State and local governments spent roughly $3.7 billion in opioid settlement money last year — more than the combined median annual income of 42,000 American families.
The funds come from companies sued for aggressively marketing prescription painkillers and helping drive the opioid crisis.
Significant sums supported addiction treatment, recovery housing, and other programs that public health researchers and families affected by the crisis say align with the settlements’ purpose: saving lives and repairing the damage caused by addiction.
Other spending, however, had far less obvious connections to the crisis. Examples included:
- $150,000 for streetlights in Camden, New Jersey.
- $130,000 for Flock surveillance cameras in Carmel, Indiana.
- At least $84,000 for municipal insurance, building utilities, vehicle repairs, and other routine city costs in Mullens, West Virginia.
- $36,200 for a pickleball court in Gilmer County, West Virginia.
KFF Health News identified these purchases and approximately 17,500 more during a yearlong investigation conducted with the Johns Hopkins Bloomberg School of Public Health and Shatterproof, a national addiction nonprofit. Reporters filed public records requests, searched government websites, and compiled spending records that were then classified into categories including treatment and prevention. The effort produced the most extensive national database to date showing how opioid settlement dollars were spent — or remained unused — in 2025.
The settlement funds, described by many people in recovery and their advocates as “blood money,” are projected to reach about $60 billion over nearly 20 years. The money is distributed among states, counties, cities, and, in some jurisdictions, newly established opioid settlement councils.
Settlement agreements include some spending guidelines, but they leave substantial room for interpretation. That flexibility exists alongside a leadership and oversight vacuum and major gaps in public reporting.
Much of the questionable spending — from law enforcement technology to ordinary municipal expenses — occurs at the county and city level. Local officials may have little experience with addiction policy and, in some cases, distribute the money to whoever submits the first proposal.
Local governments nationwide control nearly half of the settlement funds, according to OpioidSettlementTracker.com, which monitors the money. Supporters of local control argue that officials understand their communities and are closest to the people affected. Yet as questionable purchases accumulate, recovery advocates are increasingly asking whether county and city governments have the expertise needed to manage an opportunity of this scale.
“These funds should not be controlled by politicians,” said Elizabeth Burke Beaty, a New Jersey advocate in recovery who has tracked opioid settlement spending for years.
People directly affected by the crisis, she said, are best positioned to identify weaknesses in local care systems and determine how the money could make the greatest difference. “This entire opioid settlement should be managed by the people who have lost everything,” she said.
As executive director of Sea Change Recovery Community and Harm Reduction Center in Ocean County, Burke Beaty encounters those people every day: a woman who lost both her brother and father to addiction before later being hospitalized herself; an 11-year-old boy holding his grandfather’s hand at an overdose awareness event as they grieved a relative.
“This is money taken from people who died and from those left behind,” Burke Beaty said.
Many local officials have also lost loved ones or friends to the crisis, and some are deeply committed to using the money responsibly.
Unlike state agencies, which can draw on health departments staffed by policy specialists, local governments often operate with limited support. Officials may hold other jobs, have little administrative capacity, and face persistent sales pitches from companies treating the settlements as a lucrative gold rush. At the same time, they must decide how to address addiction while balancing budgets, keeping schools open, and maintaining roads.
Burke Beaty recognizes those pressures. In her region, she works with local officials by writing letters, attending public meetings, and preparing reports that offer detailed assessments of local spending.
When those efforts are dismissed, she said, she is left wondering whether the problem is a lack of resources or “a lack of willingness to do the right thing.” “Did this come from ignorance, or from an ‘I don’t care’ attitude?”
Who should control the money?
As questionable local spending patterns become more visible, it may seem logical to place all settlement funds under state control.
But the country has tried that approach before.
Under the 1998 Tobacco Master Settlement, cigarette manufacturers paid states hundreds of billions of dollars, generally without direct involvement from counties or cities. Much of that money ultimately went toward closing budget shortfalls. Over the next two decades, less than 3% of tobacco settlement and related tax revenue funded anti-smoking efforts.
“Whatever structure we choose is unlikely to work perfectly,” said Philip Rutherford, who leads substance use strategy at the National Council for Mental Wellbeing, which represents community mental health and addiction treatment organizations.
Giving local governments a share of the opioid money has benefits, he said. Local agencies can keep administrative costs lower, respond more quickly as the drug supply changes, and experiment with new approaches.
Local officials routinely make decisions outside their own areas of expertise, said Annie Qing, who oversees health and human services work for the National Association of Counties.
“Many county commissioners make decisions about roads without being construction specialists,” Qing said. Their responsibility is to consult experts, combine that advice with their understanding of local needs, and select investments “that make the most sense for their county.”
Officials seeking help with opioid settlement decisions can consult universities, county associations, and national public health and policy organizations.
Saving lives — from overdose or cardiac arrest?
Even so, translating academic research and broad policy principles into practical spending decisions can be difficult.
Consider automated external defibrillators, or AEDs. These portable devices can be lifesaving when someone suffers sudden cardiac arrest.
Last year, roughly 100 local governments in 20 states committed $3.7 million in opioid settlement funds to AEDs, cardiac monitors, and related equipment.
Many local officials viewed the purchases as part of an effort to save people from overdoses. Medical evidence, however, does not strongly support that reasoning.
