Can $55 Billion End the Opioid Epidemic?

Thanks to legal settlements with drug makers and distributors, states have plenty of money to boost prevention and treatment. Will it work? (Part two of a two-part series.)

This article comes from Freakonomics Radio. You can listen and follow our weekly podcast on Apple Podcasts, Spotify, or elsewhere.

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When I say, “the opioid crisis” or “the opioid epidemic,” you probably say, “Enough already.” I understand: you’re sick of hearing about it. We are more than 25 years in, if you use the introduction of OxyContin as the onset of this crisis, which most smart people in the field do. OxyContin is a powerful medical pain reliever that its manufacturer, Purdue Pharma, promised would not addict its users the way other opioids can. This was a big deal, since many millions of people seek out pain relief, whether intermittently or regularly. But that non-addictive promise — it turned out to be wrong. Addiction to OxyContin — and then similar drugs from other pharma firms — spiraled into a public-health catastrophe. In 2023, 81,000 people in the U.S. died from an opioid overdose, more than ten times the number in 1999. So the problem has continued to worsen.

Many of the current overdoses aren’t from prescription drugs like OxyContin, but from black-market versions — or from other drugs that contain fentanyl. That’s another synthetic opioid that began as a medical drug, and which is far more powerful than most opioids. Fentanyl has now worked its way into the supply of street drugs in the U.S., most of it smuggled across the Mexican border by American citizens. A great many people — policymakers, medical professionals and regulators, parents, law enforcement — they’ve all have spent the past few decades trying to end the opioid crisis, but without much success. So, as sick as you may be of hearing about it, imagine being the parent of someone who died from fentanyl, or the husband, or the child — although you might not have to imagine. You probably know someone who’s experienced this kind of tragedy — it’s that common. Last week, in part one of this two-part series, we asked a simple question: why? Why is the opioid crisis still raging after all these years? There are actually a lot of correct answers to that question. Here’s one:

David CUTLER: So, it looks like it’s spreading through social networks. Areas of the country that have more Facebook friends, those areas also have more deaths. Sometimes the physical product will spread through networks, and sometimes just the idea, “Oh, when I was in pain, I got this opioid, and maybe you should try this opioid.” 

That was David Cutler, a health economist at Harvard. We also heard last week from Keith Humphreys, a drug researcher and policy advisor at Stanford. Humphreys thinks that part of the blame goes to advocates who want to make drugs easier to get and want to remove the stigma of drug use.

Keith HUMPHREYS: The faith that the advocates had, that if you removed all pressure and you removed all shame from sitting on a park bench using fentanyl, then people would seek out care, proved to be completely incorrect. 

Today on Freakonomics Radio, a dissenting voice, who thinks that shame is a big part of the problem.

Stephen LOYD: Sometimes I feel like I’m working in the days of the Salem witch trials.

Also: billions of settlement dollars have started to flow from the pharmaceutical firms — although not Purdue Pharma, yet; they are still fighting over a bankruptcy plan. How the states are spending that money is not always transparent. Observers say this is not only a moral travesty.

Christine MINHEE It’s also a travesty from a data perspective, because we’re just going to have no sense of how these monies were actually spent.

“Why Is the Opioid Epidemic Still Raging?,” Part 2, begins now.

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Stephen Loyd is a physician in Nashville, Tennessee. The U.S. has more fatal drug overdoses per capita than any other country in the world — and within the U.S., Tennessee is right near the top, along with West Virginia, the District of Columbia, Delaware, and Louisiana. Loyd works as an addiction-recovery specialist, and he is chair of the Opioid Abatement Council of Tennessee, which helps direct the settlement money that is being disbursed to states. We first spoke with Loyd several years ago, for an earlier series we did on the opioid crisis. Here’s what Loyd was advocating for back then:

LOYD: I think anytime you lessen the stigma associated with addiction, you increase people’s opportunity to step out of the shadows and ask for help.

So when we got back in touch with Loyd now, I asked if the stigma has declined. He says no.

LOYD: The opioid crisis has affected everybody from politicians’ sons to people who are unhoused. And so you would think that the stigma would be easier to break here, but it just hasn’t. I went back and looked to find the first doctor in the United States that described addiction as a disease and not a moral failure. It was actually Benjamin Rush. And he did it before 1776. So, we’ve known for a really long time that this is not a moral failure. But it’s still the predominant thought out there right now. I don’t know how to break through that.

