Local Implementation of the National Opioid Settlements: Challenges and Opportunities

ABSTRACT

The opioid epidemic is a significant public health crisis in the US. The recent national opioid settlements have provided financial resources to abate the crisis; however, several questions have emerged regarding the administrative process of fund use, how Pennsylvania and external stakeholders are allocating the funds, what motivates them, what challenges they face, and what the future of the opioid crisis holds.

To understand the firsthand experiences of various stakeholders involved in the national opioid settlement, 15 semistructured interviews were conducted via Zoom between July 2024 and October 2024. Interviews addressed comparisons to the tobacco settlement, administration and use of funds, barriers to program evaluation and implementation, and future directions for the opioid crisis. Key emergent themes included tensions between county and administrative stakeholder groups, challenges in applying the guidelines created by the national opioid settlement to community-level programs, and uncertainty about the future of opioid abatement.

It is critical for administrative stakeholders to understand substance use disorder (SUD) treatment, prevention, and programming and to translate legal documents into applicable guidelines for public health professionals and community stakeholders. All stakeholders should continue education efforts to destigmatize people impacted by SUD. Providing local autonomy over spending funds is beneficial; however, the current administrative systems are not equipped to address the challenges that have arisen, underscoring the need for long-term, data-driven strategies to measure the impact of national opioid settlement dollars and ensure accountability.

Am J Manag Care. 2026;32(Spec. No. 6):In Press

The opioid crisis in the US started in the 1990s with legally prescribed opioid-based painkillers such as oxycodone (OxyContin).¹ The opioid epidemic escalated over the next 2 decades, fueled by Purdue Pharma’s aggressive marketing of oxycodone to physicians while downplaying its potential for addiction.^1,2 In the early 2000s, reports of overdoses and deaths from prescription drug products, particularly opioids, rose sharply due to widespread misuse of oxycodone and similar drugs.³ By 2021, 645,000 overdose deaths in the US involved an opioid.⁴ In 2022, national lawsuits resulted in more than $55 billion in settlements to states over the next 18 years and beyond to address the role of manufacturers and distributors in the ongoing opioid epidemic.⁵

The national opioid settlement agreement stipulates that at least 85% of settlement funds must support opioid remediation efforts as defined by the Exhibit E List of Opioid Remediation Uses.⁵ Exhibit E is a national-level document produced through a collaborative process among state attorneys general, local governments, and pharmaceutical companies involved in litigation; its purpose is to provide guidelines for how the settlement funds should be used.⁵ Exhibit E follows 2 schedules and includes a broad set of allowed uses of funds, such as naloxone purchase and distribution, expansion of recovery services, and prevention programs.⁵ This stipulation was created in response to the fact that less than 3% of the 1998 Tobacco Master Settlement Agreement (MSA) funds were used to address tobacco use.^5,6

Pennsylvania accepted the national opioid settlement terms after counties and other litigating entities dropped their lawsuits against the same defendants.⁷ Negotiations related to the national settlement resulted in Pennsylvania allocating funding to the Commonwealth of Pennsylvania (15%), counties (70%), and litigating subdivisions (15%).⁷ This also contrasts with the tobacco MSA, in which state governments had majority control over the use of settlement funds.⁶

Because 85% of Pennsylvania’s opioid settlement funding is directed to substate entities, opioid remediation strategies can be implemented at different levels depending on local needs, the local epidemiology of opioid misuse, and the organizational structure of opioid remediation delivery. For example, some county governments directly implement opioid remediation programs, some distribute funds to their corresponding Single County Authority (SCA) for use, and some counties offer funds as grants to external organizations; these organizations submit applications outlining how the funds will be used.⁸

Furthermore, the Commonwealth Court of Pennsylvania in 2022 ordered the establishment of the Pennsylvania Opioid Misuse and Addiction Abatement Trust (POMAAT), which was created with the acceptance of settlement terms and the distribution formula. POMAAT has a fiduciary responsibility to ensure that remediation programs using opioid settlement funds comply with Exhibit E. A total of 119 counties and litigating subdivisions are required to report usage of their opioid settlement funds through a biannual online reporting tool. Four disbursements and subsequent reports have occurred since August 2022. Figure 1 provides an overview of the opioid settlement and reporting timeline in Pennsylvania. More than 10 years of settlement fund distribution and data collection have yet to come, meaning that these first distributions and corresponding reports represent early data in this reporting process.

