Opioid Crisis: What the Massive Settlement Money Means for Our Communities

It was October 2013, and the opioid overdose epidemic was raging.

Ardsley’s Harris Marquesano, 19, had a job interview the next day.

Popular, kind and athletic, Marquesano had been diagnosed years earlier with an anxiety disorder, and later with ADHD. Throughout his young life, he’d been treated by psychiatrists and psychologists.

As a teen, he began to experiment and self-medicate; it started with marijuana, leading to the misuse of prescription medication.

Westchester communities, and towns across the country, were awash in opioids, and Marquesano found them at a party.

“Prescription pills were available and within a year and a half of entering the first substance rehabilitation program, Harris was dead,” his mother, Stephanie Marquesano, recounted for me in a phone interview last week. “He went to four inpatients, two outpatients, all saying he had this thing called co-occurring disorders, all saying they treated co-occurring disorders.”

But the treatments for co-occurring disorders were all wrong.

“And so when he died, I decided that I was going to figure this out, figure out why they said they did it when they didn’t do it, and what we could do from prevention and all the way through to sustainable recovery around co-occurring disorders,” Marquesano said.

When Marquesano’s body was found in a hotel room, his clothes were laid out neatly for the job interview.

He had been eager to live, and dress to impress, hours before he slipped away.

Mission Possible 

The grieving mother took immediate action, developing a mission that now dominates her life’s work.

“So I started the harris project literally at my kitchen table in October of 2013,” explained Marquesano, who lives in Ardsley with husband Alan. “Right when my son died by accidental overdose.” (The couple also have an adult daughter, 26-year-old Jensyn).

A nonprofit, the harris project advocates for prevention programming, and integrated treatment for teens and young adults diagnosed with co-occurring disorders. (The letters of the harris project are all lowercased to “take his name and make it more of a noun than a pronoun because he could be anyone,” as Marquesano explained).

Marquesano’s organization is actually the only national nonprofit committed to co-occurring disorders.

But, before we go further, you might be asking yourself, what exactly is a co-occurring disorder? At least that’s the question I was asking myself last week, only vaguely familiar with the term. In short, it’s when a person is grappling with a substance use disorder and a mental health disorder, either simultaneously or one following the other.

If you’re an advocate in this space, like Marquesano, the current moment in time is ripe with possibility to transform a troubled system.

Big Deal

Here’s the big news, in case you haven’t already heard: The predacious companies that inundated our communities with highly addictive opioid painkillers are paying more than $50 billion in settlement funds to thousands of state and local governments across the United States, in the aftermath of an array of litigation. That is a huge deal with massive implications.

One prevailing fear is that the opportunity could be largely squandered. Health authorities have expressed apprehension that, if handled improperly, the legal triumphs could result in a recurrence of the Tobacco Master Settlement Agreement fiasco of 1998. In that instance, even though states received substantial monetary compensation, they primarily utilized it for purposes other than tobacco cessation and education programs.

Covering how the money gets spent will be an enormously important job for local journalists across the United States for years and even decades to come, given the fact that distribution of the settlement money involves an 18-year plan.

But even as the crisis continues to devastate homes and communities across the country, with myriad and momentous challenges to navigate, advocates also point to research that illuminates a positive way forward.

All Encompassing 

In 2019, Marquesano met Dr. Paula Riggs, an expert in exploring the correlation between mental health issues and addiction in teenagers and young adults.

Riggs conducted successful trials for the National Institutes of Health involving more than 500 adolescents, leading to a short list of safe medications for managing psychiatric conditions in those with substance use disorders.

Ultimately, a program called Encompass was born. It involves talk therapy, medication and regular evaluation to manage co-occurring disorders.

Riggs emphasizes treating addiction as a chronic condition that requires ongoing care rather than a one-time crisis.

“Nobody graduates from a diabetes clinic,” Riggs said in an interview with The New York Times that was published in January, largely about Marquesano’s advocacy. “You just keep taking care of your health, and then if you need to intensify treatment because something is out of whack, you come back in until you’ve got it under control.”

Studies have found, for instance, that opioid-dependent adolescents and young adults treated with buprenorphine-naloxone can benefit immensely. The medication allows withdrawal symptoms to be mild for patients.

Marquesano told me a remarkable story about one of the first enrollees in Encompass. The 25-year-old woman had been an inpatient in a local hospital system. She was bipolar, unemployed, homeless, smoked marijuana and drank a pint of vodka a day.

She also needed gastric bypass surgery, but had to eliminate substances for three months in order to prepare for the procedure.

It was the height of the pandemic.

Long story short, Encompass helped the woman get healthy. She secured a job with the county as a contact tracer and stayed off substances.

