KFF Health News: Officials agree — use opioid settlement funds to curb youth addiction, but the 'how' gets hairy

When three teenagers died of fentanyl overdoses last year in Larimer County, Colorado, it shocked the community and "flipped families upside down," said Tom Gonzales, the county's public health director.

Several schools began stocking naloxone, a medication that reverses opioid overdoses. Community organizations trained teens to use it. But county and school officials wanted to do more.

That's when they turned to opioid settlement funds — money coming from national deals with health care companies like Johnson & Johnson, AmerisourceBergen, and CVS, which were accused of fueling the epidemic via prescription painkillers. The companies are paying out more than $50 billion to state and local governments over 18 years.

Much of that money is slated for addiction treatment and efforts to reduce drug trafficking. But some is going to school-based prevention programs to reduce the possibility of addiction before it begins. In some cases, school districts, which filed their own lawsuits that became part of the national settlements, are receiving direct payments. In other cases, state or local governments are setting aside part of their share for school-based initiatives.

Many parents, educators, and elected officials agree that investing in prevention is crucial to address the rising rates of youth overdoses, depression and suicidal thoughts.

"We have to look at the root causes," said Diana Fishbein, a senior scientist at the University of North Carolina-Chapel Hill and leading expert on applying prevention science to public policy. Otherwise, "we're going to be chasing our tails forever."

But the question of how to do that is fraught and will involve testing the comfort levels of many parents and local officials.

For generations of Americans, addiction prevention was synonymous with D.A.R.E., a Drug Abuse Resistance Education curriculum developed in the 1980s and taught by police officers in schools. It "dared" kids to resist drugs and was used in concert with other popular campaigns at the time, like "just say no" and a video of an egg in a frying pan with the narration, "This is your brain on drugs."

But decades of research found those approaches didn't work. In some cases, suburban students actually increased their drug use after participating in the D.A.R.E. program.

In contrast, prevention programs that today's leading experts say show the most promise teach kids how to manage their emotions, communicate with others, be resilient, and build healthy relationships. They can have long-term health benefits while also saving society $18 for every dollar invested, per a federal analysi. But that approach is less intuitive than simply saying "no."

If you tell parents, "'We're going to protect your child from dying of a fentanyl poisoning by teaching them social skills in third grade,' they're going to be angry at you," said Linda Richter, who leads prevention-oriented research at the nonprofit Partnership to End Addiction. Selling them on the most effective approaches takes time.

That's one of the reasons prevention experts worry that familiar programs like D.A.R.E. will be the go-to for elected officials and school administrators deciding how to use opioid settlement funds. When KFF Health News and InvestigateTV looked for evidence of local spending on prevention, even a cursory review found examples across half a dozen states where governments have already allocated $120,000 of settlement cash to D.A.R.E. programs. The curriculum has been revamped since the '80s, but the effects of those changes are still being studied.

Budgeting choices reflect deeper debate

Researchers say putting money toward programs with uncertain outcomes — when more effective alternatives exist — could cost not only valuable resources but, ultimately, lives. Although $50 billion sounds like a lot, when compared with the toll of the epidemic, each penny must be spent efficiently.

"There's tremendous potential for these funds to be wasted," said Nathaniel Riggs, executive director of the Colorado State University Prevention Research Center.

But he has reason to be hopeful. Larimer County officials awarded Riggs' team $400,000 of opioid settlement funds to build a prevention program based on the latest science.

Riggs and his colleagues are developing training for school staff and helping implement the Blues Program, a widely acclaimed intervention for students at risk of depression. The program, which will start in 10 middle and high schools this fall, teaches students about resilience and builds social support through six small group sessions, each an hour long. It's been shown in multiple studies to decrease rates of depression and drug use among youth.

Natalie Lin, a 17-year-old senior at Fossil Ridge High School in Fort Collins, Colorado, is optimistic the program will help overcome the stigma her peers face with mental illness and addiction.

"Having it in school" prevents people from feeling "called out" for needing help, said Lin, who carries naloxone in her car so she's prepared to reverse someone's overdose. "It's just acknowledging that anyone here could be battling" addiction, and "if you are, that's all right."

Across the country, investments in prevention run the gamut. Rhode Island is using about $1.5 million of settlement cash to increase the number of student assistance counselors in middle and high schools. Moore County, North Carolina, is spending $50,000 on a mentoring program for at-risk youth. Some communities are inviting guest speakers and, of course, many are turning to D.A.R.E.

New Hanover County, North Carolina, and the city of Wilmington, which it encompasses, pooled $60,000 of settlement money to train nearly 70 officers in the D.A.R.E. program, which they hope to launch in dozens of schools this fall.

