Brian King – The Conversation

Pennsylvania counties face tough choices on spending $2B opioid settlement funds

2025-11-07T13:18:10Z

In Pennsylvania, local governments will decide which substance use programs to fund in their communities. Jeff Fusco/The Conversation U.S., CC BY-SA

In communities across Pennsylvania, local officials are deciding how to spend over US$2 billion dollars from the state’s opioid settlement agreements.

For many, the task is proving promising yet challenging – and raises questions about how to best navigate complex local needs.

Pennsylvania will receive the money over 18 years from lawsuits filed by state attorneys general against opioid manufacturers and distributors. About 70% of these funds will be distributed to county governments, with the remaining funds going to the state legislature and the groups that leveraged the lawsuits.

The amount provided to each county is proportional to the opioid-related harms experienced by the county. Each county government is responsible for developing its own funding strategy for substance use programs, which can focus on things such as prevention, treatment, recovery or harm reduction.

Our research team at Penn State interviewed 72 county officials, health professionals and service providers across six counties in Pennsylvania to understand their early experiences with these funds.

We summarized our findings in a recent article for the peer-reviewed Substance Abuse Treatment, Prevention, and Policy journal. We found that stakeholders view the settlement funds not simply as extra money but as an opportunity to heal – and to test how well local communities can make their own choices about spending.

‘Bags of money’ but limited guidance

Pennsylvania’s distribution strategy was designed to give local governments flexibility. A document called Exhibit E lists the ways that counties can spend the settlement money.

This collaborative document was written as part of the settlement to outline shared guidelines that apply to all the states receiving funds. It lists everything from the types of approved substance use treatments to what qualifies as prevention. In practice, Exhibit E provides diverse opportunities for spending but has also created widespread uncertainty among recipients about which strategies to prioritize.

Some interviewees felt overwhelmed by the logistics of their funding decisions. They understood that the general purpose of the money is to support communities harmed by opioid overprescription. But they lacked clarity on how much time they had to spend it, what the reporting requirements are, and what counts as an eligible activity. For example, some wanted to use the funds to pay administrators for new prevention programs, but administration isn’t included in Exhibit E.

As one local elected official in southeastern Pennsylvania put it, “There’s been a whole lot of stuff that we don’t know – more than we do know. And now we’re running with bags of money through the community and (we’re) not sure how we can spend it, or if we can spend it.”

Many county officials worried about spending the funds too slowly, or on activities that could end up being ineligible or ineffective. Service providers sometimes didn’t know who in their county had the authority to decide where the money went. While they may have wanted to provide recommendations or input, they were unsure how.

A chance to experiment and innovate

Even amid confusion, most of the people we interviewed saw the settlement funding as a unique opportunity.

Exhibit E’s broad guidelines allow for experimentation, and many expressed interest in supporting local needs and implementing projects that they had wanted for a long time. This included things like expanding peer recovery support programs or establishing family support services.

“The guidelines are so varied that it gives those local communities opportunities to look at the menu and find out from community members, ‘How can we help resolve this problem together?’” one local drug and alcohol department employee told us. “It’s a collaborative that really helps the community as a whole get well as a whole. I am a real believer in ‘It takes a village.’”

Several participants emphasized that the flexibility in Exhibit E creates room to revise plans as needs evolve or change. Counties can change their funding priorities each year to adapt.

Several counties have already started issuing small grants to grassroots organizations, recognizing that those closest to people harmed by the opioid crisis often know best what kinds of interventions might work.

One county employee involved in distributing funds in her county shared that her team was “willing to try anything, really, within the bounds.”

“And if it doesn’t work, we can back off,” she added. “But I feel like you don’t know until you try it.”

A moral responsibility to get it right

Although our study focused on policy implementation, participants often framed their responsibilities in moral terms.

Many said they felt a strong obligation to use the funds wisely, given the scale of loss their communities have endured. The Pennsylvania Department of Health reported 4,719 overdose deaths in the state in 2023, and 83% were opioid-related. That number dropped to 3,336 in 2024, mirroring national trends.

One elected official described the funds as “the only hope we can provide families that have lost loved ones to this crisis,” emphasizing that he felt a “real obligation” to make the funds count.