Previous research has also sought to understand the perspectives of various stakeholders as they navigate the initial distribution of opioid settlement funds. Kampman et al aimed to understand the community-focused, county-level perspective of a purposive sample of 6 counties in Pennsylvania.⁹ Our research used a diverse sample, including both county-level and non–county-level stakeholders, and sought to gather information on how opioid settlements are being implemented in Pennsylvania. A specific focus was placed on the structure that POMAAT created in Pennsylvania for fund distribution as well as the requirements for how those receiving funds must report their expenditures relative to Exhibit E. Our inclusion of a broad set of stakeholders, including individuals from Pennsylvania counties, those who structured the terms of the settlement, those tasked with implementation of the settlement process, and those from national organizations focused on the opioid settlements and substance use, provides a rich early-stage perspective on Pennsylvania’s unique approach.

METHODS

Interview Sample

A purposive sample of 19 stakeholders involved in the administration, implementation, and/or monitoring of national opioid settlement funds—in Pennsylvania and nationally—was initially contacted via email. Seventeen stakeholders responded and consented to be interviewed regarding their experiences with opioid remediation and abatement work in the context of the opioid settlement. The Table includes details about the study respondents, including stakeholder category, description, and a category-based identifier used when citing them in later sections. Figure 2 illustrates the full recruitment process. The sample yielded 15 interviews, comprising 13 individual and 2 group interviews with 2 stakeholders. We report findings from a content analysis of the 15 interviews to understand the structures in place for disseminating, implementing, and monitoring opioid settlement funds in Pennsylvania and their influence on programming available to communities.

Data Collection

For each interview, a 30- to 60-minute semistructured Zoom interview was conducted and recorded between July 2024 and October 2024. At that time, counties and participating subdivisions in Pennsylvania had received 2 payments from the national settlement. The study was reviewed and deemed exempt by The Pennsylvania State University’s Institutional Review Board under STUDY00025332. Based on the approach described by Creswell and Creswell, the interviewer collected data by taking observational and reflective notes during the interviews.¹⁰ Next, the interviewer listened to the audio recordings of each interview and extracted direct quotes from each interviewee.¹⁰ After obtaining additional insight through the interviews, the codebook was adjusted accordingly for coding and analysis. The eAppendix Table (available at ajmc.com) shows the structure of the interview protocol.

Data Analysis

The approach to data analysis generally followed the holistic qualitative procedure presented by Creswell and Creswell.¹⁰ This process includes coding the interviews, synthesizing the data into themes, and ensuring intercoder agreement.¹⁰ Interview notes were coded using a deductive coding approach. Codes were selected based on interviewees’ responses to questions about the opioid epidemic, the tobacco MSA, Exhibit E, patterns of opioid abatement programming, challenges and successes of their work, and the future of the opioid epidemic and settlement. The author tagged passages using the developed codes and grouped similar responses to identify themes. The codes were discussed and revised with the coauthors until consensus was achieved.

RESULTS

Fifteen interviews revealed 7 key themes about the dissemination, implementation, and monitoring of opioid settlement funds.

1. Learn From the Tobacco Settlements: The “Don’t Fill Potholes” Doctrine

The 1998 tobacco MSA was the largest civil litigation settlement in US history and involved 46 states, 4 US territories, the District of Columbia, and the country’s largest cigarette manufacturers.¹¹ As outlined in the agreement, the settling states released the manufacturers from past and future legal claims for the costs incurred by the states for smoking-related illnesses and death and for equitable relief; in exchange, the participating manufacturers agreed to make annual payments in perpetuity to the settling states and to restrict their advertising, promotion, and marketing of cigarettes.¹¹ Although the settlement was intended to address costs incurred for illnesses caused by smoking, many states used the tobacco MSA to fill budgetary gaps unrelated to tobacco treatment and remediation.¹² Furthermore, states such as Kentucky and Virginia provided subsidies or direct payments to tobacco farmers using MSA payments.¹³

