Between 2000 and 2019, more than 16,500 North Carolinians died due to accidental opioid overdoses. The irrevocable loss devastated countless families and communities, and the pharmaceutical industry is being held accountable.
In 2022, North Carolina began receiving opioid settlement funds that will total roughly $1.4 billion by the end of 2038. This funding is the result of two nationwide settlement agreements that have been reached to resolve all opioid litigation by state and local governments against three of the largest drug distributors, one manufacturer, and its parent company, Johnson & Johnson. Governor Josh Stein, then serving as the state’s attorney general, helped negotiate the settlements.
At the Trust, our commitment to investing statewide in the power of local leadership focused on improving health long term is stronger than ever, particularly in these times. It is our goal for impacted communities to play a primary role in leading strategies to prevent, address, and treat opioid and substance misuse. Systems and institutions must be held accountable and listen to and learn from residents as we work toward better health outcomes for all.
While this influx of funding across the United States increases opportunity for widespread community health improvement, equity concerns around who makes funding decisions have emerged.
Too often, affected communities are excluded from decision-making
In North Carolina, there are clear guidelines around how the opioid settlement money must be spent. State lawmakers are in charge of distributing 15 percent of settlement funds, but the rest goes directly to the counties. A memorandum of agreement between the state and local governments gives counties options for how to spend their funds. Option B, one of 2 options for allocation of settlement funds, incentivizes community engagement by allowing counties that participate in collaborative strategic planning to spend funding in more dynamic ways, including upstream substance misuse solutions. Collaborative strategic planning requires engaging diverse stakeholders, exploring root causes, identifying gaps in existing efforts, prioritizing strategies, and agreeing on a shared vision. As of December 2024, 11 counties–including Columbus and Beaufort–have shared plans that approve spending for Option B strategies.
At the Trust, we know members of communities challenged by health inequities hold the expertise necessary to lead meaningful change and identify impactful solutions. Through our 10-year, place-based initiative, Healthy Places NC, we deepened relationships with communities working to center behavioral health and substance misuse. These relationships have underscored the importance of engaging the voices of those impacted, building trust, and creating a space where all stakeholders can come to the table
We encourage governing councils and local governments managing opioid settlement funds to embrace values of trust and transparency to share power and create a culture of inclusion.
Lessons to be learned from community
Since 2022, Robeson County has recorded a fatal overdose rate that was more than 2.5 times the statewide average. As of 2024, overdose rates decreased by 50% in two years thanks to 27 settlement-funded initiatives organized by the Southeastern Prevention and Addiction Recovery Resource Center (SPARC) Coalition. SPARC formed as a group of multi-sector agencies in response to a community need for deeper collaboration among groups frequently in competition.
While Robeson County has not yet selected option B for allocation of funds, SPARC’s open monthly meetings have established trust among agency partners and community members seeking to support ongoing efforts. Per membership guidelines, consortium members engage in community-based participatory research, which involves collecting and submitting client feedback, questionnaires, and surveys.
“It’s imperative that funding decisions include the voices of those impacted on a day-to-day basis.” said Dr. Summer G. Woodside, Department Chair at the University of North Carolina at Pembroke. “You can’t make informed decisions that have lasting impact without it.”
SPARC Coalition initiatives that have proven effective include a Medication-Assisted Treatment program for residents who have been detained or recently released from jail or prison, as well as a peer support network that trains community members as ambassadors to lead direct outreach for substance misuse prevention. Several of these initiatives have received additional support through opioid settlement funds allocated to Robeson County. Moving forward, if Robeson County adjusts its spending plan to include option B strategies, partners will have increased flexibility to use funding for more upstream solutions.
Bolster progress by fostering connection among stakeholders
Beaufort was the first county in North Carolina to select Option B, and community stakeholders have direct input on how funds are used.
Beaufort County Health Director Janell Octigan shared how forming the local leadership group Beaufort County 360 laid the groundwork for collaborative thinking and strategic investing of settlement funding.
“BC360 allowed us to bring key decision-makers to the table,” said Octigan. “The hospital president and our county manager were able to collaborate with residents in real-time, and that accelerated our progress.”
BC360 established task forces around a variety of focus areas including: healthy eating and active living, literacy, and behavioral health. With Trust support, BC360 was able to appoint an executive director to serve as task force coordinator.
“Having executive leadership helped us focus on communicating our purpose to those we still needed at the table,” said Octigan. She stressed the value of adding capacity, so the behavioral health task-force could host community engagement sessions to hone in on specific needs. Octigan also celebrated the program Catch my Breath, which operates in partnership with local schools to provide students information around smoking, vaping, and illicit drug use, and trains adults to lead education-based outreach.
Raising community voices changes policies, practices, and beliefs
Both organizations credit momentum gained toward addressing challenges like public transportation and housing to the open, honest, and solution-focused dialogue among local officials and community members. Opioid settlement funding offers a forum where communities can co-create actionable change and gain common understanding of how social factors influence health outcomes.
By inviting community voices and centering support around their needs, Robeson and Beaufort counties are also reframing harmful narratives about substance misuse through both programming and storytelling efforts. Individuals who have been impacted by substance misuse now have platforms to share how these experiences have shaped their lives. In turn, these stories are changing community dialogue and dismantling stigmas and assumptions that misguide beliefs about those who have personally struggled. Residents now unite against misinformation and harmful rhetoric to reinforce their collective strengths.
What role can philanthropy play?
Funders can be important advocates for equitable opioid settlement fund distribution, by amplifying the power of grassroots leaders and providing grants to grassroots organizations that are closest to communities that have been impacted by substance misuse. Supporting the infrastructure of collaborative county-based substance use coalitions is also critical to help diverse stakeholders co-create solutions. In places like Robeson, Bladen, Columbus, and Beaufort counties, the Trust has supported the efforts of local partners to develop strategic plans and ongoing collaboration around substance misuse.
Because effective community power-building often starts small, funders can help build the capacity of equity-focused, local leadership to collaborate around sustainable solutions. Supporting education efforts and mobilizing outreach helps reframe the lived experience of communities impacted by substance misuse. We encourage other funders to join us in support of effective use of opioid funds and community partners to raise their voices and lead the way.