August 1, 2023
At a time when opioid overdose deaths in D.C. are reaching record-breaking levels, the city is set to receive millions of dollars in settlements with pharmaceutical chains and drug manufacturers.
How the city will use the settlement money – which currently sits at more than $11 million dollars, with more to be paid out over time – has yet to be ironed out. According to the terms of the court agreements, there are strings attached (albeit somewhat loosely) to the money, requiring jurisdictions to use the payouts on opioid crisis solutions. Now, D.C. officials have to decide what those solutions will look like.
“I think the fund…gives us an opportunity to really do something transformative here, and to try to think outside the box on how we can reach people and get them the help they need,” said chair of the D.C. Council’s health committee, At-Large councilmember Christina Henderson in an interview.
The money comes from major multi-state settlements with companies like CVS, Walgreens, and Johnson & Johnson, which were found liable for the role they played in fueling the opioid crisis nationwide. Currently, there are a total of eight different settlements that have been finalized through the D.C. Attorney General’s office.
Some companies have already started payments, and will be on the hook for annual payments over the coming decade; all told, D.C. is expected to receive between $50 to $110 million over the next 18 years. In addition to the relief measures mandated in the settlements (like what a company has to change about its practices), they also regulate what percentage of the payment must go toward opioid abatement efforts, and give rough guidelines for what exactly “opioid abatement” could look like. In Virginia, the state’s Opioid Abatement Authority recently handed out $73 million to cities, counties, and partnerships for a variety of programs, ranging from education to youth substance use treatment. In Maryland, meanwhile, the Opioid Restitution Fund Advisory Council has held several listening sessions allowing the public to weigh in on potential uses of the abatement fund money.
The lawsuits mark the largest public health settlements since the big tobacco suit of the 1990s. Cigarette companies paid out billions to states, but without any stipulations about how the money could be used, the money rarely went to anti-smoking efforts. Instead, it was used to fill potholes or balance annual budgets. To avoid that happening this time, the agreements require states to use a portion of the funds directly for opioid resources and treatment.
But whether those solutions will meet the scale of the problem in the District – by funding grassroots harm-reduction efforts and targeting urgent housing and mental health care needs – or fall back on sanitized, abstinence-based treatment efforts, which advocates and former drug users say aren’t effective on their own, is an open question.
“It seems as though [the city] is throwing pennies at the problem, and they’re not investing in the right things,” Ambrose Lane Jr., who chairs the Health Alliance Network, told DCist/WAMU.
Across the U.S., states and cities are setting up administrative bodies to decide how to best use the money; in D.C., the council created an Opioid Abatement Advisory Commission in a law passed last year. The bill also established an Office of Opioid Abatement within the Department of Behavorial Health, which will work with the commission to direct the funds. As an oversight mechanism, the city will need to report its spending to the D.C. Attorney General’s office, as well as issue public reports tracking the impact of the commission’s work on mortality rates. (Already this past budget cycle, the council stepped in to prevent a sweep of $2 million dollars from the fund, originally proposed in Mayor Muriel Bowser’s fiscal year 2024 budget.)
The 21-person advisory commission consists of five mayoral appointees and four council appointees, as well as several government officials. The legislation mandates that among the council and mayoral appointees, one member must have lived experience with substance use, one member must have worked extensively in outreach, treatment, or harm reduction, and one member will be a family member or loved one of someone with a substance use disorder, as well as other medical and academic professionals with substance use expertise.
During a D.C. Council roundtable on the opioid crisis in late June, Dr. Barbara Bazron, the director of the Department of Behavorial Health, said the mayor has finished appointing her five seats. Council Chairman Phil Mendelson, on the other hand, is “still considering potential nominees,” according to a spokesperson. Henderson said ideally, the commission would hold its first meeting in August, in order to start distributing the more than $11 million sitting in the fund.
“Time is of the essence on the commission because we literally cannot expend any money until the commission meets,” Henderson told DCist/WAMU.
The money comes at a dire time for the city, as the number of people dying from opioid overdoses has reached an all-time high. Through April of this year, 152 people died of opioid-related overdoses, 16 more than the same time last year. According to the most recent report from the Office of the Chief Medical Examiner, in the month of March alone, 51 people died – the highest number of fatalities recorded in a single month since the city started tracking opioid overdose data in 2014. D.C. is poised to record yet another record-breaking year if the first quarter trend continues; 2022 saw 448 documented fatal overdoses – the deadliest year to date – and D.C. surpassed West Virginia to lead the country in fatal drug overdoses per capita. Nearly 100% of the fatal overdoses this year involved fentanyl, according to the OCME, and Black residents make up 88% of those deaths.