Although the stakeholders interviewed for this study did not have direct experience with the tobacco MSA, they were all familiar with the lessons learned from that settlement and subsequently applied them to the national opioid settlement. One interviewee shared, “A lot of tobacco [settlement dollars] went into a general fund, so it was used to fill potholes and went toward whatever it was needed for.... The majority of states placed their share of opioid settlement funds in a separate fund, which makes it easy to keep track of money and understand that the fund is for opioid remediation.” (C1) Another interviewee asserted that “I think we learned from the tobacco settlement process how to extract dollars from large corporations that killed people.… I think a lot of legal precedent was crafted from the tobacco settlement and other settlements too…” (B6) and ended with “You can’t fill potholes.” (B6) As a lesson learned from the tobacco MSA, 85% of opioid settlement funds must be used on opioid remediation as defined by Exhibit E, and in Pennsylvania, 85% of opioid settlement funds are being distributed at the substate level.⁷ All stakeholders agreed that the opioid settlement funds should be spent on opioid abatement, but they varied in their definition of acceptable expenditures.

2. Early Tensions Exist Between the Counties and POMAAT Operations

a. Inconsistencies remain in the definition and scope of acceptable opioid remediation programs. Pennsylvania’s Department of Drug and Alcohol Programs (DDAP) provides an online manual about case management and clinical services for general substance use disorders (SUDs), but it does not specifically address opioid use disorder (OUD). The manual includes information on halfway house services, emergency housing services, recovery housing, medication-assisted treatment (MAT), case management, recovery support services, culturally and linguistically appropriate services, and contingency management. Although most of these programs have been previously approved by POMAAT, POMAAT does not refer to the DDAP manual when evaluating the compliance of an opioid remediation program. Rather, POMAAT only evaluates programs based on their adherence to Exhibit E, ascertained by the detail provided in the reporting tool, the amount of money spent on the program, and program execution. For example, DDAP promotes the use of drug court and probation officers. An interviewee who is part of POMAAT stated that the opioid settlement funds cannot be used for law enforcement (A1); however, this is not explicitly stated within Exhibit E. DDAP and POMAAT’s guidelines overlap, but it is possible that DDAP’s funding parameters are broader than those of POMAAT.

The county stakeholders argued that a program being supported by DDAP but not approved by POMAAT is counterintuitive. One interviewee explained, “I know the trust [POMAAT] has good intentions, but I think they need to come along a little further in terms of educating themselves on SUDs and prevention and aligning with our state-required entity, DDAP, which already sets the parameters for what we can do in terms of compliance.” (B7) Compliance with DDAP, but not POMAAT, is viewed as a “complete contradiction.” (B7)

b. Concerns remain about trustee composition and qualifications. County stakeholders believed that some of POMAAT’s trustees are insufficiently educated about OUD to assess opioid remediation programs, as they indicated that POMAAT’s decisions don’t account for the realities of administering substance use remediation programs. This is likely driven by the trustee appointment process, which was written into the establishment of POMAAT. As detailed in the report to the Commonwealth Court filed on September 10, 2024, the chair and “a secretary of one of the Commonwealth’s health and human services agencies” are appointed by the governor, and 4 legislative trustees are required, with 1 appointed by each of the speaker of the House, the minority leader of the House, the president pro tempore of the Senate, and the Senate minority leader, and 7 regional trustees, with 1 appointed by the mayor of the city of first class, 1 appointed by the county executive of the county of the second class, and 1 appointed by the county commissioners of each of the 5 specified regional groupings of counties through the selection processes put forth in the Trust Order.¹⁴ As a result, the composition of the trust is heavily influenced by political representation rather than subject matter expertise.

One interviewee shared, “I think the review of the programming by the trust got a little bit muddled, only because I do not think all the individuals on the trust have as much knowledge in the drug/alcohol/social work field as we do, so it’s hard to explain that to somebody who doesn’t totally understand….” (B4) Another interviewee reiterated, “I don’t know that the trust is educated enough on SUD to include prevention to understand some of the strategies, so I guess the concern is other people are making decisions, and they don’t have all the information they need to make that decision.” (B7) The same interviewee added, “No two counties are the same, so you would expect the home county to have a level of expertise with the county and the county’s needs. This goes back to the trust making decisions across the state when they have limited information…about the counties’ needs.” (B7)

c. The extent to which law enforcement is considered opioid remediation varies among administrative and county stakeholders. An administrative interviewee who is part of POMAAT was adamant that the opioid settlement funds are not to be spent on law enforcement, but counties value probation officers who ensure adherence to treatment/recovery plans. An interviewee explained, “The job description [for social workers and probation officers] can be the same, and the probation officer’s goal is not to arrest people, but to keep them working their plan and keep them in treatment and check on them, but those have been disallowed.… I think there’s a little bit of conflict there.” (A4) It is important to note that POMAAT has approved the use of probation officers in some contexts (ie, juvenile probation officers) but has rejected other programs that utilized probation officers.