Others echoed that careful, transparent decision-making is part of a broader recovery effort. Beyond abiding by funding guidelines, they felt it was also important to be honest and transparent to community members.

“We don’t want to come out with ‘Pennsylvania wasted its money, or (this) county wasted its money,’” said an addictions researcher.

Still others cautioned that the settlement funds alone cannot repair the full scope of harms caused by the opioid crisis, warning against viewing the settlements as a cure-all.

“There’s not really a monetary value that you can put on these things,” a person who works in the substance use sector told us. “I’m glad that this money’s available, but ultimately for me … it’s a little too late. You know? All my friends are already dead.”

Read more of our stories about Philadelphia and Pennsylvania.

Glenn Sterner receives funding from the Pennsylvania Opioid Misuse and Addiction Abatement Trust, Pennsylvania Department of Drug and Alcohol Programs, Pennsylvania Department of Health, Independence Blue Cross Foundation, Montgomery County Government in Pennsylvania, the Substance Abuse and Mental Health Services Administration, National Institute of Justice, and National Science Foundation.

Brian King, Halie Kampman, Kristina P. Brant, and Maya Weinberg do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.

Increases in opioid overdoses in Pennsylvania varied by county during the COVID-19 pandemic

2023-03-21T12:42:53Z

Pills are one of the more common ways of ingesting opioids. AP Photo/Keith Srakocic

The Research Brief is a short take about interesting academic work.

The big idea

The COVID-19 pandemic intensified the opioid epidemic, according to our new research, which finds that opioid overdoses increased in Pennsylvania in 2020 compared with 2018 and 2019.

Yet general trends obscure critical local variations. Specifically, 19 Pennsylvania counties saw statistically significant increases in opioid overdose rates. The people who live in those 19 counties are both socially and economically diverse, signaling that overdoses did not just worsen for one group of people.

In our study, we analyzed age-adjusted rates of opioid-related overdose incidents, reported by emergency services personnel, at the county level in Pennsylvania from 2018 to 2020. This measure is based on the number of overdose incidents to which EMS responded during the study period. We also interviewed public health providers to identify the key factors influencing opioid misuse.

Opioid overdoses are the leading cause of accidental death in Pennsylvania, according to the Centers for Disease Control and Prevention. From 2010 to 2019, rates of opioid-related deaths in Pennsylvania almost quintupled, rising from 5 per 100,000 people to 23.7 per 100,000 people. In 2020, it rose to 42.4 per 100,000 people.

In earlier work, we showed that the initial four months of the COVID-19 pandemic saw an increase in opioid overdoses in Pennsylvania. Our latest study extended this analysis through 2020.

Why it matters

Since the early 1990s, the opioid epidemic has gone through several waves. First, high death rates were caused by prescription opioids, particularly among white rural populations. The epidemic then shifted to heroin use, and expanded to include urban and non-Hispanic Black populations. More recently, synthetic opioids like fentanyl have been the main cause of overdoses.

Overdose rates increased in Pennsylvania at the start of the COVID-19 pandemic. This initial increase occurred at the same time as a mandatory stay-at-home order that was designed to reduce the spread of the virus. While this order was a necessary response, it resulted in a range of social effects, including job losses, mental illness, isolation and reduced access to inpatient addiction treatment services.

In our newest study, we examined the longer-term trends and spatial patterns for the opioid epidemic. Our research shows statistically significant county-level changes in the age-adjusted rates of opioid-related overdose incidents before and after the onset of the COVID-19 pandemic. Some Pennsylvania counties saw a significant increase in opioid overdose rates, including some with small populations, while others saw a significant decrease.

Heroin injections can lead to heart infections that can kill.

Health care providers agree that while opioid misuse has increased across the state, local conditions matter and directly affect the epidemic. As one health provider told us in an interview, “There’s a lot of variation between counties. You can drive 20 minutes across the line, and it almost seems like a different state. I think the rates of use are similar, but you see different sorts of associated factors with substance use in these counties.”

