After a few years, medical associations revise their guidelines, warning that the drug in question should be avoided or at least prescribed more selectively. It might be added to the Beers Criteria, an influential list of potentially inappropriate medications for older patients, published by the American Geriatrics Society.

If the drug’s role is preventive, the U.S. Preventive Services Task Force, an independent expert panel, may weigh in with cautions. The FDA may issue “black box” warnings about concerning side effects.

After a few more years, researchers look at broad national data to see whether use of this drug declined. Often, the answer is: Yes, but not enough. Sometimes, though, use didn’t decline much at all or actually increased.

“Medications are like barnacles,” said Michael Steinman, a geriatrician at the University of California-San Francisco and co-director of the . “They’re easy to start, but they can be hard to stop.”

This medical inertia partly reflects the time lag involved in disseminating findings. “Clinicians have a million things they need to know and attend to, and information may take a while to get to them,” Steinman said.

But it also reflects the way “clinicians and patients get used to treating conditions in certain ways,” he said. “They become ingrained habits.” Finding alternative approaches is challenging, so “it’s easy to go with what you know.”

Recent studies of three medications or classes of drugs widely used among older Americans illustrate the problem.

The Drawbacks of Benzodiazepines

Scientists began about benzodiazepines more than 20 years ago. Prescribed for insomnia and anxiety, “they offer prompt relief,” said Mark Olfson, a psychiatrist and epidemiologist at Columbia University.

? Benzodiazepines (including Valium, Xanax, and Ativan) and the related “Z” drugs (Ambien, Lunesta) “may impair balance, coordination, and cognition that can translate into falls and fractures and motor vehicle accidents,” Olfson said. In patients also taking opioids for pain, benzodiazepines can cause overdoses.

Moreover, “once you’ve taken them for a period of time, you develop a dependence,” Olfson added. “When you come off them, you may develop withdrawal symptoms.”

So what’s happened to , who are more sensitive to these effects? In a , published in the Annals of Internal Medicine, Olfson and his team reported progress. Among people 65 and older, the rate of patients filling prescriptions for benzos dropped to 11.5% in 2024, from about 14% in 2015.

But that decline has stalled since 2020, perhaps related to the covid-19 pandemic. Moreover, prescribed use actually rose among those over 75, from 12% in 2020 to about 13% four years later. Dispensing through pharmacies in long-term care facilities more than doubled. And about a third of users were taking the drug for longer than six months, increasing the likelihood of dependence. “It’s worrisome,” Olfson said.

But he cautioned that patients shouldn’t stop benzodiazepines suddenly or on their own, which can provoke withdrawal. “It requires supervised tapering” with a medical professional, he said. “It takes many weeks.”

Overprescribing Antibiotics

For years, the standard treatment for diverticulitis, the inflammation or infection of small pouches that form in the colon, was antibiotics, primarily fluoroquinolones (like Cipro and Levaquin) or amoxicillin-clavulanate (Augmentin).

“It was unquestioned,” said Jesse Sutton, a pharmacist and researcher at the Minneapolis Veterans Affairs healthcare system. “Antibiotics are safe and effective, great, lifesaving drugs, so the mindset was: When in doubt, use them.”

But in 2015, the against routinely prescribing antibiotics for “uncomplicated” diverticulitis, which represents a great majority of cases. Other .

Clinical trials had shown that, for this condition, antibiotics on mortality, the need for surgery, complications, or recurrences. “They hadn’t improved anything,” Sutton said.

And as with any drug, “, unintended consequences,” he said. “Side effects from antibiotics account for a ” for symptoms like nausea, vomiting, and diarrhea. Antibiotics heighten the risk of the virulent C. difficile infection, too.

Plus, “the more you use antibiotics, the less they work in the future,” Sutton said. The World Health Organization has “a major global health threat.”

So Sutton and his colleagues, studying treatment in 70,000 visits to 120 VA facilities, expected to see antibiotic use for uncomplicated diverticulitis decline over 10 years.

Instead, they in the Annals of Internal Medicine that antibiotic prescriptions remained nearly universal at 97% of visits, guidelines or no guidelines. The patients would most likely have done as well with a few days of Tylenol and a clear liquid diet.

for other conditions of later life, too, including the kind of that cause no troublesome symptoms and upper respiratory infections that are typically viral, not bacterial.