Some states do not share POMAAT’s belief that opioid settlement funds are not for law enforcement. One interviewee shared, “Law enforcement is definitely a big trend across the board, [with] lots of money given to law enforcement broadly….“ (C3) Pennsylvania is one of the only states with a trust overseeing settlement expenditures. In other states, all received funds stay at the state level, whereas others allocate a combination of county/jurisdiction-level funds and state-level funds. Notably, Exhibit E does not specify how to invest in law enforcement expenses related to OUD, and not all states view law enforcement as a punitive strategy.

3. Some Stakeholders See the Opioid Settlement Funds as an Opportunity to Address Not Just OUD, but Also Broader Polysubstance Use in Their Communities

Some stakeholders view OUD as just one of the SUDs affecting communities in Pennsylvania. One interviewee explained, “While [POMAAT is] saying this opioid money cannot replace or supplant any existing funding…you have to target it to opioids…alcohol is still [a] huge problem…so it really comes down to how you are looking at individuals coming into the system.” (A4) This emphasizes that although OUD deserves dedicated funding, other SUDs are still prevalent in Pennsylvania and should not be overlooked. Another interviewee shared a similar perspective noting how the opioid epidemic has evolved over time and that it’s “not just one drug that is the issue anymore.” (A2) This interviewee added, “[The opioid epidemic] is not just about opioids. You are seeing [SUDs] in heroin, fentanyl, xylazine…as well as stimulants such as cocaine.” (A2)

Recent research indicates that for many individuals with OUD, polysubstance use is the norm rather than the exception.^15,16 Benzodiazepines and cannabis are common co-occurring substances with opioids, but the rate of co-occurring opioid and amphetamine use has increased significantly as well.¹⁶ Addressing opioid use in a silo ignores the fact that polysubstance use is extremely common among those with OUD, which underscores the importance of monitoring changes in polysubstance use alongside opioid trends.¹⁵ Allowing counties to assess the prevalence of polysubstance use in their communities and subsequently allowing opioid settlement funding to address co-occurring substance use trends is worthy of further consideration.

4. As Expected, Initial Spending Is Mainly Directed Toward Treatment and Prevention, but There Is a Surprisingly High Amount of Spending on Law Enforcement nationally

Stakeholders indicated that MAT was the most funded opioid abatement strategy.⁸ Some suggested explanations for the popularity of MAT programs include that it is listed in Exhibit E and that there is high demand for it, especially in prison systems. Many people who use drugs are incarcerated on drug-related offenses, so counties are investing in treatment to aid them while they are in custody and after they are released. Counties are also funding crisis stabilization centers, media campaigns, and prevention programs with varying degrees of quality and evidence base.

As the opioid crisis evolves, funding patterns may shift from primarily treatment efforts to more prevention efforts. One county-level interviewee explained that, as community needs evolve, interventions will be implemented earlier. The focus for many counties is addressing the immediate crisis using varied strategies. Many counties are prioritizing tertiary prevention strategies before primary interventions such as school-based programming.

External stakeholders assert that funds are being allocated to both treatment and prevention. It is difficult to discern investment patterns because the data are not readily available and program definitions vary. Treatment options vary and may include MAT, abstinence, and detoxification strategies, among other options; however, it is important to note that MAT and abstinence treatment and detoxification may be associated with increased mortality.¹⁷ Regarding naloxone purchase and distribution, an interviewee explained, “A lot of the money is going toward naloxone, especially in early days, because it’s a quick thing that most counties and states have a quick way of procuring, so now they’re just buying a lot more of it with this influx of money, and also [it] is something that can make a difference very quickly vs finding a new treatment facility, [which] takes a long time to build it, staff it, get people to go, see the impact….” (C3)