Loyd is the chief medical officer for a chain of clinics called Cedar Recovery; most of their funding comes from the federal government.

LOYD: We do outpatient treatment of people with opioid use disorder.

Stephen DUBNER: I realize this is going to sound flip, but I would guess business is booming unfortunately, yes?

LOYD: Yeah, sadly. And I’m with you — I hope one of these days to be out of business. But, yes, unfortunately, it’s growing faster than any of us would like. If I make it till July 8th of this year, I’ll be 20 years in recovery myself. 

DUBNER: Congratulations.

LOYD: You know, a unique spin with not only being a doctor, but a doctor who was addicted earlier in his career to the very drugs that started all this, with pain pills and really the drug OxyContin. 

DUBNER: Does that give you an advantage as a physician in this kind of treatment mode? 

LOYD: I sure think so, because I’ve been there. I’ve stolen pills out of people’s medicine cabinets. I’ve been dopesick more times than I can shake a stick at. So when somebody comes in to me and I can see they’re in withdrawals, it’s not something I blow off.

DUBNER: Do you tell them about your background, and how does that affect your treatment of them? 

LOYD: Most of the time, they know coming in. But I always lead off with it, because one of the hardest things to do is overcome the shame and the stigma. So I just let them know that their doctor’s been there, and I had to overcome the same things.

DUBNER: When you look at what’s been happening with opioid abuse and opioid overdose death in the last several years since we first spoke, I never would have predicted it would have continued to rise like it has. What’s your best assessment, whether it’s opinion or informed by data, of why there’s still so much opioid overdose and abuse? 

LOYD: I think the last time we talked was four or five years ago, and I’m with you, but I don’t think either one of us saw Covid-19. And Covid really changed the landscape. Because if you think about addiction, and realizing that the solution is community and relationship, it’s about connection, and then look at how we treated Covid — and I’m not saying things were done wrong, we were all isolated, right? We were in our homes, we were working from home, we weren’t interconnecting. I knew that it was going to kill our folks. And it did. Overdose rates in the South were up between 40 and 50 percent, in any state you looked at. So when you and I first talked, I never saw this, but of course, I didn’t see Covid-19.

DUBNER: Do you feel it’s plateaued? 

LOYD: I’m hoping. You know, I work in a lot of states, and so I’m starting to see some evidence of some plateauing. I know that here in Tennessee it does look like that. But even if we spend our opioid abatement dollars very, very wisely, it’ll take at least until the year 2046 to get back to pre-1996 numbers, which is a pretty daunting thought. 

Those numbers that Loyd just cited — that overdose death rates in the South were up 40 or 50 percent during Covid — I was skeptical. So I went and looked up the numbers. It turns out he was actually understating the Covid spike. Overdose deaths in Alabama, Louisiana, and Tennessee were up more like 100 percent from 2018 to 2021, a doubling during Covid.

DUBNER: So this gets me to wanting to ask you about fentanyl. When you were addicted, it was a different scenario, really. Can you talk about the substances now, and how that’s changed the game? 

LOYD: It’s so weird you ask me this, because I’ve actually struggled a little bit over the past couple of weeks because my sobriety date’s coming up, July 8, and in between May and July are usually fairly tough times for me, because I go back 20 years and remember where I was. And the thing I realized was that when I was using back in early 2000s, fentanyl was not a thing. I mean, it was a drug and it was in the hospital and they were using it in surgeries and for cancer patients, with patches and sprays. But it wasn’t illicit powder fentanyl that’s in absolutely everything now. And it dawned on me that it’s very likely towards the end of my using, when I had to go to the street to get my supply, that I would have run across fentanyl. So the landscape is night and day compared to 2004. 

DUBNER: It sounds like what you’re saying is that if you’d been born 20 years later and lived the same life, you’d have been dead by now? 

LOYD: I’d have died, yeah. And that was the struggle. Because I recently became a grandparent. I can’t help myself but to go there sometimes because 20 years later — you’re exactly right, there is a very high likelihood I would have died. 

DUBNER: I have a really naive question. Because fentanyl is so deadly and because fentanyl is now so common in the illicit drug supply, why is that not enough to diminish demand? 

