More than two decades since OxyContin and other prescription opioids were heavily marketed as safe and nonaddictive, a million people in the United States have died from opioid-related overdoses, according to the Centers for Disease Control and Prevention. Starting in 2017, state and local governments brought lawsuits against various pharmacies and pharmaceutical companies for misleading the public on the dangers of prescription opioids.
National settlements in these cases required about a dozen companies to pay out billions of dollars over the next two decades. These dollars started flowing in 2021 and are being distributed back to local governments to be used for opioid abatement services like training addiction counselors or distributing naloxone, a lifesaving overdose-reversal drug.
Opioid settlement funds were first distributed to the Spokane region in 2024. The city of Spokane expects to receive about $13.3 million over the next 17 years, and Spokane County expects to receive about $27 million over the same time.
Last week, both the city and county proposed their next slate of investments from these opioid settlement dollars. Many are joint investments to expand on existing, successful services, including sobering and withdrawal management at Spokane Treatment and Recovery Services, or STARS, and medication-assisted treatment at the Spokane Regional Health District.
"I think our citizens want and expect us to work together on some of these common challenges that we have because the opioid crisis does not respect city or county barriers or lines," says County Commissioner Chris Jordan. "It's affecting all of us."
But these advancements come at the same time that threats to cut Medicaid loom at the federal level. Cuts to the public insurance program for low-income people could make these services inaccessible for those who need it most.
VOLUNTARY VERSUS INVOLUNTARY
While some community leaders are calling on the city and county to force people addicted to fentanyl into treatment, the proposed investments are all for expansions to treat those voluntarily seeking substance use treatments.
For those who don't voluntarily seek treatment for addiction, Washington has a legal pathway for a judge to put someone in treatment involuntarily, which was created in 2018. But the bar to do so is very high.
"When we remove someone's rights, literally any right to care for themselves, or make decisions for their care and well-being, that's a heavy, heavy lift," says Justin Johnson, director of the Spokane County Community Services Department.
To put someone in involuntary treatment, designated crisis responders have to decide whether someone is an immediate risk to themselves or others. That immediate risk is legally termed a "grave disability."
"If you are psychotic and you currently have no ability to make a determination for yourself, because your symptomology is so severe — that would be grave disability," Johnson says. "If you are wanting to stay homeless and you have a behavioral condition, [like] major depressive disorder ... that's not a qualifying grave disability."
In other words, chronic homelessness or drug use itself isn't a legal pathway to involuntary treatment.
If someone does reach the criteria for involuntary treatment, they need to be taken to a secure withdrawal facility, that is, a place that can lock people in to ensure they stay for treatment. There are currently no secure withdrawal facilities in Eastern Washington.
"They usually take them to the hospital first, while they're assessed and they're given medical clearance," Johnson says. "They usually withdraw there at the hospital while they're waiting, because we have to call around the state to find a bed. Then, getting transportation is nigh impossible."
SPOKANE REGIONAL HEALTH DISTRICT
But for someone who decides to enter treatment for addiction, providers know it's important to get them in right away and to keep them in treatment by building trust and momentum. Getting turned away at the door, facing a delay in appointments or switching providers are all common ways to "lose people," Johnson says.
In a report to the Spokane regional health board a few months ago, the Opioid Treatment Program at the health district reported asking at least 20 people a month to come back later or schedule a later appointment because they weren't able to be seen that same day. The program offers services including methadone to manage withdrawal symptoms, plus on-site mental health counseling.
The treatment program's main shortage is staff. Specialists are needed to conduct extensive biophysical exams to determine someone's level of need, and licensed clinicians are needed to run specialized treatment.
Last Friday, Spokane Mayor Lisa Brown and City Council President Betsy Wilkerson proposed investing $350,000 of the city's opioid settlement dollars in medication-assisted treatment at the health district's treatment program, with the understanding that the county would match those dollars.
The matching investments would come close to the health district's estimation that it needs roughly $800,000 to expand its staff to meet the current demand from walk-ins as well as be a reliable drop-off location for police.
"If we increase that availability, then we would be able to have more individuals deflected at that early stage," Johnson says. "If you have to schedule an appointment, it could be another week or two out. We want to remove that and allow them to have that immediate service."