External-level interviewees were also surprised to see significant investments in law enforcement. One shared, “When money started coming down, I thought every state was going to do MAT for their corrections facilities. That is a huge need, has a huge impact; everyone I talk to says money is the issue there, and that has not happened. It has happened in a couple places, but it has not been overarching like I thought it would be, and I think that is because people who are incarcerated do not have a loud and well-organized advocacy.” (C1) Another interviewee shared, “Anecdotally, I would say a lot of money [is] going toward treatment facilities, not all of them that allow or use MAT, but treatment facilities at large,” (C3) emphasizing that treatment is a spectrum that does not necessarily include evidence-based practices. This interviewee also observed, “Law enforcement is definitely a big trend across the board, lots of money given to law enforcement broadly, can be personnel and equipment, but also a lot of people are doing MAT in jails and funding those programs; some of those are the result of court orders and all these jails have to do, and they want new money to help us do that.” (C3)

5. There Are Mixed Opinions Regarding Enforcement and Interpretation of Exhibit E

As described earlier, Exhibit E is a set of guidelines informing settlement fund recipients on how to spend the funds. It is important to note that Exhibit E was not developed by POMAAT; rather, it was created by those involved in the lawsuits and settlement negotiations. Some states factor Exhibit E into their consideration of programs in combination with other resources. For example, California provides a list of high-impact abatement activities that include acceptable uses of opioid remediation funds in addition to Exhibit E.¹⁸ In Pennsylvania, POMAAT exclusively follows Exhibit E. Exhibit E’s language has caused confusion among Pennsylvania stakeholders. As one interviewee expressed, “Exhibit E is challenging because it is a bit vague in nature…[and] open to a lot of interpretation.” (A2)

Some administrative-level interviewees in Pennsylvania disagreed that Exhibit E is confusing or that counties struggle to operate within these guidelines. One administrator shared, “Because [POMAAT] is vocal that the job is to follow Exhibit E, I don’t think anyone is struggling with it.” (A3) A county-level interviewee with administrative responsibilities asserted, “I can’t think of one thing that a county could really complain about if they are truly focusing in on prevention and treatment.… If they are doing it genuinely and trying to meet that goal, they can do it with Exhibit E.” (B1) Another administrator conceded that Exhibit E “could be more clearly written” (A2) and that counties struggle to operate under both Exhibit E and DDAP, resulting in some counties creatively aligning programs with Exhibit E.

County-level interviewees believed their programs aligned with Exhibit E but struggled with convincing POMAAT to agree. One interviewee explained, “One of the things covered in Exhibit E is the administration costs of programs, but one of the early pieces of guidance from the trust was to limit administrative expenditures to 3% or less of settlement funds. It doesn’t say that in Exhibit E. That’s just a decision made by the trust; that’s an interpretation.” (B2) This interviewee stated that administrative costs are typically 10% to 20% of overhead, suggesting that POMAAT’s guidance is not informed by the realities of remediating substance use. The ambiguity of using law enforcement as an opioid remediation strategy was also considered. The same interviewee said, “I’ve got mixed feelings on that [law enforcement] because Exhibit E doesn’t include specific law enforcement efforts. Some counties wanted to use the money to help fund their drug task force, and that was not OK. In that case, I agree with the opioid trust, but that also is pretty clear in Exhibit E.” (B2) Regarding treatment court, a county-level interviewee indicated, “We’re hearing that some counties have submitted expenses for a treatment court. Treatment courts are widely recognized as an evidence-based approach to help with SUD. They are listed in Exhibit E, but there are some counties that have been told that their expenses are not approved. I’m not sure why.” (B2) This individual emphasized that “The SCAs are left with confusion on how…this decision or judgment [was] made and [whether it was] because the people making the decision lack much knowledge about the drug and alcohol field and the role of treatment….” (B2)