“She was also getting treatment for her bipolar disorder with the same clinician at the same time,” Marquesano said. “And then when she was discharged from Encompass, she continued with the same clinician to ensure that there was no relapse and that her bipolar disorder was like kept in check. So we always say people need more treatment or longer treatment, they just need better treatment.”

Don’t Show Me the Money

But the last thing forward-thinking advocates like Marquesano want is for the opioid settlement money to be invested in a fundamentally flawed system.

Marquesano is a member of New York’s Opioid Settlement Fund Advisory Board, which provides recommendations on how resources should be allocated.

“First I’m going to say from the perspective of the Opioid Settlement Board, there were many people both on the board and in the larger community who wanted to get the money out the door really quickly, like boots on the ground,” Marquesano said. “And I was very firm in my conviction that the current system is not working. And so to continue to infuse funds into a system that was separate was not really going to be the answer. And we did, as a board, regroup and we did create these overarching themes and goals. So I think that it’s been a real success.”

In a nutshell, the way to treat this vexing national crisis involves integrated treatment programs. It’s about providing both substance abuse intervention and mental health services with the same practitioner or treatment team, and embracing the broader principles of Encompass.

Given this context, for Marquesano, reform in New York is also about combining the state mental health and addiction service departments to create one unified entity, in the service of best treating co-occurring disorders.

About half of people with severe mental disorders are impacted by substance abuse while nearly four in 10 alcohol abusers and more than half of drug abusers also have at least one serious mental illness, according to published reports in the Journal of the American Medical Association.

Back in 2005, the federal government drafted Tip 42: Substance Use Treatment for Persons With Co-Occurring Disorders. It’s the “gold standard,” as Marquesano put it.

Scientific Faith

I was struck by just how much faith Marquesano places in the approach to revolutionize treatment and keep people healthy.

She’s certain Harris would still be here today if our system was built right. In her mind’s eye, he’d be ready to celebrate his 30^th birthday next April 8, the same day, almost magically, a total solar eclipse is set to cross North America.

“If people were using it as a system, young people like Harris would still be alive,” she stated without hesitation. “So the mission that I chose to kind of like take on was using Tip 42 as a guide and moving the entire system in New York State towards an integrated one. So obviously that’s a big lift.”

Those with any lingering 1980s-style sense that the solution to the crisis rests in criminalization and/or preaching “Just Say No” should take cues from Westchester County police spokesman Kieran O’Leary.

“You’re never going to arrest your way out of this problem,” O’Leary told me in a brief phone conversation last week. “But there have been quite a lot of police activity and seizures, particularly fentanyl, and I know there’s some pretty significant numbers there.”

As someone who personally applauds New York’s decision to legalize recreational use of marijuana, and keep it regulated and safe, it’s also important to understand the risks of how use can manifest itself today.

Earlier this year, in a highly-publicized case, nurses rushed to help a student at New Rochelle High School, using Narcan. The student had been vaping.

While the exact circumstances of that situation remain murky, with conflicting reports, marijuana laced with lethal fentanyl presents a persistent danger for those using illegal drugs.

Less than two months ago, the U.S. Food and Drug Administration made the long overdue decision to approve over-the-counter sales of Narcan, the nasal spray which reverses opioid overdoses. The delay in doing so was largely a byproduct of the stigma around the disease of addiction.

Local Legislating 

Meanwhile, a worthwhile bill from a local legislator would allow pharmacists to dispense testing kits to detect fentanyl, which is the cause of about 88 percent of all U.S. opioid overdose deaths. State Sen. Peter Harckham (D-Lewisboro), co-chair of the Joint Senate Task Force on Opioids, Addiction & Overdose Prevention, introduced a new version of the measure earlier this year.

The kits detect drugs like xylazine, too. The adulterant is contained in an increasing number of illicit drug mixtures, and xylazine has been detected in many recent overdose deaths.

Drug-involved overdose deaths, including illicit drugs and prescription opioids, reached an apex in 2021, amid the pandemic, with more than 106,000 people losing their lives to the crisis, according to the National Institute on Drug Abuse.

Even though an estimated 79,117 Americans died from drug overdoses between January and September of last year, which is less than the 81,155 people who died during the first nine months of 2021, that figure is 50 percent greater than pre-pandemic levels.

New York State measures opioid overdose deaths per 100,000 population. Westchester averaged 13.8 deaths per 100,000 population for any opioid overdose death while Putnam is listed at 18.2, data from 2020 shows. The statewide average is 21.5.

Ardsley’s Harris Marquesano, with his mother and the harris project founder Stephanie Marquesano, in their last photo together in August 2013, on their way to Florida, just two months before he died. They were traveling to a rehabilitation program that’s no longer in existence. The program failed to deliver much-needed mental health support.