In such cases, when a doctor prescribes an antibiotic, “I’d encourage patients to say, ‘Please explain the rationale for doing this,’” Sutton said. “If they don’t, it’s OK to press pause.”

When Aspirin Isn’t the Answer

Aspirin is different. Because it’s cheap and sold over the counter, anybody can start taking it on their own — and , thinking it will help prevent cardiac problems.

For people who’ve already had a heart attack, stroke, or cardiac intervention like a stent or bypass surgery, daily low-dose aspirin for “secondary prevention” does lower the odds of another event, studies have demonstrated.

But for “primary prevention” in people who haven’t had one, the guidelines changed in 2019, when the American College of Cardiology and the American Heart Association for this purpose in those 70 or older. The , warning against aspirin for primary prevention starting at age 60.

Large clinical trials had shown scant benefit for aspirin as a primary prevention measure, but there were harms, notably gastrointestinal bleeding. “As we age, the risks of bleeding go up,” said Timothy Anderson, an internist at the University of Pittsburgh who co-directs its Prescribing Wisely Lab. More rarely, but more seriously, aspirin can cause bleeding in the brain.

In a published last year, Anderson and his co-author found the message was getting through: Aspirin use for primary prevention, as reported in the National Health and Nutrition Examination Survey, had dropped substantially from 2011 to 2023. But more than a third of those 70 or older were still taking it.

Some caveats: A subgroup of older adults with high risk factors for cardiovascular disease may benefit from aspirin for primary prevention. And, confusingly, some evidence suggests that older patients already taking aspirin face a higher risk of cardiovascular disease .

“Step 1 is a conversation with your primary care physician” about aspirin, Anderson said. “‘Is this still right for me as I get older?’”

Older patients taking aspirin, , “are interested in reducing their risk of heart attack and stroke,” he said. “They’re trying to be proactive and healthy.” But with blood pressure medications and statins for cholesterol, “we have better strategies than aspirin for that.”

The New Old Age is produced through a partnership with .

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

“Are you the person who’s going to bring my mom back?” she asked.

Gómez struggled to find an answer. It was a December morning, and she’d brought food, diapers, baby wipes, and clothes — items she hoped would help the 6-year-old girl, her baby brother, and the neighbor who had stepped in to care for them. The children were left alone after federal immigration agents arrested their parents outside their apartment in Oxnard, a mostly Latino agricultural community on the Southern California coast. But Gómez had no power to bring the parents back.

“We’re working on that,” Gómez recalled telling the girl. In reality, she was at a loss for how to answer truthfully without upsetting her.

As a project manager for a nonprofit that provides food assistance to immigrant families affected by Immigration and Customs Enforcement raids, Gómez has witnessed the tumult and pain that have roiled the lives of since President Donald Trump returned to office, with devastating consequences for children’s health. They include an estimated with at least one parent detained by immigration authorities through April, a number that has undoubtedly climbed since. Separation from parents harms children psychologically. It destabilizes families, often leaving the remaining parent or caregiver scrambling to stay housed, buy food, and fulfill kids’ medical needs. Some kids are to care for themselves.

Many kids whose parents aren’t detained are experiencing threats to their health and well-being too. Two children in the South in February 2025 after reportedly being bullied over their family’s alleged immigration status.

Millions of children live in families losing access to , , , and other supports as roll back eligibility for immigrants with and without legal status. Fear of federal enforcement has pushed parents to avoid , going to the doctor, and . Some have disenrolled from or avoided signing kids up for health and nutrition programs.

Children from immigrant backgrounds are also . They’re experiencing more , increased , and anxiety about , even when they or their family members are citizens or legal residents.

Most of these children are American citizens. About have an immigrant parent, including around 4.6 million with a parent who lacks legal status.

“I’m really concerned about how long it’s going to take for us as a country to address all of the harm that’s happening to this generation of kids,” said Wendy Cervantes, director of immigration and immigrant families at the . “This type of stress can have long-term developmental harm and can really inhibit their ability to do well in school, to have good health outcomes, and to grow into thriving, stable adults.”