LOYD: Yeah, that’s always a good one. And to understand that, you’ve got to understand a little bit about the brain changes that happen in substance use. Essentially what happens is you lose access to the frontal lobe of your brain. And the frontal lobe of your brain is only important if you care anything about insight, judgment and empathy, okay? And so if you’ve got somebody that’s solely driven by their pleasure center with no override from that insight, judgment and empathy standpoint, I think you can pretty clearly see how come fentanyl doesn’t matter. Today we’re like, “Well we’re not going to use that, it’ll kill us.” But we have fully functioning frontal lobes, and people who are using don’t.

DUBNER: How much is it that versus or in addition to the fact that it’s just a great wild card in the drug supply? In other words, even if you do know about fentanyl, even if you are aware of its danger, even if you’re willing to take a chance once in a while, no one really knows how much of it is in the supply or whether it might be in a given batch. So is that a bigger problem, or do you think the bigger problem is just the fact that the high is too appealing, and that the logic chain doesn’t even happen?

LOYD: Oh, I think both of those things in combination are the problem. I mean, when I was using, I wanted the next thing that would get me where I needed to be, and if there was something that would get me there quicker or more intensely, I mean, that was the goal. Now, you couple that with loss of that executive function coming from your frontal lobe of your brain, and you can see how people get in trouble. 

This trouble became so severe, and so widespread, that states and cities across the country sued the manufacturers of the legal opioids that started the crisis, along with the distributors and consultants who helped promote the drugs.

Judy WOODRUFF: A number of states have now agreed to a $26 billion settlement with three large drug distributors and Johnson & Johnson for their roles in the opioids epidemic.

WUNC: CVS and Walgreens paying out $10 billion to settle lawsuits over the opioid crisis.

CBS: McKinsey & Company is going to pay nearly $600 million for consulting businesses on how to sell more prescription opioid painkillers.

Although, as I mentioned earlier, the big one is still unresolved:

ABC NEWS: Today, the Supreme Court will review a $6 billion bankruptcy settlement between Purdue Pharma, the maker of OxyContin, and the victims and communities ravaged by the opioid crisis.

Coming up: how will these billions be used? And: what is it going to accomplish?

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There have been a lot of bad actors in the opioid crisis. The most widely vilified is Purdue Pharma, the private drug maker largely owned by the Sackler family, which made and sold the pain medication OxyContin under the false premise that it was less addictive than other opioids. But other companies have also been implicated: manufacturers like Johnson & Johnson, Allergan, and Teva; as well as distributors, pharmacies, pharmacy benefit plans, and the consulting firm McKinsey, which helped Purdue sell more drugs. All this has prompted thousands of lawsuits, some of them ongoing but many already settled. These settlements will direct around $55 billion to the states, to be distributed over the next 18 years. The Sackler family’s bankruptcy settlement could add another $6 billion to the settlement pool. Most of the settlements require the states to spend 85 percent of the money to directly address the opioid crisis.

LOYD: This money has to go for certain things. You can’t just use it to balance your budget in your state or build roads and highways. 

That, again, is Stephen Loyd, the Tennessee physician who chairs his state’s Opioid Abatement Council.

LOYD: And so we’ve got an actual chance at this one actually making a difference for what it was intended to.

DUBNER: Can you talk about the process in Tennessee? How much is the money flowing so far, and where it’s being applied.

LOYD: Oh, it’s flowing, thank goodness, Stephen, I’m really proud of that. So, Tennessee took 15 percent of their money from the fund administrator. It goes to our General Assembly. The politicians can spend it on what they want to.

DUBNER: Okay, so 15 percent, is essentially slush fund. That’s not directly for opioids. 

LOYD: Yeah, you said that, not me.

DUBNER: Okay, fair enough.

LOYD: And then another 15 percent went to — Tennessee has 95 counties — so another 15 percent went directly to those counties based on a formula that was agreed upon — population and problem. So they can actually use that for anything they want. So that’s 30 percent of the money.

DUBNER: But that second 15 percent, the share was derived from the amount of opioid trouble in that county, though, or no?

LOYD: That’s exactly right. 

DUBNER: But even so, it’s non-directed funds, I can use it however I want?

LOYD: You can hire a dog-catcher if you want.

DUBNER: Got it.

