It’s been a little over 2½ years since 46 states and a handful of opioid manufacturers and distributors —Johnson & Johnson, AmerisourceBergen, Cardinal Health and McKesson — signed the first big legal settlement to address the huge rise in substance use and overdose deaths in recent decades.

Since then, more legal settlements with opioid manufacturers have boosted total national settlement funding to approximately $50 billion, to be distributed over 18 years. States, counties and cities have now started getting the money, pushing it out to pay for treatment and recovery services, prevention and harm-reduction programs. 

Oregon is at the forefront of the opioid crisis — with some of the highest rates of opioid use disorder and demand for treatment in the country, according to the federal Substance Abuse and Mental Health Services Administration’s National Survey on Drug Use and Health. According to the latest data for 2021-22, nearly a quarter of Oregonians aged 12 and older needed substance-use treatment for alcohol or drugs, and nearly 80% of that group didn’t get treatment in the prior year.

The state is now starting to deploy its first tranche of opioid settlement money — $89 million during the current fiscal year — to try to bend the curve toward treatment and recovery. In total, the state will receive about $600 million over 18 years.

The Hooper Detoxification Stabilization Center — “Hooper Detox” for short — sits on a freeway-feeder road in an industrial area near downtown Portland. Along the opposite side of the street are homeless people’s tents and abandoned cars. 

Inside the center, though, there’s a bustling medical clinic. Patients line up outside at 7:30 a.m., and once admitted they sit or doze in the lobby, waiting to be screened and checked in. Some tuck a sleeping bag or sack of belongings under their chair. 

Dr. Amanda Risser is senior medical director for Central City Concern, the nonprofit that operates Hooper Detox and a range of other recovery, health care and housing services around the city. Risser supervises withdrawal management for about 55 patients at Hooper — people coming off opioids, alcohol, methamphetamine or a combination thereof.

Entering the secure treatment wards on a recent morning, Risser passed intake exam rooms, a nursing station, a kitchen and showers.

“This is the women’s dorm,” she said, entering a quiet room with narrow beds lining the perimeter. “Most people are just resting in bed. Everybody gets their own little locker. Their medications are brought to them.”

Medical staff administer a range of detox medications, from buprenorphine and morphine for fentanyl and other opioids to naltrexone for alcohol. The facility also offers acupuncture and hosts 12-step meetings.

Patients are brought in by outreach workers and EMTs, or they’re self-referred; local hospitals and psychiatric wards also send patients. They typically stay five to seven days.

Risser said Hooper’s beds are nearly always full.

“Last year, for example, we had about 2,000 patients, and we turned away about 1,200. There’s not enough detox in the state,” she said. “It’s just simple numbers. If twice as many people come for services every day that we’re open, and we’re not able to take them, we have to send them away. There’s just not enough beds.”

When patients are discharged from detox, Risser said, it’s not easy to take the next step because of a lack of recovery services in the area.

“We have folks who desperately want a bed in residential or supported housing, and we don’t have enough beds for them,” she said. “Their desire is to get treatment, and it’s just not accessible to them.”

The problem is longstanding, said Fernando Peña, executive director of NW Instituto Latino, which offers recovery and outreach services to Spanish speakers in Portland. Peña also serves on Oregon’s 18-member Opioid Settlement Prevention, Treatment and Recovery Board — which is deciding how to spend the state’s first $89 million in settlement payments. (Peña said the views he expressed to Marketplace are his own and don’t represent the Settlement Board.)

“Oregon is currently probably last or second to last in access to care,” Peña said. “A focus on treatment is important because we need more treatment beds. But we need everything: more supported housing, detox beds, psych-ward hospital beds. Our first responders are understaffed, and they’re interfacing with our clients daily.”

Peña emphasized the importance of people at high risk and in recovery being in contact with drug-and-alcohol counselors and outreach workers who share their cultural or linguistic background.

“There are so few treatment beds or recovery support organizations for the African American community, the Native community, the Latino community, rural communities,” Peña said. “We have parts of the state right now where, not only do they not have a detox, some of them don’t have pharmacies. How can you fill a Suboxone prescription [to treat dependence on narcotics] if there’s no pharmacy?”