Curbing Public Benefits

Trump has made cracking down on immigrants — including the children of immigrants — a priority since his second term began last year. On Inauguration Day, he issued an purporting to end birthright citizenship for kids born to parents without legal status or in the country on temporary visas, an attempt ultimately blocked by the Supreme Court.

His administration, with the approval of Republicans in Congress, has into immigration enforcement, detaining the parents of an estimated 145,000 U.S. citizen children as of April, and, according to an analysis by nonprofit newsroom The Marshall Project, . It’s sought to rescind , or TPS, for over 1 million immigrants, tens of thousands of whom have U.S. citizen children, and in the Deferred Action for Childhood Arrivals program, which includes the parents of about .

White House officials say the immigration crackdown by freeing up resources such as jobs and housing, reducing pressure on public coffers, expelling criminals, and restoring integrity to the immigration system. (Studies have shown that mass deportations .) Trump and other Republican leaders have argued that birthright citizenship and “,” and that TPS has allowed immigrants from “” to remain in the United States indefinitely under what is supposed to be a temporary program.

In a statement, White House spokesperson Lauren Bis did not directly address whether the administration is concerned about long-term harm to children and increased healthcare costs because of its immigration policies. Instead, she repeated past White House criticisms that President Joe Biden’s immigration policies allowed children to be trafficked across the U.S. border.

“The real story is the psychiatric impact on the tens of thousands of children who were smuggled across the border — many by human and sex traffickers,” she wrote in an email.

Only 39% of Americans approve of Trump’s handling of immigration, according to a recent Associated Press-NORC Center for Public Affairs Research poll.

Stephen Miller, the chief architect of Trump’s immigration policies, has accused the children of immigrants of draining public resources and perpetuating problems from their parents’ home countries. Research, however, shows that immigrants and the longer they live in the United States and that they and their children . Data also shows they than native-born Americans.

“This is the great lie of mass migration,” on the social platform X in November. “You are not just importing individuals. You are importing societies. No magic transformation occurs when failed states cross borders. At scale, migrants and their descendants recreate the conditions, and terrors, of their broken homelands.”

The Republican tax-and-spending law enacted last summer curbs immigrant eligibility for health and food assistance programs. And this July, the administration issued new “public charge” rules that give immigration officers broad discretion to deny green cards to lawfully present immigrants if they or family members have used public benefit programs, a move that could result in U.S. citizen children disenrolling from safety net healthcare programs.

Together but Afraid

Separation from parents is and can lead to , including anxiety, depression, cardiovascular disease, and learning difficulties. Children separated from their parents at the border during the first Trump administration were found to exhibit . Researchers have also tied deportations and detentions of immigrant parents — as well as the threat of them — to widespread , higher , , among both immigrant and U.S.-born children.

It’s also costly to society. A by federal researchers estimated that health conditions related to childhood trauma accounted for $292 billion in healthcare spending in 2021 alone, including by taxpayer-funded programs such as Medicaid and Medicare.

Emmanuel, a 13-year-old in Oxnard, gets anxious every time his dad goes to work as a farm laborer, his mother, Ana, said. He asks her for reassurance that his father will return, and about what would happen to him if his parents got detained. He tries to hurry Ana up when they’re out in public, worried that ICE could suddenly appear. Ñî¹óåú´«Ã½Ò•îl Health News is not using their full names because they fear deportation.

Doctors and therapists interviewed by Ñî¹óåú´«Ã½Ò•îl Health News said they have observed a notable increase in mental health problems, especially anxiety, in children from immigrant families. Kimberly McNally, a pediatrician at Venice Family Clinic’s Inglewood South La Brea Health Center, said she’s regularly referring children of all ages for mental health services related to fears that their parents will be taken away. At daycares, kids have been showing up with an extra bag in case their parents don’t pick them up, said Liza Davis, advocacy director for Children in Immigrant Families at The Children’s Partnership, which works with a coalition of early childhood educators.

Sometimes, the distress leads young people to take extreme actions. In June, 19-year-old Eliel José after his father was deported from the Atlanta area to Mexico, according to Univision.