LOYD: And then the remaining 70 percent, the General Assembly and our governor in Tennessee set up an independent council that has decision-making authority, made up of 15 people appointed by our governor, our speaker of the House, and our lieutenant governor. And they will decide how that 70 percent is spent. Now, 35 percent of that 70 percent goes back to the counties again, based on that same formula from last time. Only this time, it has to go from something called the remediation list. And a remediation list, Stephen, is basically an abatement plan and we will hold them accountable. So Tennessee has had two distributions to that one already, both of them in excess of $30 million, that went to those individual counties. Now that’s 35 percent of the 70. The remaining 65 percent of the 70 was made available through a competitive grant process, which we just finished up the first round.

DUBNER: Give me a list of some things where that money is going. 

LOYD: Well, there’s four big buckets out there: prevention, education, treatment, and something called harm reduction. So how do you break that money up in each of those individual buckets? And those strategies to get to the goal that you want, which is actually shrink the number of people who use drugs. And I think that is the challenge, and that is the ball that I see being dropped right now. You know, they say, well, how did you decide how much went in each of the four buckets in Tennessee? And I said, well, we use something called the SWAG method: “scientific wild-ass guess.” 

Loyd would like to replace that guesswork with something more reliable. He’s a member of a consortium called the Helios Alliance, which uses data science to try to learn which interventions are most effective, and most cost-effective.

LOYD: You start looking at this money as it comes in. How do you allocate it to the individual strategies to get to a result that you’re trying to look for? Because if you just stick it out there, Stephen, and you measure it on the back end, how do you know if you’re even successful? 

Based on what he’s learned so far, Loyd says that, of the four buckets — prevention, education, treatment, and harm reduction — prevention offers the best return on investment.

LOYD: For every $1 that you invest in prevention with opioids, it’s an $11 downstream savings. Nothing’s even close to that. Treatment’s like 1 to 4. 

DUBNER: What about education? 

LOYD: Education, I would put as part of treatment. Education is going to break down the barriers to people getting into treatment. 

DUBNER: And what about harm reduction?

LOYD: Harm reduction is simply keeping people alive. I’m not sure what the return on investment dollars is, because right now if Stephen Dubner overdoses and we take you to the hospital here at Vanderbilt, you’re going to be in there until they get you stable, and then you’re going to hit the door. And there’s a good chance that you’re going to overdose again the same afternoon and be right back in there. That happens all the time. So you’re spending a lot of harm reduction dollars, but a lot of times you’re spending it on the same people just rotating in and out of emergency departments after they overdose. And that’s where we need to look at the system of care that your patient steps into. So some of the ideas — let me give you a good one. University of Tennessee, Knoxville has an emergency department program where if you come in and you’ve overdosed, as soon as they get you stable, they’ll call a peer, somebody who’s had this problem themselves. They’ll come down and talk to you and link you up to treatment right out of the emergency department. Those are the kind of things that I’m talking about. One of the things I see that dismays me is that a lot of people in this space are only interested in their part of it. I’m part of the treatment world myself. The reality is when it comes to addiction, I’m a prevention guy. Because I think it’s the only way that we move the needle going forward. 

DUBNER: But what if I hear you give this pitch about these four buckets, and then I hear that the return on investment of prevention is $1 spent, you get $11 on return and that easily beats all the rest. I say to you, “Oh, that’s fantastic. Let’s not worry about the other stuff. Let’s put it all in prevention.” What would you say to that? 

LOYD: Well, I would think I was talking to somebody other than Stephen Dubner, first of all. Because now you’re talking about letting people die. And I hope I never get to that point in my career, because that argument has been made, and here’s the problem with letting people die: They leave people behind, and a lot of times they’re kids. And if you look at the drivers of addiction as being genetics, trauma, and opportunity, you’re really not going to be able to kill your way out of this, because of what’s left behind. So I have made the argument forever that the first step in prevention is treatment of mom and dad. And I think I can make that argument stick. Almost all of medicine is harm reduction. We don’t cure diabetes, right? We treat it to prevent the sequelae, you know, heart attacks and strokes. But it’s hard to get people to see that when it comes to substance-use disorder. In 2004, if somebody had said, Steve, you have this addiction to OxyContin, and so what we’re going to do, we’re just going to give you OxyContin, all you want, until you’ve had enough. Okay? I would have died. So did we need to keep me alive ? I hope. Yes, we did need to keep me alive. But we also needed a path for me to get into recovery so I could raise my family and make sure I’m not creating the next generation right behind me. 