6. Challenges With Pennsylvania’s Approach to Implementation

a. Challenges in implementing harm reduction strategies. County-level stakeholders reported facing challenges in getting public approval on harm reduction strategies (such as syringe service programs). Stakeholders expressed interest in implementing harm reduction strategies; however, there was concern about pushback due to a common public misperception that harm reduction strategies encourage drug use. One interviewee shared, “I would like to do harm reduction, but that is not widely accepted among communities in [county name]…. [It’s] going to be a struggle…in other counties too.… [We] also have legal barriers [to] needle exchange programs and overdose prevention centers.… [There’s] only so much you can do, but by the end of this, some of those will be removed in regards to barriers….” (B8)

b. Challenges in balancing the needs of rural and suburban counties. A rural Pennsylvania county stakeholder indicated that they are using opioid settlement funds to fill budgetary gaps and fund different programs than their suburban and urban counterparts. This interviewee explained, “Being rural, we’re very limited in our recovery support services.… One of the things we’ve identified through treatment needs assessments, we just don’t have the resources. Not the money, but we don’t have the resources as far as programming.… Individuals have gotten grants in the past for recovery houses and other programs, but they’re not really well attended.” (B4) Counties with well-funded social services now have the bandwidth to innovate; rural counties are seemingly trying to adequately fund the programs their communities need.

c. Concerns about sustainability and capacity of POMAAT’s administrative structure. One interviewee commented, “My concern with the trust is the demand that it has on them to process these reports and approve these programs in addition to their regular 40-hour workweek. I don’t have enough time in the day to do my job, let alone add another 15-hour week to the trust in approving these programs. I think it’s important, and the money that is there is significant. It would be better served to hire someone at the state level to fulfill the same role as what the trust does….” (B4) Concerns over POMAAT’s current structure exacerbate distrust in trustee decision-making capabilities. An interviewee added, “[The] opioid trust is doing a better job of making sure the money is being targeted to the opioid use disorder.… It feels to me that there isn’t a huge administrative structure behind this. DDAP has a virtual army of people who are in charge of the federal opioid numbers [expenditures] and monitoring those contracts, monitoring those plans, and monitoring expenditure reports. And then on the trust side, there is a volunteer director and chair of the trust.… I think we have 1, maybe 2, staff [members] at CCAP [County Commissioners Association of Pennsylvania] administering the money. I just don’t know how sustainable that is over 18 years.” (A4)

d. Challenges in navigating public scrutiny. County and administrative stakeholders expressed concerns about the public prematurely passing judgment on expenditures. One administrator emphasized, “There’s a lot of public scrutiny on this as well.… There was a concern that the public is going to look at this like the trust is just rubber stamping everything.… That is not the case.” (A3) This individual clarified, “The trust wants to feel good about how the money is being spent. It’s not our job to tell them how to spend the money; it’s the trust’s job to make sure that it is being spent correctly.” (A3) Another interviewee shared, “Some of the reporting has also resulted in more government entities publishing more information or being a little bit more transparent…incremental gains and I like seeing those; it’s rewarding.” (C3) This suggests that the public receives information more positively when it is volunteered.

7. Optimism and Uncertainty Regarding Future Outcomes

Interviewees could not predict the future of the opioid crisis and opioid remediation; however, significant efforts are being dedicated to bringing awareness to the situation and striving for positive outcomes across communities. Multiple interviewees responded with variations of “I don’t know what the opioid crisis will look like 18 years from now” (A2) and that this is “uncharted territory.” (A4) At the same time, however, another interviewee pointed out, “The awareness of the crisis and bringing it front and center, the destigmatization of addiction and better understanding of addiction certainly has advanced because of this unfortunate spotlight that’s on it.” (A6) This point was echoed by a county-level interviewee, who added, “I think that [the opioid crisis] has touched enough lives and we’ve made enough progress that people are seeing a light or hope. Hope has been reinstilled. People lost hope for people who were abusing drugs, and they blamed the person. Through education, they now understand that they are inherently driven or had a medical emergency that created this situation.” (B1)

Stakeholders also feel optimistic about reducing the rates of hospitalizations and overdose deaths, having fewer people in treatment, and getting more people into recovery. One administrative interviewee said, “So many people feel like they’re doing really good work, and for the first time ever, there’s enough money in the substance use system to have an impact, so people are anxious to be able to show that.” (A4) The same interviewee said, “We all believe that the primary prevention actually works. We believe that; we’ve just never had the resources to put up.” (A4) The settlement funds can sufficiently fund public health programs and facilitate large-scale positive outcomes.

DISCUSSION

Stakeholders were interviewed to gather their perspectives on the opioid epidemic and national settlements distributed in Pennsylvania. Understanding these perspectives is critical to evaluating the ramifications of these stakeholders’ decisions on communities.

