Maximizing the Public Health Benefits of Opioid Settlements: Policy Recommendations for Equity, Sustainability, and Impact

See all articles in the special issue, Mental Health and Substance Use Challenges Facing the United States: What Can State Policymakers Do?

The US overdose crisis is one of the most severe and devastating public health problems of the 21st century. Since 1999, more than one million Americans have lost their lives to accidental drug overdose.¹ In recent years, drug overdose mortality rates have increased most rapidly in Black, Hispanic/Latino, and American Indian/Alaska Native populations, a manifestation of structural racism throughout the health care, social service, and behavioral health systems, highlighting the urgent need for interventions to address these health inequities.^2, 3 The economic impacts of the crisis are significant, with more than $1 trillion lost annually owing to the costs of health care and substance use treatment, criminal justice involvement, reduced quality of life, and years of life lost.⁴ The historical origins and ongoing drivers of the crisis are complex with a combination of intersecting behavioral, social, and structural determinants of health that result in an enduring, three decade long exponential increase in drug overdose deaths.⁵ Important fundamental causes of the modern US overdose crisis include the following: (1) concentrated poverty, rising income inequality, and unemployment as a result of economic recessions, globalization, and deindustrialization throughout the 20th century; (2) significant increases in precarious employment and occupationally induced pain and injuries owing to loss of workplace protections, weakening of unions, and deregulation; and (3) long-standing structural racism throughout US health care, substance use treatment, and recovery systems.⁶ Although the mechanisms through which structural racism exacerbate the US drug overdose crisis are complex, specific drivers include extraordinarily elevated rates of overdose death in the immediate period following release from incarceration (which disproportionately impacts Americans who are Black, Indigenous, and Hispanic) and racial and ethnic inequalities in access to evidence-based treatment for substance use disorder (SUD), including medications such as methadone and buprenorphine.⁷ In more recent years, the increasing potency of substances that constitute the unregulated drug supply—including the introduction and proliferation of fentanyl starting in 2013—has further compounded these problems and contributed to rapid increases in drug overdose deaths.⁸

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