STARS
Last May, the county announced it would invest more than $5 million of its opioid settlement dollars to expand the Spokane Regional Crisis Stabilization Center by building a 23-hour crisis relief and sobering center. More space for people in crisis and withdrawal could help divert people away from jail and the emergency room. But that project is currently scheduled to be completed around spring 2027, at least two years from now.
To provide more immediate relief, Spokane County also partnered with the state Department of Commerce to help STARS buy the Cowley Street building it currently rents to provide withdrawal management, which should enhance the nonprofit's stability and free up immediate savings to reinvest in new services.
"As soon as we started leasing the building, it was my priority to one day purchase it," says Ryan Kent, executive director of STARS.
The county provided $775,000 as a 25% match to state funding. The purchase will most likely go through this May, Kent says.
The Cowley Street facility currently sees an average of 265 clients each month in both its sobering and withdrawal management services. Counselors also assess about 120 people every month to help those seeking treatment decide what level of care, program or facility works for them.
The city of Spokane is also proposing to invest $500,000 in STARS. With the new investments and a newly owned building, Kent says STARS will also be able to renovate the facility to include a new 16-bed inpatient treatment wing. A 30-day inpatient program is the only level of care STARS currently lacks, and the new beds could change that.
"If we do provide that, we would effectively be able to have everything in one building," Kent says. "People would be able to get a warm handoff from sobering to withdrawal management to a 30-day inpatient [program] to then the Karen's House or Cub House," which are residential treatment programs for women and men, respectively. STARS also coordinates intensive outpatient care for those who graduate from residential treatment.
The renovation will probably take a couple years, but it won't impact current operations.
Kent also hopes that STARS will be able to create a new, highly specialized medically managed withdrawal program, a tailored treatment plan the region now lacks.
Under medically managed withdrawal, nurses and licensed health care professionals can manage the pain of withdrawal symptoms with on-call care. Kent says other withdrawal management programs like methadone aren't required to be overseen by the same level of medical expertise.
The caveat is that the American Society of Addiction Medicine just released a new edition of its criteria for providing treatment, which is "kind of like the Bible for behavioral health treatment," Kent says.
The new edition is very different from previous versions and could spell chaos for providers. There's legislation awaiting approval by Congress to delay its implementation until 2027 or 2028, but until that is certain, Kent wants to be clear that STARS' plans are subject to change.
THE FUTURE
This is a moment of somewhat rare unity and cooperation between the city and the county, whose relationship has "ebbed and flowed" in the past, Jordan says.
"The ideas for this program have come primarily from staff," the commissioner says. "[Justin Johnson's] been having conversations with city staff who've got a lot of experience in this area, and it certainly originated from their wisdom in terms of the needs of the community."
In addition to the joint projects, the city has a few initiatives of its own. The mayor's proposal includes $139,000 for a dedicated project employee to track the performance of opioid settlement dollars, and $500,000 to research and launch culturally appropriate behavioral health treatments.
As the region expands opioid treatment services, one big threat looms large. Nearly everyone seeking addiction treatment relies on Medicaid, Johnson says.
But to finance President Donald Trump's plans for mass deportations, increased military spending, and cutting federal spending by at least $1.5 trillion and taxes by $4.5 trillion over the next decade, the House of Representatives just passed a plan to cut $880 billion from the health care and energy sectors over the next 10 years. Some in Congress don't believe this is possible without cuts to Medicaid.
"Any cuts [to Medicaid] will have downstream effects and will affect care and quality of care throughout the state," Johnson says. "Our long-term planning with these projects was not to do it alone or with one infusion of funds and be done with it. It was to look long term and weather different changes and patterns and funding."
Kent feels the threat more acutely.
"It's definitely something that has kept me awake at night quite often," he says.
If people aren't able to access the services STARS offers, they'll end up getting the help they need from other places, like emergency departments and first responders.
"You'd see a lot longer wait if the average person is having an emergency," Kent says. "The cost to the city and the county would increase significantly due to police officers, firefighters, AMR ambulances responding to a lot more calls — which equates to a lot more money, which equates to more taxes."
Commissioner Jordan says it's too early to tell how potential cuts to Medicaid would affect opioid treatments, but it's something he's tracking closely.
"Depending on how cuts are implemented, it could be a big deal," he says. "I think we are assuming when we set up this crisis stabilization center expansion that Medicaid dollars will help fund the ongoing operation of that facility, for example. I haven't seen a specific proposal that would threaten that, but we might get there, and I'm very concerned about it." ♦
