Editor’s note: This story was first published on May 18, 2023.

Billions of dollars are expected to come to Pennsylvania to help the state respond to the opioid epidemic, but tracking how counties and other local governments plan to spend that money isn’t easy.

“A lot of the decisions that are happening now are really going to set the tone for: What are we prioritizing?” said Alejandro Alves, who works on overdose prevention issues for the international public health nonprofit Vital Strategies.

Those decisions could have an impact for years to come because once counties start funding programs, it can be hard to eliminate or reduce them later—or switch to another initiative. Here’s what you need to know about the money, the process for deciding how it will be spent, and how you can influence it.

How much will PA receive?

The attorney general’s office has said the state is “set to receive more than $2.2 billion” from various investigations and cases. An office spokesperson declined to provide a detailed breakdown of how the office reached that number. There are several different sources of money, and the attorney general’s office has described them as coming in waves.

Pennsylvania expects to receive up to $1.07 billion over 18 years from a national deal with Johnson & Johnson and three major drug distributors—Cardinal Health, McKesson, and AmerisourceBergen. All 67 counties in Pennsylvania joined that agreement, the attorney general’s office announced in January 2022.

The state received about $130 million in 2022 from that deal, according to Tom VanKirk, chair of the state’s opioid trust.

During a public meeting in late March 2023, the state attorney general’s office described a second wave of opioid settlements, saying that agreements with five companies could bring over $770 million more to Pennsylvania. The list consisted of drug manufacturers Allergan and Teva and retailers Walmart, CVS, and Walgreens.

Who’s in charge of spending the settlement money?

County government officials will have the most control.

The distribution plan in Pennsylvania says 15 percent of funds go to the state legislature to decide how to spend. Another 70 percent goes to county governments based on a formula that factors in opioid-related harm that occurred while also guaranteeing a minimum of $1 million for each county, and 15 percent goes to local governments that had initiated their own litigation. The latter includes some counties.

Separately, some opioid settlement money pays for attorney fees and expenses related to litigation, as well as management costs for the trust, according to court documents.

How can local governments spend the money?

Settlement documents describe a list of approved and recommended opioid remediation uses.

That list—known as Exhibit E—includes drugs that reverse opioid overdoses, medication-assisted treatment, support for pregnant and postpartum women, recovery services, prevention programs, regional planning, and media campaigns.

But that list doesn’t cover every possibility, and local governments will have some discretion.

Who ensures the money is spent appropriately?

The 13-member PA Opioid Misuse and Addiction Abatement Trust is primarily responsible for oversight of how counties and other local governments spend their money.

Local governments don’t need permission from the trust before they spend money, according to the court order that created the trust and defined its powers. Once a year, counties must report to the trust on settlement expenditures, but the trust hasn’t provided information on how much detail will be required.

The trust can withhold future payments if locals spend the money in a way that “is not in accordance with the requirements of Exhibit E.” Local governments will have up to three months to fix the misspending and still receive their full payment.

But if they don’t resolve the issue, the trust can cut or withhold money going forward.

What are the best ways to spend the money?

Johns Hopkins Bloomberg School of Public Health has shared a set of five principles to help guide states and local governments: spend the money to save lives, use evidence to direct spending, invest in youth prevention, focus on racial equity, and develop a fair and transparent process for deciding how to spend the funds.

Experts say the experience of a previous major public health-related settlement—a master agreement to resolve claims against tobacco companies—has shaped the opioid settlements.

“It was diverted for a number of reasons to other basic needs of governance that didn’t have anything to do with tobacco,” said Alves of Vital Strategies. “No one wants to repeat that experience.”

But there’s still wide disagreement about the best way to respond to the opioid crisis. As Spotlight PA and WESA reported, an early point of contention is whether counties can and should spend the money to boost drug task forces, hire more police officers, and pay for guns and vests.

How can people track the spending?

In Pennsylvania, there’s currently no single resource for people to see where the money is going. Requesting information from your local government under Pennsylvania’s Right-to-Know Law can help.

Staffers with Community Education Group, an advocacy organization focused on public health issues, have been scouring meeting minutes, county government websites, and local news articles to track different discussions and plans. Tricia Christensen, director of policy for the organization, said these funding decisions are “fundamentally a political process.”

There are ways to influence that process. Jordan Scott, regional field organizer for the Pennsylvania Harm Reduction Network, encourages people to try to serve on local task forces, research what their communities’ needs are, and attend local meetings where the decisions happen.

“It’s much harder to dismiss a group of 20 versus one person,” Scott said.

Some advocates are pushing for more community involvement in the process.

“We lived it,” Marianne Sinisi, whose son Shawn died from a drug overdose in 2018, told Spotlight PA and WESA. “So it shouldn’t be decided by government officials or somebody that just thinks they have all the answers. It should be the victims that are at that table.”

When must counties report their spending?

Their deadline is March 15 of each year. But the trust waived that requirement for this year. The order creating the trust does not specifically say other local governments that received money because of their role in litigation have to submit an annual report by that same deadline. But another section of the order says those other local governments can be penalized if they misspend money or don’t file an annual report.

Spotlight PA (spotlightpa.org) is an independent, nonpartisan newsroom powered by The Philadelphia Inquirer in partnership with PennLive/The Patriot-News, TribLIVE/Pittsburgh Tribune-Review, and WITF Public Media.

See related story, "Wayne to get $1.5 million in opioid settlement."