Advancing Health Equity Through County Opioid Abatement Strategies

Executive Summary

From 1999 to 2020, prescription opioids were involved in more than 263,000 overdose deaths in the U.S.¹ Prescription opioids were involved in more overdose deaths than any other substances during this period, including cocaine, heroin and psychostimulants, such as methamphetamine. Though not the only cause of the opioid epidemic, prescription opioids played a unique role in the onset of the epidemic due to years of false marketing and commercial distribution as non-habit forming medicines.² Between 2014 and 2021, over 3,000 state, county and municipal governments filed lawsuits against companies in the pharmaceutical industry for the societal and economic costs associated with their products.  

In 2021, to resolve lawsuits brought against them, opioid manufacturer Johnson & Johnson and three major pharmaceutical distributors (McKesson, Amerisource Bergen and Cardinal Health) offered a settlement of up to $26 billion (“the master settlement”). To unlock the full offer, ninety percent of cities and counties in each of the 46 participating states needed to surrender their individual lawsuits and join their state agreements. Negotiated by a coalition of state attorneys general, an agreement was reached in early 2022 for $26 billion – the maximum amount offered – to be distributed in annual payments over 18 years.³ Since the master settlement, six other companies have settled lawsuits with a national scope (Purdue, Walmart, Walgreens, CVS, Teva and Allergan). As of July 2023, the total amount of opioid settlement funds obligated to states, counties and cities is over $50 billion.⁴  

The master settlement agreement requires participating state and local governments to spend the majority (eight-five percent) of settlement funds on strategies that will mitigate the effects of the opioid epidemic.⁵ This requirement is codified in an extensive – though not exhaustive – list of eligible expenditures. In addition to paying $26 billion, the master settlement agreement requires the defendants to impose significant changes in their operations to improve safety and oversight over the distribution of their products.  

The terms of the master settlement agreement allow counties to invest settlement funds in localized solutions. As disparities in substance use-related outcomes have increased in recent years, new investments are needed to meet the needs of community members who are at greatest risk. From 2019 to 2020, the overdose death rate among Black men and American Indian/Alaska Native men increased by 39% and 44%, respectively, compared to a 30% increase in the general population.⁶ Between 2017 and 2020, overdose deaths among pregnant and postpartum women more than doubled.⁷  

As the level of government closest to the American people, counties understand how residents are performing across health indicators relative to one another and are well positioned to allocate resources, including opioid settlement funds, to intervene upon drivers of health disparities.

The U.S. Centers for Disease Control and Prevention (CDC) defines health equity as “the state in which everyone has a fair and just opportunity to attain their highest level of health.”⁸ Achieving health equity involves identifying the preventable differences in health-related outcomes among members of a population and changing the systems and policies that contribute to these preventable health disparities. To support counties in utilizing opioid settlement funds to advance health equity, the National Association of Counties, in partnership with ChangeLab Solutions, developed case studies on five counties that are integrating opioid settlement funds into ongoing health equity initiatives. This resource details steps taken by these counties during the first year of payments from the master settlement and considerations for counties in other jurisdictions.  

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