Guiding settlement funds
Having such massive infusions of funding into public coffers can bring great benefits to treatment of substance use disorders, damage reparations, and new treatment discoveries. However, we need to look back at the Master Settlement Agreement (MSA) from the tobacco lawsuits that were settled 20 years ago in 1998.What happened with those billions of dollars? States collected an estimated $27.3 billion from the MSA and taxes in fiscal year 2019, yet today no state funds tobacco prevention at the level recommended by the Centers for Disease Control and Prevention (CDC). Overall, states spend less than 3% of MSA funds on programs that would help prevent smoking in youth and help smoking cessation. Twenty-nine states and the District of Columbia spend less than 20% of the CDC recommendation. On the other hand, Alaska and California spend more than 70% of the CDC recommended funding—$655 million annually—on prevention and cessation programs. In contrast, tobacco companies spend more than $14 to market tobacco products for every $1 the states spend to reduce tobacco use.1
Because there are new challenges in reducing tobacco and nicotine use since the agreement, the MSA funds could have been better directed to detecting and addressing future threats than to the many other conditions unrelated to health care for which they were used. Among the new challenges is e-cigarette use by youths, which has skyrocketed to epidemic levels; the CDC and FDA show that from 2017 to 2018 e-cigarette use increased by 78% among high school students (to 20.8%) and by 48% among middle school students (to 4.9%).
The associated morbidity and mortality attributed to vaping with e-cigarettes has been startling and led to dramatically quick actions by Federal government standards, but with no benefit from the MSA funds. Similarly, the legalization of cannabis and its widespread smoking and vaping in many parts of the US has brought with it many health burdens in psychiatric and medical comorbidity, which have not been addressed with any portion of the MSA funds.
This lack of vision and missed opportunities associated with MSA funds should not be repeated with the accumulating opioid epidemic settlement funds. The obvious parallel for opioids with comorbid abuse of other DEA scheduled medications such as stimulants and sedatives strongly argues that these opioid settlement funds need essential investments in prevention, treatment, and research into related types of addictive substances and their delivery systems. However, such an investment is not likely to happen without substantial effort from the medical community.
To jump start these future opioid settlement funds, the federal government currently has allocated funding for the Helping to End Addiction Long-term (HEAL) initiative for the ongoing epidemic of deaths, which are now primarily from fentanyl. These HEAL funds are very welcome in the field and should provide some significant help for our patients, but these funding sources are not sustained and even their re-authorization in Congress will only carry for another year. Thus, the upcoming challenge will not be in the courts, but in the state legislatures, which are likely to get a substantial influx of financial resources for sustained periods from the opioid settlements.
These funds can help address the current opioid epidemic, but perhaps more importantly, these sustained funds need to be directed toward the rapidly growing epidemic of stimulants, particularly methamphetamine. While the fatalities associated with this opioid epidemic have indeed shifted to an illicit market of heroin and fentanyl and away from the original challenges with marketed commercial opioids, fentanyl is not only mixed with opioids, it is also being mixed with stimulants and causing increased mortality among drug users.
Stimulant abusers are also fueled by pharmaceutical companies who market stimulants for adults and children with attention-deficit/hyperativity disorder; however, many adults are getting stimulants for such off-label uses as depression, anxiety, and improved concentration. College campuses are awash in illicit stimulant use, and many young adults are becoming addicted to stimulants. Moreover, there is now the added risk of illicit fentanyl adulteration and overdose.
The financial resources that are clearly on their way to states and communities from both pharmaceutical company settlements and the more immediate federal HEAL grants need appropriate planning for wise spending—not wasting these resources by missing the mark for which they were intended.
So, have we made progress since that article was published in 1968 or are we on a two-steps forward, one backward pattern? Let us hope a future psychiatrist will be able to write a more positive article.
Dr Kosten is Jay H. Waggoner Endowed Chair, Co-Founder, Institute for Clinical and Translational Research, and Professor of Psychiatry, Neuroscience, Pharmacology, and Immunology, Baylor College of Medicine, Houston, TX.
1. Campaign for Tobacco-Free Kids. A State-by-State Look at the 1998 Tobacco Settlement 21 Years Later. January 16, 2020.