Recommendations

1. Ensure POMAAT Trustees Are Educated and Experienced With SUD/OUD

To build trust in POMAAT’s decision-making processes and ensure comprehensive program review, trustees need to be able to make informed decisions about expenditures to benefit populations impacted by SUD/OUD. As noted earlier, trustees are selected through a political process rather than on the basis of their subject matter expertise. Perhaps this warrants a change in the trustee selection process, or that training be required for trustees to educate them about the realities of administering SUD/OUD remediation programs. POMAAT has done this before, but inviting subject matter experts to regularly educate trustees and advise on the evaluation of programming could build greater trust with the counties and hold POMAAT accountable. Other educational opportunities include creating POMAAT retreats and education sessions, which are common practices across the boards of various organizations.

2. Address Ambiguity in Guiding Documents

To address the ambiguity in Exhibit E and its interpretation, POMAAT should consider supplementing it with additional resources (eg, DDAP resources) to guide decisions on opioid remediation programs. This would make the review process more comprehensive and help identify overlapping information. Future settlements should avoid the inapplicability of Exhibit E by minimizing legal jargon, providing specific examples of approved programming, and considering other state-level frameworks for comparison.

3. Continue to Address Stigma

SUD/OUD education must continue to address stigma. Education about implementing evidence-based programming is also necessary. Investing in prevention education requires implementing evidence-based curricula with fidelity to maximize positive outcomes.

4. Acknowledge Differing Needs Across Geographic Regions

Discussions with both rural and suburban counties revealed that available resources vary by geographic area. Consequently, some counties are trying to fill budgetary gaps, whereas others are innovating opioid abatement. The different starting points among these counties demonstrate the need to ensure sufficient resources are universally available so that all counties can creatively utilize opioid settlement funds.

5. Long-Term Strategic Planning

Lastly, little consideration was given to long-term strategic planning for the settlement funds, especially to using data to monitor their impact. Time and resources should be dedicated to creating a long-term strategy that allows funding to evolve with changing needs while enabling stakeholders to ascertain the effectiveness of programs and quantify their impact.

Limitations

The interviewees do not represent the entirety of lived experiences related to opioids, and their views may differ from those employed to address the opioid epidemic. Representation from various stakeholder groups in Pennsylvania was achieved by including multiple interviewees within each group. Other important perspectives, such as details on county-level processes for deciding how to spend settlement dollars, as reported in Kampman et al,⁹ are also valuable and complement our analysis, which is more focused on the process of implementing and operationalizing the settlement in Pennsylvania.

CONCLUSIONS

These interviews highlighted 7 key emergent themes raised by administrative-, county-, and external-level stakeholders involved with the implementation of the national opioid settlement rollout in Pennsylvania. They identified opportunities for POMAAT to adjust its approach to reviewing programming to gain the counties’ trust, as well as for counties to consider long-term strategies and program sustainability. These insights also provide ideas to consider for future, similar settlements, especially regarding the formation of organizations such as POMAAT and the appointment of trustees with appropriate backgrounds for the role. All stakeholder groups agree that reducing stigma around OUD by continuing education is critical to ensure effective distribution of opioid settlement funds. Although there is still work to be done to address the opioid crisis, these interviews demonstrate that all stakeholders are committed to serving their communities.

Author Affiliations: The Pennsylvania State University (AA, AY, DPS), University Park, PA.

Source of Funding: This work was supported by a contract with the Pennsylvania Opioid Misuse and Addiction Abatement Trust.

Author Disclosures: Ms Altstaedter, Ms Yeung, and Dr Scanlon received grant funding from the Pennsylvania Opioid Misuse and Addiction Abatement Trust. Dr Scanlon is the editor in chief of Population Health, Equity & Outcomes.

Authorship Information: Concept and design (AA, AY, DPS); acquisition of data (AA, DPS); analysis and interpretation of data (AA, AY, DPS); drafting of the manuscript (AA); critical revision of the manuscript for important intellectual content (AY, DPS); obtaining funding (DPS); and supervision (AY, DPS).

Send Correspondence to: Amy Yeung, MPH, The Pennsylvania State University, 504 Ford Building, 498 Allen Rd, University Park, PA 16802-6500. Email: aby5225@psu.edu.