DUBNER: When you talk about diabetes, it strikes me that could be a pretty apt comparison in that a lot of cases of diabetes are brought about by personal choices and personal behavior, right? Diet, nutrition, exercise — or the lack thereof. Would you agree with that, or not quite? 

LOYD: Absolutely. I mean, now, type one’s different, right? 

DUBNER: Type one’s different. Yeah, let’s cross that off.

LOYD: But far and away, most common cause of diabetes in the U.S. is type two. And it’s behavioral. Most of type two diabetes is because of eating chocolate cake and drinking Mountain Dew Code Red. And we have no issues with intervening with medication in diabetes. What’s the first-line treatment for diabetes? Diet and exercise. All right. And I challenge anybody out there to show me five patients in their practice that adhered to their diet and exercise and controlled their blood sugar. Yet if you see somebody out there who’s got their A1C less than 6.5 and you’re on three different medications in order to do so, nobody’s asking them when they’re going to come off. They’re just glad that they’re not at such high risk to have these bad things happen. Again, addiction is treated differently than every other disease I can think of in our country.

DUBNER: So, Stephen, you’ve been sketching out a lot of the problems here. Do you have any good news? 

LOYD: You know, if you’re listening to this and you want to know what’s going on with the money in your county, then you need to get involved and you need to make your voice heard, particularly if you have lived experience. And so I think there is good news, Stephen. And I think there’s people out there that are starting to listen to some of the things that we’re talking about. When that happens and when it happens on a big-enough scale, then I think we have a chance at tying some systems together that have a chance to become a system of care over the next two to three decades.

DUBNER: How do you suggest people get involved?

LOYD: Starts at the local level. A lot of this money is going directly to the counties, as I described to you. I guarantee you that the mayor of your county or the city commission or county commission where you live, they know they got a big check — okay, it came as a wire transfer. Ask them what they’re doing with it. Ask them what the process is, and how to spend it.

There’s also a way to track the $55 billion in settlement money — or at least try to track it. That is thanks to this person.

MINHEE: My name is Christine Minhee. I’m the founder of opioidsettlementtracker.com.

Minhee received her law degree, from the University of Washington, in 2019. 

MINHEE: I started the project after I got obsessed with the Big Tobacco litigation as a law student, quickly realized that we were hurtling into the same dismal landscape of poor spending with opioid settlements, without any guardrails.

In 1998, the four biggest tobacco companies in the U.S. agreed to what was called the Tobacco Master Settlement Agreement. This meant paying out some $250 billion to the states to help cover the costs incurred by the consumption of their product — a product that, like OxyContin, was legal, but carried significant risks that the manufacturers lied about. That $250 billion has gone into state budgets, where it was spent on healthcare costs for smokers, on anti-smoking campaigns — but sometimes just to make up budget shortfalls. That’s what Christine Minhee doesn’t want to see repeated with the opioid settlement money.

MINHEE: That nightmare of Big Tobacco spend certainly casts a pall over the opioid settlement landscape. And so I didn’t trust that there was going to be another entity that would watch how these settlements would be spent. And I decided to just create a beta concept that I imagined some agency would take over after. But lo and behold, a number of years later, I’m continuing to do this.

As we heard earlier from Stephen Loyd, there is a formula for how the opioid settlement money is to be distributed.

MINHEE: The way that they’re divvied up across the states is determined by a single table in the settlement agreements, actually. And this global-allocation percentage table is derived by using a formula that uses three factors: How many pills were shipped to a particular jurisdiction, how many folks have died from an opioid use disorder related overdose, and how many folks are currently suffering from O.U.D. within a particular jurisdiction. 

But once you get past that formula, Minhee found, there wasn’t much in the way of accountability of how the money would be spent.

MINHEE: The reporting requirements attached to the opioid settlement agreements are virtually nonexistent.

With opioidsettlementtracker.com, she is hoping to change that. So far, 20 states do voluntarily report all of their settlement spending; others, like Tennessee, are reporting some of their spending; but some don’t make any information public.

MINHEE: Texas has decided not to report its specific expenditures. We have no official state-promulgated proof of spend for Texas’s $2.8 billion. And that is a travesty for all of the million moral reasons that I can input. But it’s also a travesty from a data perspective, because we’re waltzing into this landscape where we’re just going to have no sense of how these monies were actually spent, or whether or not they’re moving the needle on public health.