Southfield, Michigan, bought six Lifepak cardiac monitors and related supplies for approximately $350,000. Mayor Kenson Siver said overdose response has grown more complicated because people increasingly combine opioids with stimulants. Paramedics, he said, need equipment capable of handling a range of emergencies.
Cardiac monitors provide more information than standard AEDs, including how effectively a patient is breathing. That data can help responders determine whether “interventions are working and identify deterioration or complications that require additional treatment,” Siver said.
Emergency medical professionals, however, say that reflects a basic misunderstanding. AEDs and cardiac monitors are essential public health devices, but they are rarely needed in opioid overdose cases.
“I’m not saying it never happens, but the number is extremely small,” said Dalton Barrett, a paramedic in Edgecombe County, North Carolina. Barrett leads the county’s post-overdose response team and oversees its opioid settlement funds.
During an opioid overdose, a person generally stops breathing. The usual interventions are oxygen and naloxone, a medication that can reverse an overdose.
AEDs are designed for cardiac emergencies and work only when a device detects a shockable heart rhythm — something that is uncommon in overdose victims, Barrett said.
When jurisdictions use opioid money to buy AEDs, they are often filling holes in general government budgets, even though those budgets should cover equipment required for ambulance operations, he said. “I struggle to see this as a particularly strong or targeted use of settlement funds.”
The exception, Barrett said, would be a new ambulance unit specifically dedicated to overdose response that needed an AED to meet regulatory requirements.
In general, he would rather see opioid funds used to hire staff who can follow up with overdose survivors and connect them with treatment, housing, and other services.
“People living with addiction are looking for trust,” he said. “They aren’t looking for expensive equipment.”
Oversight without enforcement
Some advocates are urging states to place tighter limits on how local governments use settlement funds.
Yet few officials are eager to assume that responsibility. State leaders risk alienating local governments by controlling their money, and in some states they lack the legal authority to intervene.
Jennifer Tourville leads a University of Tennessee initiative that advises local governments on opioid spending. The program is financed by the state’s opioid abatement council.
“We are not allowed to tell counties what they can or cannot purchase,” she said. “Our role is to explain the purpose of the funds and offer guidance on what could have the greatest impact in their communities.”
A small number of states have published lists of prohibited purchases, often called unallowable-use lists. They commonly bar law enforcement equipment such as body cameras and drones, along with routine emergency medical supplies including first-aid kits and gloves.
Even those restrictions, however, often lack enforcement power.
Spencer County, Indiana, for example, spent about $16,700 on eight AEDs for its sheriff’s department. AEDs were included on Indiana’s unallowable list, as they are on similar lists in California, Massachusetts, and South Carolina.
Asked whether Spencer County would face consequences, the Indiana Commission to Combat Substance Use Disorder said the list was advisory only.
“State law does not give us enforcement authority over how local entities spend opioid settlement funds,” said Shelby Thomas, a spokesperson for the commission.
Spencer County officials did not respond to requests for comment.
Iowa offers another example.
Van Buren County spent $1,000 in opioid settlement funds to help develop a recreation site with pickleball, bocce, and tennis courts. In a report filed with the state, the county said the project would create a youth-oriented activity and help prevent opioid misuse. Similar reasoning has been used to defend a wide range of purchases, from an ice-skating rink to sock hops and concerts.
County auditor Lisa Plecker said the county reported the spending to the Iowa attorney general’s office as required. “Our justification” for the expenditure, she said, “was not questioned.”
But the attorney general’s office does not review or approve those reports.
The office “does not sign off on funds used by the counties,” said Jen Green, a spokesperson for Attorney General Brenna Bird. “The office serves as the collector and holder of the counties’ reports.”
Those examples have frustrated advocates across the country, many of whom believe they are effectively the only watchdogs overseeing the money.
Local governments see the funds as “really easy money,” said Burke Beaty of New Jersey. Even when public health experts and families affected by addiction consider a purchase inappropriate, she said, “legally they can do it.”
She hopes a recently introduced New Jersey bill will change that. The measure would require the New Jersey Department of Human Services, which already gathers county and municipal spending reports, to review them and require local governments to repay money deemed improperly used.
Without stronger oversight, advocates fear the country will repeat the failures of the tobacco settlement — and create a warning for future settlements involving social media addiction.
Read the methodology behind this project and download the data.
KFF Health News’ Rachel Spears; Shatterproof’s Kristen Pendergrass, Kelly Collins, and Mary Coyne; and the Johns Hopkins Bloomberg School of Public Health’s Abigail Winiker, Benjamin Eidman, Olivia Allran, Katibeth Blalock, Isha Desai, Saathvika Diviti, Joseph Olasupo, Veronica Steck, Amy Lund Stone, Erin Wang, and Lillian Williams contributed to the database used in this article.
KFF Health News is a national newsroom producing in-depth journalism on health issues. It is one of the core operating programs of KFF, the independent source for health policy research, polling, and journalism.
The Johns Hopkins Bloomberg School of Public Health has played a leading role in helping state and local governments determine how to use opioid settlement funds. Faculty members worked with other experts to develop principles for using the money, which have received endorsements from more than 60 organizations.
Shatterproof is a national nonprofit focused on substance use disorder through initiatives that include advocating for state and federal policy, reducing addiction stigma, and educating communities about the treatment system.
Shatterproof is working with some states on projects financed through opioid settlements. KFF Health News, the Johns Hopkins Bloomberg School of Public Health, and the Shatterproof staff involved in this report are separate from those efforts.
