enough resources, there's not enough beds," he said. "A couple of guys I was helping a few months ago, they wanted to go in, but they had to wait a week, two weeks before they could get a good bed. By that time, people have changed their minds."

Alfred Long Jr., a CENTER board member who has worked in prison ministry and addiction recovery, agreed with Barr.

"I think they should make facilities more accessible," he said, adding that there should be options for people without insurance. "Cognitive behavioral therapy, spirituality, [medication-assisted treatment], everything. I think it takes the whole package."

Others think settlement funds should go directly to people and families affected by addiction in the form of reparations. In Missouri and across the country, that's disproportionately Black men .

"Looking at how the African American community has been impacted the worst, I think it should go directly to people that are recovering or trying to recover," said Andreas Prince, a CENTER board member and health worker.