In order to understand social factors, we examined differences in opioid overdose rates between men and women and between Black and white people. Our research shows overdose rates among men and women were declining from 2018 to 2019 but jumped in 2020. These trends were also declining among Black and white individuals from 2018 to 2019, but those groups also experienced a large increase from 2019 to 2020. A benefit of our research is that it shows that broader segments of the population are now being affected by the opioid epidemic.

What’s next

Our work is finding that the stress associated with the COVID-19 pandemic was overwhelming for many people, resulting in an increase in substance misuse or relapses. We believe research and policy attention to these factors is urgently needed, especially in states like Pennsylvania that were experiencing high rates of substance use prior to the pandemic.

Future work could evaluate whether funds are effectively distributed to address the effects of social isolation and the social inequities surrounding opioid misuse.

Brian King receives funding from the Department of Geography and College of Earth and Mineral Science at the Pennsylvania State University.

Andrea Rishworth, Louisa M. Holmes, and Ruchi Patel do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.

Opioid overdoses spiked during the COVID-19 pandemic, data from Pennsylvania show

2021-06-14T12:24:36Z

Since the first diagnosed case of COVID-19 in the United States on Jan. 20, 2020, news about infection rates, deaths and pandemic-driven economic hardships has been part of our daily lives.

But there is a knowledge gap in how COVID-19 has affected a public health crisis that existed before the pandemic: the opioid epidemic. Prior to 2020, an average of 128 Americans died every day from an opioid overdose. That trend accelerated during the COVID-19 pandemic, according to the Centers for Disease Control and Prevention.

We are a team of health and environment geography researchers. When social distancing began in March 2020, addiction treatment experts were concerned that shutdowns might result in a spike in opioid overdose and deaths. In our latest research in the Journal of Drug Issues, we take a closer look at these trends by examining opioid overdoses in Pennsylvania prior to and following the statewide stay-at-home order.

Our findings suggest that this public health response to COVID-19 has had unintended consequences for opioid use and misuse.

History of the opioid epidemic

Opioid misuse has been a major U.S. health threat for over two decades, largely affecting rural areas and white populations. However, a recent shift in the drugs involved, from prescription opioids to illegally manufactured drugs such as fentanyl, has resulted in an expansion of the epidemic in urban areas and among other racial and ethnic groups.

From 1999 to 2013, increasing death rates from drug abuse, primarily for those from 45 to 54 years of age, contributed to the first decline in life expectancy for white non-Hispanic Americans in decades.

There was a modest national decline in overdose mortality from prescription opioids from 2017 to 2019, but the COVID-19 pandemic has upended many of these advances. As one of our public health partners explained to us, “We were making progress until COVID-19 hit.”

We believe this presents an urgent need for research on the relationships between COVID-19 policy responses and patterns of opioid use and misuse.

Opioid use increases during the pandemic

Pennsylvania has been among the states hardest hit by the opioid epidemic. It had one of the highest rates of death due to drug overdose in 2018, with 65%, a total of 2,866 fatalities, involving opioids.

The state’s stay-at-home order, implemented on April 1, 2020, mandated that residents stay within their homes whenever possible, practice social distancing and wear masks when outside the home. All schools shifted to remote learning, and most businesses were required to operate remotely or close. Only essential services were allowed to continue operating in person.

In the following months, the public’s overall cooperation with these mandates contributed to measurable declines in coronavirus infection rates. To learn how these mandates also affected people’s use of opioids, we assessed data from the Pennsylvania Overdose Information Network for changes in monthly incidents of opioid-related overdose before and after April 1, 2020. We also examined the change by gender, age, race, drug class and doses of naloxone administered. (Naloxone is a drug widely used to reverse the effects of overdose.)

Our analysis of both fatal and nonfatal cases of opioid-related overdose from January 2019 through July 2020 revealed statistically significant increases in overdose incidents for both men and women, among whites and Blacks, and across several age groups, most notably the 30-39 and 40-49 groups, following April 1. This means there was an acceleration of overdoses within some of the populations most affected by opioids prior to the COVID-19 pandemic. But there were also uneven increases among other groups, such as Black people.

We found statistically significant increases in overdoses involving heroin, fentanyl, fentanyl analogs or other synthetic opioids, pharmaceutical opioids and carfentanil. This is consistent with previous research on the main opioid classes contributing to increases in drug overdose and death. The results also affirm that heroin and synthetic opioids such as fentanyl are now the major threats in the epidemic.