Rosie Harrison, executive director of Grow Initiative GA, a community organization that serves low-income families, said she’s received calls over the past year from immigrant parents seeking help for suicidal and depressed kids. Their situations are often made worse because many lack health insurance and can’t afford to pay for therapy. That’s often because parents have lost jobs that came with health insurance due to worksite raids or because of eligibility changes imposed by the Trump administration.

“I’m concerned about the families that are going to be burying their child,” Harrison said. “I’m concerned that we are going to miss out on having an amazing person do amazing things for our community, for our country, because they took their life.”

Strength Under Pressure

Many children are showing resilience, though.

In a role reversal, some children have become their parents’ protectors. They go grocery shopping and take their younger siblings to school so that their parents don’t have to leave the house.

Giselle Gonzalez, a university student and volunteer with the immigrant protection network VC Defensa in Ventura County, California, said she’ll never forget the morning last summer when she woke up to the sound of kids on bicycles pedaling through her immigrant-heavy neighborhood in Thousand Oaks, yelling “La migra! La migra! Don’t come out!” They’d spotted ICE agents grabbing factory workers and gardeners on their way to work, she said.

Neighbors, community groups, health providers, and others have also in a to support children and families affected by immigration enforcement. They , provide , , and help parents create in case they get detained or deported.

Ultimately, more humane immigration policies and enforcement tactics will be required to end the harm being done to children, academic experts and advocates said.

Researchers at point to a pilot called the as a model for keeping families together while also enforcing immigration laws. Launched in January 2016 under President Barack Obama, the program allowed families seeking asylum to remain in the community while awaiting resolution of their cases. Through a case manager, they received support in meeting the obligations of their immigration cases and preparing for deportation if needed. The program, which and cost-effective, was terminated by the first Trump administration.

At Venice Family Clinic in Los Angeles, case manager Mabel Alavez sees the pressures facing families who are still together but worried they could be separated. Many of the people are parents or grandparents who have been in the U.S. for decades. Some are afraid to take their children to school, the park, or the beach. They ask whether it’s safe to enroll their U.S.-born kids in Medicaid. She helps families who are facing eviction because they’re afraid to go to work and can no longer afford rent. She often helps them create plans for who will look after their children if they get detained.

Raised in an immigrant family herself, Alavez knows how challenging it can be for kids who are first-generation Americans to navigate growing up, going to school, and finding a sense of belonging in a country their parents aren’t from.

“It’s hard for me to imagine how they could possibly do that in addition to what’s going on now,” she said. “I do feel like there will be a big impact on them. What that might look like, I’m not exactly sure.”

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

Ñî¹óåú´«Ã½Ò•îl Health News senior correspondent Aneri Pattani discussed Louisiana sheriffs’ spending of opioid settlement payouts on Attitude With Arnie Arnesen on Sept. 1. Pattani also discussed addressing loneliness and isolation as part of suicide prevention on Good Faith Media’s Our Stigma on Aug. 31.

• , starting at 5:45.
• , starting at 3:50.
• Read Pattani’s “A State Gave Sheriffs 20% of Its Opioid Settlement Cash. We Followed the Money.”
• Read Pattani’s “Trivia Nights, Valentine’s Cards: Overlooked Social Connections Can Prevent Suicide.”

Ñî¹óåú´«Ã½Ò•îl Health News senior correspondent Renuka Rayasam discussed primary care shortages on PBS News’ Horizons on Aug. 28.

• .

Ñî¹óåú´«Ã½Ò•îl Health News Florida correspondent Daniel Chang discussed how gun violence affects Florida’s children on Fox 13 Tampa Bay on Aug. 26.

• .
• Read Chang’s reporting in “Where Florida’s Gun Violence Exacts Its Biggest Toll on Black and Latino Children.”

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

Then, last October, Wood took a fall, broke her neck, and spent three months in rehabilitation. When she returned to the house she shares with her niece, she couldn’t walk without assistance. “I still don’t dare go up and down stairs unless someone is with me,” said Wood, 93.

That has redefined their neighborly relationship. Straight, 53, a retired chef, now visits weekly, bringing lattes and cookies, and often leftovers from dinners she has made. Her husband installed a grab bar in Wood’s bathroom, put up shelves, and changed her light bulbs and smoke detector batteries. The texts fly back and forth.

