With millions in opioid settlement dollars to combat the epidemic’s devastating effects, counties are navigating complex funding streams, rigorous reporting requirements, and shifting state policies. Their efforts are not just about meeting standards but ensuring these resources make a real difference in their communities.

Maryland counties have long demonstrated their commitment to transparency and accountability in managing public funds, including those tied to the recent series of opioid settlement agreements, arising from multiple lawsuits against the manufacturers and distributors of addictive medicines misused by millions. As the process of distributing and employing these funds continues,  counties are already complying with a wide array of reporting requirements developed to ensure the appropriate commitment of these resources. Often, counties are already meeting—and often exceeding—the necessary standards.

Understanding Opioid Settlement Allocations

Maryland counties receive opioid settlement funds through several channels, each with distinct allocations and oversight structures:

• Opioid Restitution Fund (ORF): 15% for state use.
• Targeted Abatement Subfund (TAS):
  • 15% for state use (competitive grants).
  • 45% for local governments (non-competitive grants).
• Local Allocation: 25% for local use.

Each of these funding streams has reporting requirements outlined in various agreements, legislative acts, and grant guidelines.

History of Rollout of Funds

Opioid settlement funds started being distributed in 2022 following settlement agreements reached in 2019. As previously covered by MACo, the Maryland General Assembly passed legislation in 2019 ensuring that proceeds from the State’s opioid litigation are directed toward addressing the opioid crisis. This law mandates that monetary damages awarded to the State through litigation against the opioid industry be deposited into a dedicated Opioid Restitution Fund.

The rollout of funding required to go through the State has run into a handful of infrastructure challenges that have significantly hampered how well and quickly information and funding can get through to the counties and other remediation teams. Government procedures historically take time, but some of the shuffling and reshuffling around opioid funding has exacerbated that reality.

What was initially a process running through two state entities – the Office of the Attorney General (OAG) and the Opioid Operational Command Center (OOCC) – ballooned into a procedure requiring the involvement of five agencies. Those agencies are the Office of the Attorney General, Maryland Department of Health, Maryland’s Office of Overdose Response (MOOR) (formerly the OOCC), the Behavioral Health Administration, and the Opioid Restitution Fund Advisory Council. This was the outcome of a policy decision by the Moore administration in December of 2023, through an executive order, that consolidated the Command Center (OOCC) into the largest state agency in Maryland – Maryland Department of Health. 

In essence, the initial process hinged almost entirely on the authority of the relatively nimble, independently established Command Center (now restyled as Maryland’s Office of Overdose Response), and in accordance with strict oversight and reporting standards. After the executive order, decision-making authority shifted from MOOR to the Secretary of Health. A third iteration of funding authority shifts is now underway, changing how funds are distributed and decided. Meanwhile, Maryland’s Opioid Restitution balance is around $75.4 million, as recently published in the agency’s report.

The challenges faced in this rollout did not happen overnight; they are the result of complex policy shifts, infrastructure issues, and the realities of government procedures.

Opioid Dollars Put to Work

The opioid epidemic has had devastating effects on Maryland communities, affecting countless lives and straining public health and safety resources. In response, elected officials, state agencies, county governments, and many other key stakeholders work to find solutions. The State of Maryland and its local jurisdictions are now receiving the initial stages of millions in multi-year settlement dollars to address the opioid epidemic’s harms through evidence-based strategies. Local health departments in every area of the state implement local strategies to tackle the crisis’s public health aspects as required.

As previously covered by MACo, localized remediation efforts have been highly responsive to the unique needs of individual communities, which often differ across jurisdictions. Local agencies have swiftly implemented several tactics to put settlement funds to effective use:

• medication assisted treatment
• crisis intervention and stabilization
• harm reduction services
• linkage to care
• mobile crisis response units
• peer specialists and coordination
• school-based prevention
• recovery housing
• naloxone distribution

As previously covered by MACo, Cecil County launched the Medications for Opioid Use Disorder program, which provided access to care and served 189 individuals within the first six months of implementation. The county also partnered with Voices of Hope, an organization that supports individuals and families in recovery. In the first year of the program officials logged 2,465 total encounters, connecting 753 individuals to behavioral health treatment. Additionally, all 23 local detention centers have established medication-assisted treatment programs that drive down the overdose risk for returning citizens leaving local facilities.

At the 2024 MACo Winter Conference affiliate session, “There’s No Rest in Restitution: Opioid Dollars Making a Difference,” an esteemed panel of health leaders and policy experts will explore all of the great work local health departments are doing, specifically to fight the opioid crisis. Click to learn more about MACo’s Winter Conference.