REFERENCES

1. The origin and causes of the opioid epidemic. Georgetown Behavioral Health Institute. August 14, 2018. Accessed July 15, 2025. https://www.georgetownbehavioral.com/blog/origin-and-causes-of-opioid-epidemic
2. Bedene A, Dahan A, Rosendaal FR, van Dorp ELA. Opioid epidemic: lessons learned and updated recommendations for misuse involving prescription versus non-prescription opioids. Expert Rev Clin Pharmacol. 2022;15(9):1081-1094. doi:10.1080/17512433.2022.2114898
3. Timeline of selected FDA activities and significant events addressing substance use and overdose prevention. FDA. Updated January 13, 2025. Accessed July 15, 2025. https://www.fda.gov/drugs/food-and-drug-administration-overdose-prevention-framework/timeline-selected-fda-activities-and-significant-events-addressing-substance-use-and-overdose
4. Understanding the opioid overdose epidemic. CDC. June 9, 2025. Accessed July 15, 2025. https://www.cdc.gov/overdose-prevention/about/understanding-the-opioid-overdose-epidemic.html
5. Exhibit E: list of opioid remediation uses—schedule A: core strategies. National Opioid Settlement. Accessed July 15, 2025. https://nationalopioidsettlement.com/wp-content/uploads/2023/02/TEVA-Exhibit-E.pdf
6. The Master Settlement Agreement. National Association of Attorneys General. Accessed July 15, 2025. https://www.naag.org/our-work/naag-center-for-tobacco-and-public-health/the-master-settlement-agreement/
7. Rhubart D, Chen Q, Sterner G, Newton R, Shaw B, Scanlon D. Conceptualizing and measuring abatement from the opioid epidemic: a case study from Pennsylvania. Milbank Q. 2022;100(4):991-1005. doi:10.1111/1468-0009.12589
8. Payment, spending, and reporting. PA Opioid Misuse and Addiction Abatement Trust. Accessed July 15, 2025. https://www.paopioidtrust.org/payment-spending-and-reporting
9. Kampman H, Brant K, Weinberg M, Sterner G, King B. Initial stakeholder perceptions around opioid settlement funds in Pennsylvania. Subst Abuse Treat Prev Policy. 2025;20(1):45. doi:10.1186/s13011-025-00665-7
10. Creswell JW, Creswell JD. Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. 5th ed. SAGE Publications; 2018.
11. The Master Settlement Agreement: an overview. Public Health Law Center. January 2019. Accessed July 15, 2025. https://www.publichealthlawcenter.org/sites/default/files/resources/MSA-Overview-2019.pdf
12. Jones WJ, Silvestri GA. The Master Settlement Agreement and its impact on tobacco use 10 years later: lessons for physicians about health policy making. Chest. 2010;137(3):692-700. doi:10.1378/chest.09-0982
13. Tobacco Settlement: States’ Use of Master Settlement Agreement Payments. US General Accounting Office; June 2001. Accessed July 15, 2025. https://www.gao.gov/assets/gao-01-851.pdf
14. Second annual report of the Pennsylvania Opioid Misuse and Addiction Abatement Trust pursuant to paragraph VI(A)(6) of the order entered July 12, 2022. Commonwealth Court of Pennsylvania. September 10, 2024. Accessed July 15, 2025. https://www.paopioidtrust.org/getmedia/2b2c1be9-df2f-4948-ac58-62aa7f201d85/2024-09-10-Second-Annual-Report-to-Cmwlth-Ct.pdf
15. Cicero TJ, Ellis MS, Kasper ZA. Polysubstance use: a broader understanding of substance use during the opioid crisis. Am J Public Health. 2020;110(2):244-250. doi:10.2105/ajph.2019.305412
16. Mahoney JJ III, Winstanley EL, Lander LR, et al. High prevalence of co-occurring substance use in individuals with opioid use disorder. Addict Behav. 2021;114:106752. doi:10.1016/j.addbeh.2020.106752
17. Heimer R, Black AC, Lin H, et al. Receipt of opioid use disorder treatments prior to fatal overdoses and comparison to no treatment in Connecticut, 2016-17. Drug Alcohol Depend. 2024;254:111040. doi:10.1016/j.drugalcdep.2023.111040
18. California opioid settlements allowable expenditures. California Department of Health Care Services. September 2023. Accessed July 15, 2025. https://www.dhcs.ca.gov/Documents/CSD/CA-OSF-Allowable-Expenses.pdf