The city has also started tracking deaths related to xylazine, a non-opioid animal sedative that has infiltrated the drug supply of cities like New York, Philadelphia, and Baltimore in recent years. When fentanyl is cut with xylazine, because it’s not an opioid, xylazine slows or prevents the effects of Narcan in reversing an overdose. It can also cause painful lesions and wounds on the skin. According to a study published in Oct. 2022, xylazine was found in the drug supply of 36 states and D.C. Since 2020, a total of 22 people have died from opioid-related deaths that also involved xylazine, according to the OCME. A spokesperson for the Department of Behavorial Health did not return DCist/WAMU’s request for comment in time for publication on whether the city will start providing xylazine test strips.
For the city’s part, there have been efforts to curb the crisis, starting before the pandemic triggered skyrocketing overdose rates. In 2018, Bowser launched a $24 million initiative to curb opioid-related deaths, shortly after a Washington Post investigation detailed how the city’s response failed residents – predominantly, older Black men in the city’s poorest neighborhoods. While the initiative, called Live Long D.C., missed its goal of cutting overdose fatalities in half by 2020 (in fact, the opposite happened) the city has upped its distribution of Narcan and test strips for fentanyl, maintained a needle exchange program, and provided grant funding for local harm reduction organizations.
In a Live Long D.C. summit meeting last week, Bazron also announced plans to begin the grant process for a 24/7 residential substance use treatment center for youth — a long-held demand by health advocates.
During her testimony before the Council, Bazron listed the accomplishments of the city’s overdose reduction efforts thus far, highlighting the Narcan and test strip distribution, and a new housing model for individuals at-risk of relapsing or those exiting incarceration. She said the city is on track to release an updated version of Live Long D.C.’s plan this fall.
“We anticipate the revised plan will double down on what we know works now; increase funding for faith-based groups, award many grants to community-based efforts, targeted housing for those with medical needs, and pregnant women and women with young children, and add support for young people,” she said.
Still, advocates say, the current approach isn’t meeting the reality of the crisis in the moment.
“Obviously the Narcan distribution, the fentanyl test strips…none of that is working to the effect that it needs to be,” Lane Jr. said. “I’m not saying that Narcan isn’t important, what I’m saying is the methods they’re using now are not as effective as they think they are.”
In an interview with DCist/WAMU, Henderson echoed the same criticism of the city’s response, saying, “it seems right now, like the District’s only strategy with regard to opioids is Narcan and fentanyl strips, and that’s not cutting it.”
Harm-reduction advocates and outreach workers see the opioid abatement fund as a chance for the city to embrace grassroots community-based solutions, like making housing services, mental health care, and safe consumption options affordable and available. An abundance of research shows measures like these effectively curb opioid deaths by building compassionate relationships with community members, instead of solely focusing on interventions that prioritize abstinence or criminalization.
LJ Sislen, a campaign organizer for the Decrim Poverty DC campaign and outreach volunteer with HIPS, a D.C. harm reduction organization that serves sex workers, drug users, and residents experiencing homelessness, testified in the roundtable to their own experience in abstinence-based treatment – and about how it isn’t a one-size-fits-all solution.
“Abstinence only and tough love, or a heavy hand does work for some people. It worked for me,” Sislen said. “But the reality is, the drug supply is just too different to continue to do the same low-reaching tactics. Rather than scratching our heads and wondering why individuals just won’t get better, we need to diversify the approach.”
While the city frequently touts the number of lives saved by its efforts to expand the availability of Narcan and fentanyl test strips, advocates see these as only one piece of a much broader response. Narcan only works once an overdose has occurred. In order to stop overdoses before they happen, advocates want the city to invest in more housing and dignified mental health care, address the social factors that might lead someone to drug use, like poverty, and open a safe-consumption site, where people could use drugs with medical supervision.
“In a place so abundant like D.C., it’s just outrageous that we don’t have housing for everybody,” said Sislen said in an interview with DCist/WAMU. “Isolation is a huge reason why people are dying because no one can revive you.”