Straight calls to say I’m going to the grocery store. Do you need anything? Wood, who no longer drives, provides a shopping list.

“She is a gift from heaven,” said Wood, a retired insurance executive. “We talk and talk. Sometimes we shed a few tears, but mostly we laugh. I never thought I’d have a new best friend at this time of my life.”

Eldercare, typically considered a family obligation, is evolving to adapt to demographic shifts that make reliance on spouses and children less assured.

“The number of older adults who have never married or are divorced has been increasing, so we have more people aging alone,” said Deborah Carr, a sociologist at Boston University who has investigated these trends.

“The proportion who are childless, by choice or not, is also growing,” she added, and families with children have fewer of them than in past generations.

Geographic distances or also fuel the need for other kinds of caregivers — roles that friends or neighbors can fill.

How commonly do friends step into caregiving gaps? A recently published study in JAMA Network Open, led by researchers at the University of Michigan, looked into , usually in supplementary roles.

They used data from the National Health and Aging Trends Study, in which more than 2,600 older people with health limitations (average age: 79) identified friends and family members who provided help. Family members were most likely to care for aging relatives, but about 14% of participants identified friends (including neighbors) in that role. That represents 2.4 million caregiving friends nationally, the authors estimated.

Last year, a by AARP and the National Alliance for Caregiving put the proportion of caregivers supporting nonrelatives at 11%.

“Friends are among the auxiliary caregivers who have not been acknowledged,” said Karen Fingerman, a gerontologist at the University of Texas-Austin and co-author of a the study. “We neglect the sacrifices they make.”

The study, believed to be the first nationwide look at caregiving friends, found they functioned differently from relatives. They’re unlikely to live with the person they’re helping, for example, and rarely serve as the sole caregiver.

“They provide fewer care hours,” said Yee To Ng, a gerontologist and lead author of the study, which found that friends supplied 18 hours of help a month on average, compared with about 67 hours from family.

They assist in different ways, too. “Friends are more likely to provide transportation,” Ng said. Two-thirds of caregiving friends drive their friends around; shopping, helping people go outside, preparing meals, and accompanying patients to medical appointments round out the top five tasks.

Sometimes they do more. Czes Ferrino, 82, is widowed and lives alone in Westerly, Rhode Island. She has no disabling health problems, but when her car died recently, her next-door neighbor went with her to several Subaru dealers to find a used replacement. “He walked me through it like a son would for a mother or grandmother,” Ferrino said.

On the other hand, “there are some tasks friends might not be well equipped to provide or be comfortable with,” Ng said. Personal care, like bathing and dressing, remains largely the province of family members.

“Those can infringe on people’s self-esteem,” Ng said. “With family, we accept that when you’re really ill, they step up with intimate activities. It’s embarrassing to have your friends help you use the toilet.”

The researchers also found that respondents who named friends as caregivers were younger than those with only relatives in that role, and more apt to have college degrees. People with higher education levels have larger social networks, Fingerman said.

Those assisted by friends were also, unsurprisingly, less likely to be married and more apt to live alone — like Ann Greenwater, 84, who lives in a mobile home park in rural Humboldt County, California.

She managed independently until a few years ago, when severe back pain rendered her bedridden for nearly three months. Although she’s up and about now and can handle housekeeping, cooking, and personal care, “I’ve never really fully recovered,” Greenwater said.

She is single, with no family beyond a distant nephew she barely knows, and has stopped driving. But a cadre of friends she knows from a nearby Zen Buddhist center stepped in.

Milli Quam, 86, does her laundry and drops it off, sometimes picking up prescriptions en route. A 73-year-old helped Greenwater with her computer and, along with several others, takes her grocery shopping or shops for her. Members of a local volunteer organization drive her to medical appointments.

“I love Ann, and I’m happy there’s something concrete I can do,” Quam said. “I hope I can keep doing it for a long time.”

Friends have some advantages as caregivers. “Our friends are our own age and understand what we’re going through,” Carr said. “They may have more empathy and sometimes real knowledge they’ve acquired.” When family caregivers are on the job, friends’ efforts can reduce their burden.