---

Just Say Prevention 

While “Just Say No” was infused with an overly simplistic and faulty premise, prevention is a significant piece of the puzzle.

Marquesano noted how it’s critical to “educate and empower our young people as early as you can,” and mentioned how prevention constitutes her “happy space.”

“So if we don’t talk to them about pathways to substance use and the risks of experimentation and self-medication – and then things happen – we can’t wonder why we’re not breaking the cycles,” she said. “It’s about getting people navigated to resources earlier, identifying who you would talk to if you were concerned about yourself or a friend, like all of those kinds of things. Because we as a nation land in the place of overdose, suicide and alcohol-related death and we silo those causes of death and we don’t look at the common factors and the root causes.”

In Mount Kisco, there’s a Lexington Center for Recovery clinic. Lexington is a community-based substance use treatment organization. Last week I spoke to James Hughes, the program director.

He pointed out how it’s critical to understand the deeper reasons why people start to use.

“It does something positive for that person,” he told me in a phone interview last week. “Is it a healthy solution? Is it a healthy long-term support that’s going to help them through whatever that might be? No, but it does something. Unfortunately, the drug works a lot of times. It’s understanding why does a person use a substance?”

This observation from Hughes is linked to the mental health side of the co-occurring equation: Why do people use?

“We hear a plethora of reasons,” Hughes said. “It’s either because they’re having a hard time sleeping, they’re being bullied in school, they feel like it’s the only thing that helps them stay social. It’s the only thing that helps them get enough energy to complete their work. It’s because they maybe experienced a lot of trauma in their life. They’re going through depression, anxiety with ADHD. They’re just bored. There’s a lot of reasons why a person uses.”

As Hughes explained, “it’s doing something for them.”

“(The substances are) either in the moment stopping them feel the pain or stopping something, emotionally or physically,” he elaborated. “It’s stopping them feeling stressed. It’s helping them fall asleep. It’s helping them stay focused. It’s helping them now.”

In other words, any approach that neglects to address underlying issues is a recipe for failure.

And the Winner is…

As for the local impact of settlement money, a deadline for providers to answer requests for proposals from Westchester County is right around the corner on May 19.

Decisions on who gets awarded funding will be announced by about June 1, Community Mental Health Commissioner Michael Orth told me last week.

The county is seeking proposals for various services related to its Opioid Response and Overdose Prevention Initiative, including primary prevention, recovery, integrated co-occurring substance misuse and mental health treatment, as well as harm reduction services.

A Westchester Co-Occurring System of Care Committee had been established in 2017 to coordinate co-occurring strategies among various stakeholders, including county departments, behavioral health providers, school districts, advocacy organizations, peers and other human service organizations.

The Opioid Response and Overdose Prevention Initiative, convened in 2020 by County Executive George Latimer’s office, was designed to address the rise in opiate overdoses and deaths. The committee meets monthly to review effective prevention and harm reduction strategies, as well as best practices around training and access to addiction and mental health treatment services.

As optimistic as Orth appears to be about the effectiveness of evidence and science-driven models, he also acknowledges significant hurdles that complicate the equation.

“The biggest concern and challenge that we have is the availability and even some of the newer drugs that come out,” he explained in a phone interview last week. “So just when we think we’ve addressed fentanyl…there’s another drug that’s out on the street, and people don’t know what they’re taking. So that’s the concern just in terms of availability and just the substances that are being put out in our streets.”

In Westchester alone, Orth said, there are about 10 fatal overdoses a month, a staggering number to consider. (Many are in Yonkers, the county’s largest urban center, although no suburban corner of Westchester is spared.)

“I think what we’ve seen locally within Westchester County, it clearly has impacted a very broad population, including young people who either think they don’t have a sense of what actually is in some of the substances they’re using,” Orth said.

But if you think this crisis is just impacting young adults, think again.

“We’re surprised by the high rates of our seniors who are also self-medicating, and it may go undetected because of other medical issues,” said Orth, who works closely with Marquesano to develop ideas for reform. “It’s really reached our broader community and the data illustrates that.”

Reaching Consensus

Despite the depth of the crisis, with more than 200 Americans dying daily of overdoses, most experts generally agree on many key points – prevention works, addiction is treatable (not curable), relapse can be part of the process and evidence-based treatment is the key, given the strength of existing research, not programs based on gut and what “sounds good.”

As for the pandemic’s part in where the issue stands today, local officials are still combatting related fallout.

Just last month, the Putnam County Legislature voted to approve funding to aid the Putnam County Prevention Council, a substance prevention and education nonprofit.

“It’s no secret that prior to COVID, the opioid epidemic was the public health crisis of our lifetime,” Putnam County Executive Kevin Byrne said in a prepared statement at the time. “And the truth is, the pandemic only exacerbated the opioid crisis.”