For years, outreach workers with organizations like HIPS and advocates with the DecrimPovertyDC campaign have been pushing the city to open a safe-consumption site or overdose prevention center. A life-saving strategy that’s been embraced in countries around the world – and more recently in New York City – the model gives people a space to use drugs safely with medical staff nearby and without fear of criminalization. OnPoint NYC opened its first two overdose prevention centers in 2021, providing meals, showers, beds, and harm reduction supplies like syringes, in addition to a safe place where people can test and use drugs with medical staff on-hand to handle emergencies. In its first year of operation, OnPoint NYC saw zero deaths and reversed hundreds of overdoses. (Critics of such centers maintain that they enable drug use and increase crime, but research has not shown a link between these programs and an increase in crime.)
Ward 4 Councilmember Janeese Lewis George visited OnPoint NYC last year and pushed to include funding for D.C.’s own overdose prevention centers last budget cycle, but there are no current plans to open such a center in the city.
Instead, D.C. has dedicated funding towards sobering centers, with a new location set to open this August near Union Station. Instead of being taken to an emergency room, D.C. Fire and EMS can drop off residents at the sobering center, where they will have a bed, medically-assisted addiction treatment with buprenorphine –a drug used to treat opioid dependence – and support from peer specialists. The center, operated by a nonprofit organization based in Arizona called Community Bridges, will not have a safe-use component; residents are not allowed to bring any drugs into the facility with them.
While the sobering center will help some residents in need of immediate care, advocates worry it’s a missed opportunity to create a space that would help residents who are currently using to do so safely.
“Right now we are in a fentanyl crisis, we are in a xylazine crisis, we are in an isolation and overdose crisis, we’re in a stigma crisis, we’re in a criminalization crisis, regardless of all the efforts to switch to a public health model… so the desperate part of me is like, ‘I want anything that’s going to help people that use drugs’,” Sislen said of the sobering center. “The advocate in me, that knows about all the possible options and funding that we have, and that we really could move with the most comprehensive approach, is disappointed.”
Lane Jr. said he wants to see the city use the fund’s money in immediate ways; in addition to opening a safe consumption site, he wants to create a substance-use and behavioral health urgent care center at United Medical Center.
“When we’re talking about the dispersal of the opioid settlement money, these are things that can be implemented within six months,” he said.
Sislen, for their part, would allocate some of the money toward groups like HIPS and other outreach workers on the ground, who have already built trusted relationships with communities and operate under a harm-reduction philosophy.
“There are so many phenomenal groups already doing the work… it is a little frustrating when we’re always trying to find something new… when, from the harm reduction perspective, we have so many phenomenal groups already doing the work.”
Some obstacles – both politically and logistically — stand in the way of true harm-reduction programming being implemented in D.C. Despite long-standing calls for the city to decriminalize opioid use – which disproportionately harms the city’s Black residents, who are also the people dying most frequently from opioid-related causes – opioids remain a criminalized drug in the city. Federal statutes could also prevent the city from opening a safe-use site; a provision of the National Controlled Substances Act colloquially known as the “crack house statute” prohibits individuals or organizations from maintaining or opening a place for the purpose of using a controlled substance. While New York state officials have vowed not to enforce that statute on facilities like OnPoint, D.C. faces the unique hurdle of Congressional control over its budget, which could make spending government dollars on an overdose prevention center difficult. (OnPoint is funded primarily through private dollars.)
More broadly, harm reduction advocates and experts maintain that there needs to be governmental and community buy-in for such programs, which would require a shift in the public perception of drug use and people who use drugs. (Asked earlier this year if she supported a safe-consumption site, Director Bazron herself said she did not know enough about them “to have an opinion.”) While the opioid epidemic’s impact on white communities has spurred a more compassionate, public-health-based response to addiction, the criminalization and stigma of drug use continue to perpetuate a narrative in which addiction is seen largely as an individual issue, rather than the result of systemic failures, poverty, and racism.
“In some cases, I see how addiction is being switched from saying ‘oh it’s a moral failing’ to ‘it’s a disease,’ and in a lot of ways that’s good because now we’re thinking about it in a public health model,” Sislen said. “But a lot of these things are completely natural responses to a housing crisis, employment crisis, generational trauma… actually drug addiction makes a lot of sense to me, given the realities we live in. So it’s about being willing to see people as human beings.”
In order to ensure that the opioid settlement money ends up being used for holistic harm reduction and safer consumption resources, Sislen said it will take courage and a willingness on the part of both the community and the city’s leaders to try what the evidence and lived experience has proven to be successful in saving lives.
“I think the most clear thing to me is that — gosh, we got to just be a little willing to do it.”