The woman on the phone had nowhere else to turn.
“My son’s going to be calling. I already lost two sons this year. Help him, because I can’t have all three of my sons dying in one year,” she pleaded with the addiction support centre in Buffalo, New York.
Andrew Sikorsky, the director of rehab facilitation at Save The Michaels, has taken his fair share of calls from the people hooked on opioids who have hit rock bottom, but this one hit particularly hard.
All three of the woman’s sons were heroin users in their 20s and 30s. Two lost their lives to the latest wave of the US opioid epidemic driven by highly potent fentanyl laced into heroin, cocaine and other drugs.
“That’s hard. I wanted to help her but I said: ‘We can’t speak to you about him. You have to have him call and we’ll help,’” said Sikorsky.
The first challenge was to get the young man to call. The second was to find him a place in a treatment program amid a surge in demand and growing frustration at what critics say is the slow pace of New York state’s allocation of hundreds of millions of dollars paid by the pharmaceutical industry as compensation for creating the worst drug epidemic in US history, while rehab centers and others cry out for money to provide more beds.
Prescription drug manufacturers and distributors agreed to pay the state more than $2bn to fund programs to counter the opioid crisis, which has claimed more than 750,000 lives over the past two decades. The money is New York’s share of nationwide settlements worth more than $55bn from 14 major pharmaceutical firms.
Robert Kent, a former general counsel for the New York state body responsible for distributing the funds, the Office of Addiction Services and Supports (Oasas), said that it received about $200m from the opioid settlements in the last financial year but little of it has reached organisations at the frontlines of the epidemic.
“Urgency is everything. Get the money out the door. There’s an immense amount of need and the numbers aren’t going in the right direction. People are dying,” said Kent, who went on to serve in the Biden administration’s White House office of National Drug Control Policy for two years.
“I know from my work in the White House that the drugs are incredibly lethal. They’re not going to get less lethal. In the budget year 2022 to 2023 there was over $200m that came to the state and none of it ended up being spent. They had to reappropriate that money in the budget that was adopted this year and add another couple of hundred million for this year.”
From the beginning, local governments and groups campaigning for compensation, mostly run by Americans who lost relatives to opioids, insisted on binding guarantees that the money would go to combat addiction. They had one eye on the 1998 tobacco settlement which saw cigarette manufacturers pay US states $246bn for the health care costs of treating smokers. State governments diverted the money to pay for schools, build roads and fill gaps in their budgets.
In response, the New York legislature created an opioid settlement fund advisory board to oversee the distribution of the funds and to ensure they were used to supplement, not replace, existing spending.
Avi Israel, founder of Save The Michaels, was appointed to the board. He rapidly became frustrated by the slow pace of action he blames on New York’s governor, Kathy Hochul, for failing to convene the board for months and then Oasas for tying distribution up in bureaucracy. He said the delays are costing lives because people seeking treatment are liable to change their minds if they are asked to wait.
Save The Michaels is named after Israel’s son, who was prescribed the opioid hydrocodone to treat Crohn’s disease. Michael required ever larger doses of the drug to keep the pain at bay and became addicted.
Israel said his son sought help from a treatment centre but it could not find him a bed. Michael shot himself and died in his father’s arms in 2010. He was 20 years old.
“When Michael called for help, and asked for a bed to go into inpatient treatment, it took his counsellor 5min and 47sec to come back and say there’s no bed. And then he took his life. So our people all know that it takes 5min and 47sec to make a difference between life and death,” said Israel.
“If you can convince a person to go right there and then when they’re ready, they’ll go. If you ask them to wait, you don’t know what will happen. As this demand is escalating, the state is not stepping up. Where is the access to treatment that needs to be available?”
Save the Michaels has taken on more than 1,000 cases of people seeking treatment this year and placed about 800 of them in beds. But Sikorsky said more than 150 of those dropped out before they were admitted.
“Sometimes they call and they’re coming off the drugs. But in the meantime, while we find them a bed, they find more drugs and they’re happy again and go: ‘I don’t need treatment,’” he said.
Sikorsky was able to find a bed for the man whose mother called. But Israel said his organisation has seen a surge in demand that he attributes to the rising toll of fentanyl laced into much of the drug supply, although there has also been a rise in the number of people addicted to alcohol seeking treatment.
“We’ve never had a waiting list at Save the Michaels. Now we do. It tells you people are scared. They want to go into treatment. There are very few beds available in the state outside of New York city. Thank God that there’s [a] couple of places in Pennsylvania that will take people, so we’re sending people to Pennsylvania,” he said.
The oversight board issued recommendations as to how the settlement money should be allocated. It assigned 22% of funds to harm reduction such as distributing fentanyl test strips and naloxone, which can rapid reverse an opioid overdose. Lesser amounts were committed to treatment, housing and recovery programmes.
Anne Constantino, a member of the advisory oversight board who ran one of the largest addiction services providers in western New York, said Oasas misinterpreted the larger amount allocated to harm reduction as an instruction to prioritise it over other areas, particularly treatment, when the intent was for a holistic approach because there is an urgent need in all areas.
She said there is a particular need for funds to retain trained staff at addiction centres.
“Every organisation is struggling with workforce issues. There are not enough trained therapists. There is a high turnover rate because the work is so difficult. It takes time and money to recruit, train and develop a workforce that’s able to do good work. It’s really the foundation for the system and it needs to be a priority,” she said.
“One of the reasons why I wanted to be on this board is I don’t want short-term solutions or finger in the dike solutions. I want long-term, systemic change that we have an opportunity here to do. I feel like we’re missing that opportunity.”
Constantino said the allocation of funds has also been held up up by a bureaucratic application process that will cost lives by creating needless delay.
“The contracting process is a difficult, certainly for smaller organisations which may not be familiar with all the hoops that you have to jump through. I think that certainly leads to delays in money flowing,” she said.
Israel said the focus on harm reduction meant that treatment and support services for those who have been through rehab, such as accommodation and jobs to keep them away from being drawn back into drug use, are being neglected.
“I hate to say it, but there’s really no compassion and understanding at Oasas as to what goes on a day-to-day basis in the field. I just don’t think that the focus of Oasas is on treatment and after treatment care. There’s really not much that’s being done on prevention. They’ll provide the needle exchange and test strips and all of that stuff. But where is the access to treatment that needs to be available?” he asked.
Israel is unusual in being prepared to challenge Oasas publicly. Other providers say they are concerned that public criticism will cost them grants, but those who spoke privately paint a picture of repeated delays that have limited their work and the number of people they are able to assist.
Officials at Oasas are stung by the criticisms, saying that their hands are tied by the legal processes. The organisation said oversight board was convened as soon as all of its members were appointed in mid-2022, and that Oasas was obliged to wait until the board issued its spending recommendations last November before it could begin allocating funds.
In a statement, Oasas said it then began dispersing funds within weeks. It said that state law requires that all contracts be submitted for approval through the attorney general and state comptroller’s review processes.
“This affects the timing of when funding can be paid to awarded entities, as they must have an approved and executed contract,” it said.
“New York state received $192.8m from the settlement funds in fiscal year 2022 to 2023. This entire amount has been made available.”
However, officials acknowledge that the bulk of the funds have yet to reach organisations on the frontline of the addiction crisis. The oversight board is scheduled to issue a new set of recommendations next month, which Oasas officials say should clarify differences about spending priorities.