LOYD: You keep distributing money to the same things that you’ve been distributing it for the last 20 years that have led you here.

Stephen Loyd again.

LOYD: The only way to break that is to do something different. I mean, the definition of insanity, right? Doing the same thing over and over, expecting a different result. 

DUBNER: When you talk about the money that’s been spent and hasn’t achieved the goal, how is that money historically or traditionally spent? 

LOYD: It comes in from the federal government usually in a block grant through a state Department of Mental Health or Substance Abuse or whatever their equivalent is, and then they dole it out to their organizations who are carrying out programs in their state. And my issue with that — and I’m not knocking the work that’s being done, there’s a lot of people doing really, really good work — I want to see meaningful outcomes. Not how many people we are able to do a physical exam on in 24 hours. Is that important? Yes. Do I care? No, I don’t care. What I care about is how many of those people went through the program and when they got out, were able to sustain their recovery? How many of them got back into their jobs? How many of them got a new job? How many of them were able to provide for their family? I want meaningful data. Just like we would for a heart attack. If you put a stent in somebody and said, “Oh, we got a stent in there and the flow was great,” and two days later they died of a heart attack. Okay, if you just measured the flow and said, “That’s a success,” I would tell you that was a failure.

DUBNER: So it sounds like there is a greater than zero chance that if we were talking 15 or 18 years from now, that someone — maybe you — would have the same complaints about how the money has been spent that you’ve had about how the money has been spent, for instance, in West Virginia over the past 20 years. What do you think are the odds of that? 

LOYD: It’s my nightmare. I mean, not very many things keep me up at night anymore. This one keeps me up at night because I’m scared that we’re going to blow it. 

DUBNER: So when I speak with you, Stephen, I get the sense that addiction is sort of a language that if you don’t speak it, you don’t speak it. And that’s a problem, because you need people who don’t speak the language to be involved in, let’s say, the treatment or the teaching of that language. 

LOYD: If you have policymakers that don’t speak the language and don’t understand what I just said, think of some of the things that you can come out of this with. I mean, policy that’s harmful. 

So: what kind of policies won’t be harmful?

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The United States has the highest rate of drug overdose deaths in the world, and in recent years, the problem has continued to worsen. As we’ve been discussing over these past two episodes, the opioid epidemic has a variety of causes; but what about the consequences? The death and suffering and broken families — those are all front-and-center. But there are others. Because this crisis originated with the legal, medical distribution of an addictive substance, the medical community especially has fought back, hard. Everyone now admits that opioids were wildly overprescribed for a long time, and since 2010, the rate of opioid prescription has fallen by at least 50 percent. The system has made it significantly harder to get certain drugs. But this too has had a cost: a lot of people who need these drugs for pain management aren’t able to get them. Most people who use prescription opioids don’t become addicted. But because some do, and because this addiction to a legal product created a massive market for illegal versions of that product, the legitimate prescription of some opioids by legitimate physicians has been constrained. And people have suffered because of that too. In 2022, the CDC issued new prescription guidelines that continue to emphasize opioid alternatives, but also call for flexibility to allow their use when needed. Perhaps all these wrinkles shouldn’t surprise us. Every epidemic has its own history, its own trajectory and rebound effects, its own way of making trouble. I asked Stephen Loyd if he could point to an epidemic from history, whether ancient or modern, that seems to parallel the opioid epidemic.

LOYD: Stephen, I think the opioid epidemic is this generation’s H.I.V. and AIDS. There’s so many parallels. I’m getting ready to be 57, and so I lived through that in the early 80s. First of all, it was a death sentence. You know, if somebody had H.I.V. disease, they were going to die, and we knew it. The really big thing was stigma. “Don’t swim in the pool with these kids.” And really the biggest hurdle — because we actually had AZT pretty early on in the AIDS epidemic — but there were barriers to getting the treatment. And then you had these groups, the one I remember is ACT UP, got out and made a lot of noise and started fast-tracking medications through the F.D.A. And then you had several notable cases that started to change the face of it. Ryan White, Arthur Ashe, Earvin “Magic” Johnson. You look at H.I.V. disease and AIDS now — when’s the last time you saw an article on it? My son just turned 30 years old and he doesn’t remember H.I.V. and AIDS being a death sentence. And if you paralleled that to what we’re seeing with the opioid epidemic, there are so many similarities. What’s the biggest thing that prevents people from getting treatment right now? Stigma.