But nonrelatives may also prove less stable as a source of help. Neighbors move. Strains can develop if the person needing care becomes too demanding or feels guilty about accepting help, challenging the egalitarian expectations for friendships. These in those with physical limitations, a study led by Carr found.

Nor is there much policy support for these caregiving relationships. The federal Family and Medical Leave Act, for instance, “with rare exceptions does not provide job-protected leave from work to care for a friend with a serious health condition,” Laura Lawless, a labor and employment lawyer with Squire Patton Boggs, said in an email.

“For family, ‘through thick and thin’ is the expectation,” Carr said. “There’s huge stigma to being estranged from your family, but it’s kind of normal for some friendships to just fall away.”

In Sausalito, Wood tells Straight that “she’s not allowed to move until I die.” She’s joking, sort of.

Greenwater’s friends in Humboldt County, to her gratitude, have not fallen away either. But they are aging along with her; at 86, Quam pointed out, she may stop driving before long, too.

“I’m wondering what will happen when these friends aren’t able to come to me,” Greenwater said. “I guess we’ll deal with it when it comes.”

The New Old Age is produced through a partnership with .

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

Julie Rovner Ñî¹óåú´«Ã½Ò•îl Health News Read Julie's stories. Julie Rovner is chief Washington correspondent and host of Ñî¹óåú´«Ã½Ò•îl Health News’ weekly health policy news podcast, "What the Health?" A noted expert on health policy issues, Julie is the author of the critically praised reference book "Health Care Politics and Policy A to Z," now in its third edition.

Summer may be approaching its end, but the health policy stories that have marked the season continue. In Washington and across the country, public health officials are still struggling with outbreaks of vaccine-preventable diseases such as measles, while states and health systems are preparing for the impact of major federal funding cuts to their Medicaid programs.

This week’s panelists are Julie Rovner of Ñî¹óåú´«Ã½Ò•îl Health News, Shefali Luthra of The 19th, Rachel Roubein of The Washington Post, and Margot Sanger-Katz of The New York Times.

Panelists

Shefali Luthra The 19th

Rachel Roubein The Washington Post

Margot Sanger-Katz The New York Times

Among the takeaways from this week’s episode:

• More Americans are struggling to afford health coverage, even before some of the biggest GOP-initiated changes to Medicaid and Affordable Care Act plans take effect next year. And the federal government’s efforts to block coverage of drugs used in gender-affirming care and to claw back ACA subsidies are creating access issues for a wider pool of Americans.
• Pennsylvania health officials this week reported two measles-related deaths amid an ongoing outbreak and the national debate over vaccines. While many of the actions taken by the U.S. Department of Health and Human Services under Robert F. Kennedy Jr. remain held up in litigation, President Donald Trump has made his personal skepticism about vaccines known, including through his recent executive order. Meanwhile, the administration is scaling back enforcement of civil rights protections for people with autism.
• The Trump administration is inviting states to participate in price negotiations with manufacturers over GLP-1 drugs if the states opt to offer the drugs through their Medicaid programs. But, amid concerns over cost, only one state has taken the federal government up on its offer.
• And farewell to Dolly Parton, the superstar country music singer and songwriter, also known for her philanthropic work, who died this week at age 80. In addition to her donation in 2020 supporting the development of the mRNA-based covid vaccine, Parton funded pediatric infectious disease research, a women’s health center in the Tennessee county where she was raised, and training for pediatric medical professionals.

Also this week, Rovner interviews Dean Rosen about his work for former Sen. Nancy Landon Kassebaum, a Kansas Republican and the first woman to lead a major Senate committee, who died last week at age 94.

Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too: 

Julie Rovner: The Washington Post’s “,” by Tamar Haspel.  

Margot Sanger-Katz: Stat’s “,” by Anil Oza.  

Rachel Roubein: The New York Times’ “,” by Noah Daly and Andrew Jacobs.  

Shefali Luthra: The Washington Post and Ñî¹óåú´«Ã½Ò•îl Health News’ “,” by LJ Dawson.