County commissioner Rob Zapple said it's one piece of a "multiprong approach" to show young people they can lead productive lives without drugs. Officials are also putting $25,000 of settlement cash toward public service announcements and $20,000 toward other outreach.

They acknowledged there's little research on the updated D.A.R.E. curriculum but said the county views its investment as a pilot, which they will track closely. "Instead of committing everything at once, we're going to let the spending of the money grow with the success of the program," Zapple said.

Munster, Indiana, also decided to further its D.A.R.E. effort, using $6,000 — a small slice of its total settlement funds — annually. Jasper County, Iowa, is using $3,800 to cover materials for the program's graduation ceremonies for several years.

In some places, officials are frank that they're not getting enough money to do anything inventive.

Solon, Ohio, for example, received $9,500 in settlement funds this year and is expecting similar or smaller amounts in the future. "While the funding is welcome," finance director Matt Rubino wrote in an email, it's "not material enough to be transformational" to the budget. Putting it all toward the existing D.A.R.E. program made the most sense, he said.

Out with the scare tactics

Francisco Pegueros, CEO and president of D.A.R.E., said though the program has been in place since the '80s, "it's really significantly different" today. The curriculum was redone in 2009 to move away from scare tactics and lectures on specific drugs to focus instead on decision-making skills. Officers undergo intensive training, which includes understanding how children's brains develop.

"Telling somebody a drug is harmful isn't going to change their behaviors," Pegueros said. "You really need to deliver a curriculum that's going to build those skills to help them change behaviors."

With the rise of fentanyl and some state legislatures mandating education on drugs, interest in D.A.R.E. has grown in recent years, Pegueros said. He believes it can be effective as part of a comprehensive, community approach to prevention.

"You're not going to find one curriculum, one program, one action that's going to achieve the results you want," he said.

Still, D.A.R.E. can play an important role, he said, pointing to a recent study that found the new curriculum had a "positive effect in terms of deterring the onset of alcohol use and vaping" among fifth graders.

But many public health experts remain skeptical. They worry the changes are superficial. The few studies of D.A.R.E.'s new curriculum have been short-term, yielded mixed results, and in some cases had high dropout rates due to the covid-19 pandemic, which raises questions about how applicable the findings are for schools nationwide. According to some law enforcement officials and advocates, even the revamped program is often taught alongside campaigns like "One Pill Can Kill", which warns youth that trying drugs can be fatal the first time.

That type of scare tactic seems futile to Kelli Caseman, executive director of Think Kids, a nonprofit that advocates for children's health and well-being in West Virginia. "It's not as if these kids are unsuspecting and have never seen the consequences of drug use before," she said.

In 2017, West Virginia reported the highest rate in the nation of children living with their own or a parent's opioid addiction.

"We need stronger communities that are willing to just give those kids more guidance and support than fear," Caseman said. "They've already got enough fear as it is."

Some local governments are trying to straddle both paths.

Take Chautauqua County in western New York. Last September, the county and a local child-development collaborative spent $26,000 — including $5,000 of opioid settlement cash — to bring former NBA player Chris Herren to speak at several assemblies about his past addictions to alcohol, heroin, and cocaine. Herren recounted to more than 1,500 students the first day he had a beer, at age 14; how addiction ended his career; and how he landed on the streets before entering recovery.

Patrick Smeraldo, a physical education teacher and the head of the local collaborative that organized Herren's visit, said the basketball player's story resonated with students, many of whom have parents with addiction. "When he talks about selling his kid's Xbox to get drugs, I think he's touching on facts that they've had to go through," Smeraldo said.

But a one-time speaker event has little lasting impact, researchers and public health experts say.

That's why the county is also investing opioid settlement funds in several other initiatives, said Steve Kilburn, who oversees addiction-related grants for Chautauqua County. A likely six-figure sum will go to Prevention Works, a local nonprofit that teaches a nationally acclaimed "Too Good for Drugs" curriculum in 23 schools and runs a "Teen Intervene" program that provides one-on-one coaching and support for students found using drugs or carrying drug paraphernalia in school.

Melanie Witkowski, executive director of Prevention Works, said some students are scared to come to school because their parents might overdose without someone at home to revive them.

Smeraldo, the physical education teacher, is planning to build on Herren's talk with an after-school program, in which students will be able to discuss their mental health and transform interests like cooking into internships to help break the cycle of poverty that often contributes to addiction.

Herren is "the catalyst to get the kid to services that exist in the county," Smeraldo said. It's a starting point, not the end.

InvestigateTV is Gray Media Group's national investigative team and provides innovative, original journalism from a dedicated investigative team and partners. InvestigateTV and its weekend and weekday programs are available on AppleTV, Roku, and Amazon Fire; at InvestigateTV.com; and across Gray's 113 broadcast markets and digital media properties.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — an independent source of health policy research, polling and journalism. Learn more about KFF.