DUBNER: But it’s been a while now. Why do you think the stigma has not receded? 

LOYD: People just look at addiction differently, Stephen. Last night, I was in a rural town here just east of Nashville. And the decision-makers in that town understood almost nothing about addiction. You’re still under the impression that, well, this little town doesn’t need what you want to bring here, because we’re not Memphis or we’re not Nashville or New York City. And that’s somebody who doesn’t understand the demographics of this. I mean, this started out as a rural problem. And it still is a rural problem. And so you’re off-base there. But then you want to send somebody away for 10, 20, 30 days and have them come back fixed. And that’s not how this works. It’s a lifelong process. And so if those are the people driving your policy, then you can start to imagine some of the things you come out of this with, and you actually have people that will die never knowing that there’s life-saving medication out there to help them. Sometimes I feel like I’m working in the days of the Salem witch trials. Because we know so much about addiction now. We know things that are effective, we know medications that are effective. But when you start getting in rural territories, you’re right back to those times where you’re looking at this as a moral failure, and the only treatment is a higher power or a deity. I ran into it last night in front of that zoning commission. And I couldn’t overcome it. I lost.

DUBNER: You said you couldn’t get them to buy what you were selling. What were you selling in that case?

LOYD: I was trying to show them the fact that addiction is like any other medical disease that deserves the same opportunities for treatment. That’s it. 

DUBNER: Were you proposing a facility? Were you proposing —

LOYD: Facilities that did everything. You know, behavioral health counseling, mental health issues, getting at family of origin issues. All the stuff that goes around addiction like housing, stable food source, income. And then for the population that needs it, medication. And when you start talking medication, particularly in rural areas, the thing that plops out right off the bat, “Oh, you’re just trading one drug for another.” That’s it. They seem to not understand that we’re going to save lives. And if I’m completely honest, the biggest drawback that I have in the states I work in is the church. 

DUBNER: Because the church has a kind of bright line over use/don’t use?

LOYD: Absolutely. If you pray enough, and you walk enough little old ladies across the street, then you won’t have this issue. One of the arguments last night is — and these are their words, not mine, ’cause I don’t use these words, but — “We’re going to bring drug addicts in here.” Well, I’ve been working in that particular town for a good while, and I can promise you they’re already there. 

DUBNER: This is a paraphrase of you describing how the Helios model works. The idea is to “use statistical modeling and artificial intelligence to simulate the opioid crisis, predict which programs will save the most lives, and help local officials to decide the best use of settlement dollars.” It sounds good, but I could also see someone hearing that and saying, “Oh, that just sounds like consultants getting their piece of this, and it doesn’t sound close enough to the ground to me. It doesn’t sound like it’s going to physically address the actuality of this epidemic.” What would you say to that suspicion?

LOYD: First of all, I’ve never been accused of being a consultant. And I’m certainly not McKinsey material. It’s what I see. And I saw it, when we modeled the cases, because my job in the cases was to show causation, right? To draw a direct line from the mispromotion of the drug OxyContin to today’s heroin and fentanyl epidemic. That’s my job. And when I saw what modeling did to reinforce the story that I told, that I physically saw and experienced as a patient and a provider, I was overwhelmed by it. And so it may sound like consultant-speak, and maybe somebody cleaned my words up. I mean, you’ve talked to me long enough to know that I probably can’t talk that well.

DUBNER: Yeah, I was going to say those words on the page don’t really sound like you sound, now that I’m talking to you.

LOYD: They don’t. So somebody cleaned them up, but the idea is the same. And the idea is that we have to know what our current assets are, what our current system is. We have to be able to model that so that we can make the best decisions on how to allocate the money. And that’s Steve Loyd’s words.

Stephen Loyd plainly believes that the stigma associated with addiction is a major reason this epidemic has continued to rage on. In part one of this series, we featured the Stanford drug researcher and policy advisor Keith Humphreys. He believes that stigma is important, that if you remove all the barriers from drug use — not just legal barriers but social barriers — then you are inviting trouble. That said, Humphreys and Loyd do agree that the opioid crisis has gone on far too long, that there are ways to stop it, and that the settlement money coming in now from the opioid producers is a key to all of that. We went back to Humphreys for his take on how the money should be spent.