Also mentioned in this week’s podcast:

• Stat’s “,” by Daniel Payne.
• Modern Healthcare’s “,” by Nona Tepper.
• Stat’s “,” by John Wilkerson.
• The Washington Post’s “,” by Naema Ahmed, Lena H. Sun and Aaron Steckelberg.
• CIDRAP’s “,” by Meghan Holohan.
• Stat’s “,” by Elizabeth Cooney.
• Politico’s “,” by Kelly Hooper.
• Ñî¹óåú´«Ã½Ò•îl Health News’ “Trump Puts Autistic Kids in the Spotlight and Cuts Agencies Built To Protect Them,” by Claire Sibonney.

Credits

Click here to find all our podcasts.

And subscribe to “What the Health? From Ñî¹óåú´«Ã½Ò•îl Health News” on , , , , , or wherever you listen to podcasts.

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

Ñî¹óåú´«Ã½Ò•îl Health News worked with three Louisiana news outlets — , , and — to ask all 64 sheriffs in the state how they’ve spent their opioid settlement funds. The responses were shared and presented in a data table for all four newsrooms to use. Reporters then conducted individual reporting for separate articles.

Every state is from companies accused of flooding the nation with prescription painkillers and fueling overdose deaths. But only one state is directing 20% of those payouts to sheriffs — the largest carve-out for law enforcement nationwide.

In Louisiana, sheriffs are elected, do not serve at the pleasure of another local official, and have independent budgets. They’re also not required to proactively report to the public or another authority how they spend billions in opioid settlement cash.

Short of filing public records requests or waiting for official audits, that has made it difficult for the average person to track the windfall. Many consider the dollars to be “blood money” and believe the spirit of the settlements is to spend it all on abating the addiction crisis.

Ñî¹óåú´«Ã½Ò•îl Health News worked with three Louisiana news outlets — , , and — to track those dollars. The newsrooms contacted all 64 Louisiana sheriffs over five months, often filing public records requests, to produce the first detailed accounting of millions spent.

The findings include:

• Thirty-eight sheriffs reported spending more than $8.1 million total. Much of it went to crime-fighting equipment, such as surveillance cameras and drug detection products, though smaller amounts funded mobile apps, addiction treatment in jails, and educational programs for youth.
• $5.4 million, about 66% of reported spending, was deemed inappropriate by a three-person review panel. The panel, assembled by Ñî¹óåú´«Ã½Ò•îl Health News and its partners, included a Louisiana resident in recovery who lost his son to a fentanyl overdose, an addiction medicine doctor, and a public health policy analyst who has been tracking settlement dollars since 2022. They judged the expenditures using their professional and personal expertise. Expenditures the panel disapproved of included salaries and overtime pay for homicide detectives and officers conducting jail shakedowns to find contraband.
• $4.7 million, nearly 60% of reported spending, went to items or services that other states say should not be purchased with opioid cash. Six states have , such as technology to extract data from cellphones and automated external defibrillators, which are . Although Louisiana does not have its own “unallowable” list, the state’s — a five-member body that advises sheriffs and parishes but does not control the money — said it has shared the guidance from other states.
• Nine sheriffs stood out for promising uses: All of their expenditures, totaling nearly $1.8 million, were deemed appropriate by the review panel and allowable in other states. These included providing addiction treatment in jail, training officers to respond to overdoses, and increasing public awareness of addiction resources.
• Twenty sheriffs did not provide their expenditures, leaving roughly $10.7 million that hidden from public view. The Jefferson Parish Sheriff’s Office, which covers an area just outside New Orleans and was allotted the highest amount — nearly $4 million through 2025 — did not respond to more than a dozen calls and emails.

Nationwide, debates over law enforcement’s role with opioid settlement money have been underway since the funds began flowing significantly in 2022 and have continued as the pool of money has grown. Purdue Pharma, , finalized its this year, and various settlements are set to pay out for an additional decade-plus.

Since the earliest days, these dollars have been viewed across government agencies and the private sector as a pot of gold for which many are vying.

Law enforcement agencies are part of this scrum. They say seizing drugs and arresting dealers save lives, but that costs money and the addiction crisis has burdened their budgets. However, many recovery advocates staunchly oppose any opioid cash flowing to what they see as the .

Since there are few guardrails on how the money is spent, decisions often come down to how local politicians and residents see addiction and what type of approach they believe will be effective in combating it.

