NEJM Interview: Benjamin Scher on opioid litigation and governance systems for spending related funds.

Settlements of lawsuits against opioid manufacturers and related entities are expected to provide state and local governments with billions of dollars over the coming years. With the major agreements now finalized, attention is shifting to how associated funds will be spent. I'm Stephen Morrissey, managing editor of the New England Journal of Medicine, and I'm talking with Benjamin Scher, a lecturer and postdoctoral research associate in the Global Health Program at Princeton University. Dr. Schur has co-authored a perspective article about the use of opioid settlement funds and lessons from the Tobacco Master Settlement Agreement. Dr. Schur, let's start with the Tobacco Master Settlement Agreement. What were the major parties in that litigation and how big was that settlement?

The Tobacco Master Settlement Agreement was settled in 1999 and was providing states with over $200 billion over 25 years. This was mainly tobacco manufacturers who were selling products with known harms that they were advertising as not having those harms. States have been able to use those funds, but as we addressed in the perspective piece, which we'll be discussing today, only around 7% of those funds were ultimately used for tobacco control. So there are a lot of really interesting lessons and takeaways that we can now apply to the current opioid settlements.

So moving to the opioid cases, which entities are receiving funds as part of those settlements?

So today, opioid settlements are being distributed to states, counties, municipal governments, as well as tribal governments, so much more dispersed than the MSAs were. And these funds are being gathered from class actions that states joined together to sue pharmaceutical companies who were, again, manufacturing and distributing opioids that were knowingly addictive and had harms. But again, were being marketed as being safe and were being pushed to consumers. And when we talk about the various waves of the opioid crisis that have occurred, This last one that we're currently going through with kind of the proliferation of fentanyl and seeing synthetic opioids in the street drug system, this really came off the back of a huge wave of opioid deaths that came from people who are being prescribed these highly addictive substances.

You talked about the unfocused use of the tobacco settlement funds. And you say in your article that the opioid settlements have been structured to avoid the shortcomings of the tobacco agreement. So what's different about the opioid settlements?

Yes. So with the MSA, only 7% of funds were ultimately used for tobacco control. And the vast majority of the money was used for completely unrelented government spending. So infrastructure, education. Medicaid expenditures. With these current opioid settlements, there are protections in place to try and avoid some of those shortcomings. So a few examples, upwards of 85% of all settlement funds need to be used for opioid abatement. So it's quite a broad term, which we discuss in the article, but in theory, 85% of the money needs to be used to combat the opioid crisis today and moving forward into the future. Also, it's made very clear in the settlements