According to a recent presentation to the Oregon Opioid Settlement Board, Native American communities have an overdose-death rate more than 2½ times that of other Oregonians. That’s one reason the board recently decided that 30% of state settlement funds will go to Oregon’s nine federally recognized tribes — $26.7 million through 2025, and the same percentage continuing through the remaining years of the settlement.

Meanwhile, the Oregon Health Authority projects that the state needs to add 3,000 treatment beds by 2025 — nearly double the current capacity.

And they won’t come cheap, said Annaliese Dolph, director of the Oregon Alcohol and Drug Policy Commission and co-chair of the Opioid Settlement Board.

“We need half a billion dollars” for that number of new treatment beds, she said. “So certainly the opioid settlement dollars alone are not going to close that gap.”

Oregon’s entire settlement is projected to total approximately $600 million —spread over 18 years. Only 45% of those funds will be allocated by the state; 55% will be distributed directly to cities and counties to spend.

Meanwhile, Dolph said, there are plenty of uses for the settlement money besides funding more inpatient opioid treatment, which is mostly covered by federal and state Medicaid dollars.

“There are gaps in the system that just are not going to be met by commercial health insurance or through Medicaid,” Dolph said. “For example, providing services in jails.”

Oregon also needs more funding to attract and pay the staff who work with those afflicted with substance-use disorder, said Mike Marshall, executive director of Oregon Recovers, a statewide coalition of people in recovery.

“We have a workforce crisis. Even some of the current treatment providers are still not running at full capacity based on the number of beds they have because they don’t have the staff.”

Risser at Hooper Detox Center agreed. “The workforce has been really hard to maintain, especially in the last five years. So there’s a question: Even if we increased beds, would we be able to serve the folks that need to be served? Because we may not be able to find folks to actually take care of them.”

Like Oregon, states across the country are starting to plan how to deploy their funds, said Katie Greene, director of public health at the National Academy for State Health Policy, which tracks the settlement nationwide.

“We have seen states allocating funding across the spectrum of prevention, treatment, recovery and harm reduction,” Greene said. “It’s built into the terms of the settlement itself: 85% of the funding has to go to opioid abatement purposes, and there’s a specific list of allowable uses.

“States are trying to think creatively about wraparound and support services, care navigation, reentry and in-reach services in the last 90 days of incarceration. And given increased overdoses and the toll of fentanyl, a lot of funding is going towards activities like mobile response, wound care, expanding methadone distribution and fentanyl test strips,” Greene said.

Dolph said Oregon is also focusing on harm prevention.

“We leveraged federal funding during COVID for the purchase of [opioid overdose reversal drug] naloxone, and our first allocation from the state Settlement Board was to fund our Save Lives Oregon harm-reduction clearinghouse,” Dolph said.

NW Instituto Latino gets supplies from Save Lives Oregon. Peña showed off a storage room full of emergency kits packed into paper lunch bags: “Narcan, safer-use supplies, safer-sex supplies, wound-care supplies.”

Israel Pineda, 42, works on NW Instituto Latino’s harm-reduction (“reducción de daños”) team. After years in prison, he got clean and now does outreach. “We go into the streets, talk to clients and see what they need,” Pineda said. “We help them when it’s cold, provide sleeping bags and tents. A lot of people know me in the streets because I was in the streets too. The language barrier is a problem for a lot of Latinos, and I want to help my community get out of addiction, so they can get a better chance in life.”

Mike Marshall of Oregon Recovers was circumspect about the impact opioid settlement money can have, given the state’s high rate of substance use and low access to care. “Without a doubt, it’s hugely positive,” he said. “But is it a game changer? By itself, it’s going to turn the dial, but not very far.”

For his part, Peña is under no illusions about Oregon’s first installment of settlement funding. “It’s difficult to get this across, but $89 million — when I’m talking about generational underfunding — is not a lot of money.”

Still, every little bit can help, and maybe save a life, he said.