Existing Reporting Requirements

These reporting layers ensure transparency, but they also highlight the sheer volume of administrative work counties undertake to secure and use these funds. Here are some of the key requirements:

1. Exhibit E of the National Settlement Agreement agreed upon in 2022 to govern the allocation of the Janssen settlement funds. It was updated in 2024 to include proceeds from settlements with Walmart, Walgreens, Allergan, and Teva, according to MOOR.
2. The State Subdivision Agreement details the agreement between the State and local governments. The State must audit counties.

Section VI. Audit of Settlement Proceeds and Enforcement

(a) The Secretary shall establish procedures for the audit of Subdivisions receiving Settlement Proceeds under the National Settlement Agreement and this Agreement consistent with the procedures for other grants to Subdivisions administered by the Secretary.  The auditing procedures shall ensure that the requirements of the National Settlement Agreement and this Agreement concerning the use of Settlement Proceeds for Permitted Uses and for Opioids Remediation are followed.

(b) If the Secretary believes that the provisions of the National Settlement Agreement or this Agreement are being violated, the Secretary shall report the violation to the Attorney General who may enforce the Consent Judgment incorporating the National Settlement Agreement and this Agreement against any Subdivision.

3. Local abatement fund plan form
   • Counties must submit plans before the State releases Targeted Abatement Subfund (TAS) dollars. Local governments must update local abatement plans every five years.
4. Grant Application for the State’s discretionary money – reporting requirements. Jurisdictions have quarterly reporting requirements through MOOR – FY2025 Competitive Grant Program RFP.docx. Reporting requirements:

1. • Maryland’s Office of Overdose Response (MOOR) will distribute awarded funds to grantees on a quarterly-reimbursement-of-expenditures basis. Timely submission of a corresponding Quarterly Project Report (see Exhibit A) with updated Performance Measures, and a Reimbursement Request (see Exhibit B) with adequate supporting documentation is required for all activities and costs.
   • Grantees will be required to submit reimbursement forms for costs on a quarterly basis, as they are incurred, and will be reimbursed for those costs after MOOR and the Maryland Department of Health (MDH) financial staff review and approve the invoices and supporting documentation. All costs submitted for reimbursement must be included in the applicant’s project application and budget. Supporting documentation must clearly provide evidence that funding was spent as per the grant budget justification and that these expenses have already been paid. MOOR will not reimburse any expenses not included in the approved budget and detailed in the budget details.

5. Additional Reporting Layers

1. • GOCCP (Governor’s Office of Crime Control and Prevention): Counties submit additional reports for programs like medication-assisted treatment in local detention centers.
   • SAMHSA (Substance Abuse and Mental Health Services Administration): Federal funds require more rigorous applications and reporting.

Public Chapter 852: Opioid Restitution Advisory Council and Fund – Revisions

Last session, the Maryland General Assembly passed HB 980/SB 751, which added another layer of accountability. This bill tasks the Maryland Department of Health (MDH) with developing a plan to make all opioid settlement expenditures accessible to the public. The Department must recommend by December 1, 2024, the best way to consolidate and share information about how state, county, and municipal levels use opioid settlement funds. Counties have already laid the groundwork for this initiative by submitting detailed data to the State, which is well-positioned to synthesize these reports and make them available to the public.

Looking Ahead

MACo anticipates upcoming legislation that would require increased reporting requirements for local jurisdictions receiving money from opioid settlements. While intending to show transparency and a comprehensive view of how settlement funds are allocated and used across the state, counties already comply with copious reporting requirements. Continuously adding layers of reporting could ultimately result in a system that unintentionally prioritizes paperwork over meaningful remediation efforts. As such, it is important to balance accountability with effective solutions to address the opioid crisis at the local level.

Additionally, in recent negotiations covered by MACo, the Maryland Attorney General indicated a proposal for more money to go directly to counties rather than through the state. He highlighted that routing funds through the state slows down remediation efforts and adds unnecessary layers of process. These layers, he noted, do not enhance oversight or transparency and may hinder better outcomes. Directly funding counties would streamline efforts, reduce delays, and ensure more effective use of resources to address local needs.

Conclusion

Ultimately, Maryland counties are proving themselves as leaders in responsibly managing opioid settlement funds. Their robust compliance not only meets existing standards but sets an example for other states to follow. By recognizing and supporting these efforts, we can ensure that communities use these resources to their fullest potential in addressing the opioid crisis and its devastating effects.

Stay tuned to the Conduit Street for more information.

This article is part of MACo’s Deep Dive series, where expert analysts explore and explain the top county issues of the day. A new article is added each week – read all of MACo’s Deep Dives.