When a pandemic and an epidemic collide

While we found significant change in opioid overdoses during the COVID-19 pandemic, the findings say less about some of the driving factors. To better understand these, we have been interviewing public health providers since December 2020.

Among the important factors they highlight as contributing to increased opioid use are pandemic-driven economic hardship, social isolation and the disruption of in-person treatment and support services.

From March to April 2020, unemployment rates in Pennsylvania shot up from 5% to approximately 16%, resulting in a peak of more than 725,000 unemployment claims filed in April. As workplace shutdowns made it harder to pay for housing, food and other needs, and the opportunities for in-person support disappeared, some people turned to drugs, including opioids.

People in the early stages of treatment or recovery from opioid addiction may be particularly vulnerable to relapse, suggested one of our public health partners. “They might be working in industries that are closed down, so they have financial problems … [and] they have their addiction issues on top of that, and now they can’t like go to meetings, and they can’t make those connections.” (Under our clearance with Penn State for doing research with human subjects, our public health informants are kept anonymous.)

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An addiction treatment counselor told us that especially for those with past or present opioid use problems, or histories of mental health issues, “It’s not a good thing to be alone in your own thoughts. And so, once everybody was kind of locked down … the depression and anxiety hit.”

Another counselor also pointed to depression, anxiety and isolation as driving increased opioid misuse. The pandemic “just spun everything out of control,” they said. “Overdoses up, everything up, everything.”

One question is whether states like Pennsylvania will continue to support telehealth in the future. While the transition from in-person to telehealth services has increased access to treatment for some, it has raised challenges for populations like the rural and elderly. As one provider explained, “it’s really hard for that [rural] population out there” to utilize telehealth services due to limited internet and broadband connection. In other words, flexible modes of addiction treatment might work for some but not others.

The goal of our research is not to criticize efforts to mitigate the spread of COVID-19. Without the mandatory stay-at-home order in Pennsylvania, both infection and death rates would have been worse. However, our research shows that such measures have had unintended consequences for those struggling with addiction and emphasizes the importance of taking a holistic approach to public health as policymakers work to confront both COVID-19 and the addiction crisis in America.

Brian King has received funding from the National Science Foundation.

Andrea Rishworth and Ruchi Patel do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.

How bucking climate change accord would hinder fight against HIV/AIDS

2017-01-10T02:00:22Z

South African women trying to soak up stagnant water during the drought in January 2016. Denis Farrell/AP

The potential withdrawal of the United States from the Paris climate agreement has broad implications for society and the environment. While much attention has concentrated upon melting glaciers, rising sea levels and conflicts over scarce resources, another area represents a major cause for concern: human health.

According to the Intergovernmental Panel on Climate Change (IPCC), global climate change has direct health impacts tied to changes in the frequency of extreme weather events including heat, drought and intense rain. Additionally, increasing temperatures alter ecosystem dynamics, making it easier for mosquitoes and other organisms to come into contact with human populations and spread infectious disease (Smith et al. 2014).

Climate change also undermines improvements in the management of existing disease outbreaks. This is the case in South Africa, a country where I have conducted extensive research over the past decade. As I detail in my book “States of Disease,” the South African government has become more aggressive in responding to the HIV/AIDS epidemic while establishing itself as a leader in the testing and treatment of HIV-positive individuals. As a result of its efforts, the government has reduced the likelihood of patients progressing from HIV disease to AIDS, thereby extending the lives of many for years or decades.

South Africa’s HIV approach holds important lessons for the future of HIV management, but it also reveals new challenges that will arise from global climate change. One such challenge is ensuring that HIV-positive individuals have food.

Food shortages overshadow drug shortages

An estimated 36.7 million people worldwide were living with HIV/AIDS at the end of 2015, and about 2.1 million individuals became newly infected with HIV in the same year. Roughly two million patients receive treatment in South Africa each day, which means that more people are living with HIV there than in any other country.

These treatment efforts have resulted in a new language for HIV in which the disease is more regularly asserted to be a chronic condition, similar to diabetes in that it can be managed through monitoring and drug provision.