HUMPHREYS: These settlements are massive. They are multibillion dollar settlements. They are, however, paid out over very long periods. So I was talking to a governor about what impact it has. She said, “It’s like an extra 6 percent of our budget for the next 25 years.” So when you thought of it that way, it’s like, oh, that’s not really that much. I mean, it’s billions, but if it’s paid out over very long times, right? So the question will be, since this is to abate the problem, is how do municipalities and states use it as wisely as possible? And what I tell them is like, don’t spend any money on anything some other funding stream covers. Like building a clinic. That’s — where do you get money? Medicaid, Medicare will not pay to build a clinic. But if you build a clinic and if you have staff, then Medicaid, Medicare will pay your staff salary forever. I’ve also been pitching, please do something for prevention because we have funding streams, private and public insurance that pay for the care of people who are ill, but there really isn’t good funding streams for prevention for people who are not yet ill. You know, mainly kids.

There’s an organization at the University of Washington that Humpheys sees as a good model for setting up youth-prevention systems. They’re called Communities that Care, and they consult with various communities to, in their language, “promote the healthy development of young people.”

HUMPHREYS: Making investments in kids around the age of 10, 11, 12, has many good outcomes. A lot of people don’t think about prevention enough. They think about the current crisis, but you have to think long-term if you want to deal with epidemics. So, I would use this money for things nothing else can pay for. So that would be prevention with kids, because there is no funding stream for that. I would certainly do infrastructure. There’s places where there are no methadone clinics, so you need a building. You can’t pay for a building with health insurance, but you could pay for it with this. Could also potentially do some things with technology. So you can have investments for telehealth, so people don’t have to come in as often, that often is a way to retain them and care better. That’s something we could do. Let’s think what hangs over all this, is the shadow of the tobacco settlement. Very little of it was spent on tobacco. You know, potholes and that kind of thing. So there’s far more monitoring and far more transparency of where the money is going. However, these decisions, remember, these are cities, states, counties, the fed. The levels of decision-making are varied. And there will be places where they say, “Well, what we need are new police cruisers.” So there’s going to be problems, for sure, of misallocation. I think that’s just inevitable.

DUBNER: You wrote, in 2019, “If no Sacklers end up behind bars, an entire class of people will continue to feel that writing a check is the worst thing that will happen to them, no matter what they do.” As far as I know: no Sacklers in jail. What’s your position now, a few years later?

HUMPHREYS: I’m only more cynical, because not only did no Sacklers go to jail, but another company they own — Mundipharma — is now selling OxyContin all over the world, just like they sold it here. So they haven’t been punished, and they’re continuing to profit. 

Mundipharma, headquartered in England, is indeed owned by members of the Sackler family, although they may be required to dispose of it as part of Purdue Pharma’s bankruptcy settlement. So what happens next? Does the opioid crisis spread to other parts of the world? Does the U.S. create a successful playbook to fight the crisis here? I hope these are the questions that people in power are asking themselves right now. I also hope that we don’t find ourselves back here, in another five years, making yet another episode about this epidemic. I’d like to thank Stephen Loyd, Keith Humphreys, Christine Minhee — and, last week, David Cutler and Travis Donahoe — for speaking with us. And most of all, I’d like to thank you, as always, for listening. Let us know what you’re thinking; our email is radio@freakonomics.com.

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Freakonomics Radio is produced by Stitcher and Renbud Radio. You can find our entire archive on any podcast app; also, at freakonomics.com, where we publish transcripts and show notes. This episode was produced by Alina Kulman and Zack Lapinski. Our staff also includes Augusta Chapman, Dalvin Aboagye, Eleanor Osborne, Elsa Hernandez, Gabriel Roth, Greg Rippin, Jasmin Klinger, Jeremy Johnston, Julie Kanfer, Lyric Bowditch, Morgan Levey, Neal Carruth, Rebecca Lee Douglas, Sarah Lilley, and Theo Jacobs. Our theme song is “Mr. Fortune,” by the Hitchhikers; our composer is Luis Guerra.

LOYD: Big hockey game tonight. For a kid who grew up in the South and realizing there’s a hockey team in Nashville is kind of a weird thing.