There are multiple buckets of settlement cash, and while local counties haven’t yet dispersed any money, New York State has started to dole out some dollars.

The issue should keep reporters across the United States on their toes, with millions of dollars being distributed to communities as the result of litigation against opioid manufacturers, distributors and pharmacies. The potential for fraud, abuse and mismanagement is worth watching closely.

NY State of Mind

In New York, about 62.5 percent of the $1.33 billion in settlement money will be controlled by local government, with 20 percent in an abatement fund and the remaining 17.5 percent handled by state government.

New York Attorney General Letitia James has outlined guidelines for funding, citing appropriate uses, such as expanding availability of medication-assisted treatment, telehealth and training for health care providers, as well as providing access to recovery services such as housing, transportation and peer support.

The Mid‐Hudson region, our part of the state, was allotted more than $15 million from New York’s abatement fund.

Journalists will play a major role in helping to ensure government officials keep commitments of transparency, especially because there is currently no federal employee designated as an oversight coordinator.

Last week, I joined a Zoom meeting on the topic. It was coordinated by the New York Press Association and hosted by Jonathan JK Stoltman and Ashton Marra, co-directors of Reporting on Addiction, a nonprofit created to help media cover addiction and recovery in a responsible way.

They provided a brief history of the lawsuits and the subsequent settlements from which this money is being distributed.

“These are dollars that city, county and/or state policymakers will be charged with spending to mitigate the harms of the opioid epidemic in communities big and small,” the New York Press Association said in promoting the event. “But this story won’t come and go. Over the next 18 years, local journalists will be tasked with covering how the money is spent and holding their community leaders accountable for their choices.”

The Billion Dollar Question

The New York Opioid Settlement Fund is overseen by the state’s Office of Addiction Services and Support.

Money allotted to localities must aim to address and reduce the impact of addiction and opioid use disorder. State and localities are already starting to spend some settlement money, and no two states are approaching the issue the same exact way.

New York Gov. Kathy Hochul has announced some initiatives. For example, last month she noted how more than $5.8 million will go toward providers across New York State to establish comprehensive integrated outpatient treatment programs for addiction.

In the Mid-Hudson region, a Westchester County Health Care Corp & Health Alliance facility in Ulster County and a Lexington Center for Recovery’s Duchess location were both pegged to receive $374,000.

The amount of money available to each county in New York is calculated based on a formula using population, overdose death rates and mental health and equity indicators.

Profiting off Pain

In terms of the culpable companies that profited off pain, one way to think about the role they played, leading up to today’s moment, is to compare them to stereotypical drug dealers.

While we might conjure images of shadowy figures standing on street corners when we envision drug dealers, the most rapacious wore fancy suits and sat in boardrooms.

The legal drug makers, dealers and sellers all played their part, like the guy cooking the meth, the guy distributing the meth and the guy selling the meth, carrying the illegal drug sales analogy further.

Regarding the national opioid settlements, they hit manufacturers (Purdue Pharma, Mallinckrodt, Johnson & Johnson, AbbVie’s Allergan, Endo), distributors (McKesson, AmerisourceBergen, Cardinal Health) and pharmacies (CVS, Walgreens, Walmart).

In fact, this story is a fluid one. Just two months ago, the U.S. Department of Justice brought action against Rite Aid, accusing the company of violating the False Claims Act.

Put another way, much more settlement money could be coming down the pike.

Related questions moving forward will be more about how to spend money on the crisis, not whether sufficient funding is available.

‘He’s Always Going to Be 19’

Body count stats from the drug epidemic aren’t the only jaw-dropping numbers. An analysis released just this past September from Congress’s Joint Economic Committee found the opioid crisis cost the United States nearly $1.5 trillion in 2020 alone. Solving this immense problem, or even chipping away at it substantially, would be a profound economic boon.

As for Marquesano, she’s buoyed by the fact that Harris’s spirit resonates so deeply with the more than 100,000 students she’s addressed at assemblies and youth summits.

The 2012 Ardsley High School graduate’s story is a prevention tool.

Harris’s life-force was something special; some friends and family honored him forever with tattoos, like the jersey number seven he wore as an all-section soccer star.

“And he’s always going to be 19,” said Marquesano, referring to the age Harris was when he died, and the way young people see him at presentations. “The little kids love him. He was just a very relatable person, but really struggled profoundly.”

But, with the right approach, Harris’s life and the lives of hundreds of thousands of other Americans could have been spared.

Even though the settlement money can’t revive all the people lost to the crisis, it can be used to honor their memories.

The ghastly status quo is not at all inevitable.

Recovering from addiction is possible. For help, call the free and confidential treatment referral hotline, 1-800-662-HELP, or visit www.findtreatment.gov.