Local Control Is Driving Opioid Cash Into Unexpected Purchases
State and local governments spent about $3.7 billion in opioid settlement funds last year, a sum larger than the median annual income of 42,000 American families combined. The money came from companies sued for aggressively pushing painkillers and helping fuel the opioid crisis, and it was meant to help repair the damage through addiction treatment, recovery housing, prevention, and related services.
A large share of the spending fit that purpose. Another slice did not.
Among the expenditures uncovered in a yearlong investigation were $150,000 for street lighting in Camden, New Jersey; $130,000 for Flock cameras in Carmel, Indiana; at least $84,000 for city insurance, building utilities, vehicle repairs, and other standard municipal costs in Mullens, West Virginia; and $36,200 for a pickleball court in Gilmer County, West Virginia. Those purchases sit uneasily beside the public health rationale behind the settlements and help explain why recovery advocates are alarmed by how freely some local governments are using the money.
The issue is not a lack of cash. It is a lack of discipline.
A Yearlong Review Found Spending That Stretches the Settlement Mission
KFF Health News, working with the Johns Hopkins Bloomberg School of Public Health and Shatterproof, examined about 17,500 expenditures through public records requests, government websites, and data extraction. The team then sorted the spending into categories such as treatment and prevention, creating the most comprehensive national database to date documenting how opioid settlement money was used, or left unused, in 2025.
The database makes the central problem visible: the money is often treated less like a public health fund and more like a flexible local revenue stream. Settlement agreements include spending guidelines, but the rules leave substantial room for interpretation. In practice, the result is a vacuum of leadership and oversight, along with major gaps in public tracking. County and city officials control nearly half of the settlement dollars nationwide, and many of those decision-makers do not work in addiction policy or health systems.
At the local level, that can produce a dangerous mismatch between cause and cure. An opioid settlement is designed to remediate addiction’s toll, not to become an all-purpose fix for municipal needs.
Advocates Say the People Closest to the Crisis Understand the Need Best
Elizabeth Burke Beaty, executive director of the Sea Change Recovery Community and Harm Reduction Center in Ocean County, New Jersey, argued that people directly affected by the addiction crisis should have the strongest voice in how the money is spent. She has watched families lose parents, siblings, and children to overdose, and she sees the aftermath in her work every day.
“This whole opioid settlement should be run by the people who’ve lost everything,” she said.
Burke Beaty is not dismissing local government outright. She recognizes that many local officials have also lost loved ones and want to use the funds well. The problem, in her view, is whether those officials have the expertise, staff support, and willingness to resist pressure from vendors who see the settlements as a lucrative opportunity. County leaders often juggle multiple responsibilities at once, with lean administrative support and constant pressure to keep core government services functioning.
Recovery advocates have tried to help fill that gap. Burke Beaty has written letters, attended public meetings, and produced reports on how localities in her region spent the money. When those efforts fail to change course, she said, the question becomes whether the problem is ignorance or indifference.
The Tobacco Settlement Offers a Cautionary Parallel
The debate over who should control the money echoes an older public health failure. During the 1998 Tobacco Master Settlement, cigarette companies paid hundreds of billions of dollars to states, usually without county or city involvement. Much of that money later disappeared into budget gaps, and over two decades, less than 3% of tobacco settlement and tax-related revenue went to anti-smoking programs.
That history makes a strong case for caution. Centralized control alone did not protect tobacco dollars from diversion, and a fragmented local model has not guaranteed wiser opioid spending. Philip Rutherford, who leads substance use strategy at the National Council for Mental Wellbeing, said no model is likely to function flawlessly. Local governments can spend less on administration, move faster, and test new ideas, but the same flexibility can also invite drift away from addiction care.
Annie Qing of the National Association of Counties described a familiar public-sector reality: officials routinely make decisions outside their core technical expertise. County commissioners do not need to be construction experts to decide roads, but they do need to seek subject matter expertise when the issue is complex. Settlement dollars should be treated the same way, with local leaders drawing on university centers, county associations, and public health policy groups for guidance.
AED Purchases Show How Easily the Mission Can Blur
Automated external defibrillators are a sharp example of how a legitimate-sounding purchase can still raise hard questions. AEDs can save lives in sudden cardiac arrest, but they are not addiction treatment, relapse prevention, or overdose response in any direct sense. Last year, about 100 localities across 20 states committed $3.7 million in opioid funds to expenditures that included AEDs, cardiac monitors, and related accessories.
The clinical logic behind an AED is straightforward: it can restore rhythm during a cardiac emergency. The policy logic is less clear. Opioid settlement money is meant to confront the harms of addiction, and while overdose often presents as a medical emergency, not every emergency tool belongs in this account. When funds are stretched to cover general public safety or routine local equipment, the connection to opioid remediation weakens fast.
For people in recovery, those choices carry symbolic weight as well as fiscal consequences. Many see the settlements as money extracted from companies that profited while communities buried their dead. When that money is used for street lighting, parking lots, or pickleball courts, trust erodes.
The Oversight Problem Will Shape What Settlement Money Still Can Do
The deeper risk is not only wasted dollars. It is the quiet normalization of drift, one local purchase at a time, until the public health mission becomes hard to recognize. Nearly $60 billion in settlement money is expected to flow over almost two decades, and the decisions made now will determine whether those funds support treatment capacity, harm reduction, and recovery infrastructure or fade into ordinary government spending.
The people closest to the overdose crisis are already warning that local control without stronger safeguards invites misuse. The database created through this investigation gives public view into how often that happens, and it will keep raising the same question with each new budget cycle: whether opioid settlement cash is being used to address addiction, or to patch everything else.
The spending rules leave plenty of room for interpretation, and the next rounds of local allocations will show how far that room can stretch before the settlement’s public health purpose disappears.