Chronic HIV suggests universal access to antiretroviral therapy (ART). This assumes a politically neutral terrain for sick and dying people. Regardless of the government’s assertions of widespread access to antiretroviral drugs, in South Africa as elsewhere, some people lack access to treatment regimens that offer the possibility for survival. This is further challenged by new guidelines from the World Health Organization recommending that HIV-positive individuals pursue ART earlier.

Stigmas also matter. Although public health institutions advocate universal access to antiretroviral drugs, people experience stigma differently. Men and women have different anxieties about the virus, which shape their approaches to testing and adherence to ART.

While the availability of drugs to treat HIV/AIDS reflects encouraging developments in the global response to the epidemic, presenting HIV as a chronic condition has limitations. In particular, a major concern for people in this part of the world is less a shortage of antiretroviral drugs than a shortage of food.

‘I starve every now and then’

My work in South Africa is showing that managed HIV encounters a variety of social and environmental challenges that confront the possibility for healthy lives. This begins at rural clinics and hospitals where testing occurs, and then continues with the procedures for continued treatment. Educational messages provided by clinics and hospitals emphasize the need to access certain foods to maintain good health, not all of which are readily available to needy populations.

Because it is difficult to take these drugs on an empty stomach, diet and nutrition are emphasized. Additionally, a diverse diet can help boost the immune system and offset the possibility of secondary infections. HIV-positive individuals are encouraged to plant gardens to acquire healthy foods.

A roadside food market in South Africa. Author provided., Author provided

For those managing HIV, there is a stark divide between public health messaging and the feasibility of such mandates. Food insecurity is widespread in South Africa and is experienced at different levels.

My research team conducted a survey in 2013 of 327 rural households that showed that 26 percent of household heads ate less than desired because there wasn’t enough food. Nearly twice as many HIV-positive individuals indicated that they had lost weight because there wasn’t enough to eat. As one person said, “I starve every now and then. And I don’t get different types of food. Sometimes I get bananas, sometimes nothing” (“Eat Healthy and Nutritious Food”).

These interviews demonstrate the importance of food security to ensure the effectiveness of treatment regimens. Yet food security is possible only for families that have economic resources to purchase healthy foods, or access to land for growing their own crops. This remains a challenge because historical systems of racial segregation have resulted in insecure land tenure systems and few opportunities for land ownership, thereby pushing food production to household gardens.

Female-headed households are particularly vulnerable because they show the highest rates of food insecurity in the country.

Without water, ‘we are not well’

Food production is further challenged due to weather variability associated with global climate change. I conducted interviews in January 2016, at the height of a drought that gripped the southern African region. Driven by El Niño conditions that brought dry and warm patterns, 2015 was the driest year in South Africa since official records began in 1904.

The South African Weather Service reported that during a heat wave in early January 2016, 31 locations reached new maximum-temperature records. Food prices have increased, and millions of tons of maize, a dietary staple for the country, were imported to meet consumer needs.

An elderly woman drinking water after waiting hours in line for it in January 2016 in South Africa. Denis Farrell/AP

These challenges were reflected in a lengthy interview I had with an HIV-positive grandmother. Pointing to the household garden where she grew vegetables for the family, she noted that because of the lack of rain she had not yet planted. As she explained, “We are suffering because of the scarcity of rain. If there is rain we are able to do it all, we can grow some sweet potato and cassava, but if there is no water, we are not well at all.”

For many people, the constraints in producing their own food from household gardens were compounded by shifting environmental patterns that increased their vulnerability to food insecurity.

While there have been remarkable improvements in combating the HIV/AIDS epidemic in the Global South, managed HIV faces other challenges beyond accessing lifesaving drugs. Food production and food security, which are tied to shifting climate dynamics, place additional burdens upon social and natural environments in resource-scarce settings.

Managed HIV is survival, and this survival depends not just on access to antiretroviral drugs but also on a gamut of social and environmental resources that have become necessary to meet health needs in the era of global climate change.

Brian King receives funding from the National Science Foundation (NSF) of the United States. The research discussed in this article is supported by a NSF CAREER grant (BCS/GSS 1056683).