Louisiana provides a natural experiment to see which priorities prevail when money is handed directly to sheriffs.

First Public Look at How Louisiana Sheriffs Have Spent Over $8M in Opioid Settlement Cash

In Louisiana, sheriffs receive 20% of the state's opioid settlement cash — the largest carve-out for law enforcement nationwide. But since sheriffs are not required to proactively report how they spend the money, it's hard to track. Reporters from Ñî¹óåú´«Ã½Ò•îl Health News, The Current, Gulf States Newsroom, and Verite News contacted all 64 sheriffs to uncover spending details. <br><br> Click column headings to sort the table.

Note: In some cases, the amount of money spent exceeds the amount allocated because sheriffs may have reported spending that included their 2026 allocations or because sheriffs combined their opioid settlement dollars with the share received by parish governments or other funding sources. Descriptions of spending are based on emails or phone calls with the sheriffs' offices and have been lightly edited. <br> Source: The money allocated to sheriffs was obtained by summing values for years 1-5, representing 2021-2025, from the Louisiana Opioid Abatement Task Force’s <a href="; target="_blank" style="color:#0071ce">public spreadsheet</a>. Data on money spent was collected by Ñî¹óåú´«Ã½Ò•îl Health News, The Current, Gulf States Newsroom, and Verite News. • <a href="/download-the-data-louisiana-sheriffs-opioid-settlement-expenditures/&quot; target="_blank" style="color:#0071ce">Download the data.</a> <br> Credit: Ñî¹óåú´«Ã½Ò•îl Health News' Lydia Zuraw and Aneri Pattani, The Current’s Alena Maschke, Gulf States Newsroom’s Drew Hawkins, and Verite News’ Katie Jane Fernelius

The state’s agreement with parishes and sheriffs receiving settlement cash contains broad categories for , including “law enforcement expenditures relating to the opioid epidemic.”

But even if the sheriffs’ spending is legal, that doesn’t mean it’s appropriate or effective, addiction and public health experts say.

“What’s happening here is they have a lot of money and they want to distribute it to all the wrong places,” said Danny Bolner Jr., a Jefferson Parish resident who has been in recovery from addiction for more than two decades and lost his 28-year-old son to a fentanyl overdose in 2016. On the panel that reviewed expenditures, Bolner represented the view of families who have lost loved ones to the crisis.

The purchase of drones and vehicles struck a nerve for him. He’d prefer for opioid cash to support programs that educate youth about healthy ways to process emotions, provide job training to people in recovery, and distribute overdose reversal medications.

“This money is what we have to save lives,” he said. If sheriffs use it in other ways, the finite pot “is going to be gone and then they won’t have nothing to help.”

A Safe, a Scanner, and Surveillance Cameras

For , a public health policy analyst and national opioid settlement expert who was a member of the review panel, determining if expenditures fit the spirit of the settlements often centered on whether they facilitated arrests or prevented overdoses.

“The impetus of this opioid settlement money is to spend on innovative ways to not let this happen again,” she said, referring to the overdose crisis that has claimed since 2000. She said sheriffs should be asking, “How could we use this to reinvest in the community, not just build up our office?”

Many of the sheriffs’ equipment purchases didn’t meet her bar.

For example, the East Baton Rouge Sheriff’s Office bought a safe to store evidence from opioid investigations and a scanner for their traffic division to identify narcotics in hidden compartments. The Terrebonne Parish Sheriff’s Office spent $465,000 on , which are automated license plate readers that capture data about passing vehicles and share them with law enforcement agencies nationwide. The Bossier Parish Sheriff’s Office purchased 130 body cameras and 50 dash cameras.

Sheriffs already receive taxpayer dollars and federal grants to buy law enforcement tools, Christensen said. Opioid cash, which is finite and has a specific purpose, should not be used for that, she and the other reviewers said. In fact, some states don’t allow it.

13 Louisiana Sheriffs Spent 100% of Opioid Settlement Money Inappropriately, per an Expert Panel

The expenditures were reviewed by Tricia Christensen, a public health policy analyst who has been tracking opioid settlement spending since 2022; Stephen Loyd, an addiction medicine doctor and a person in recovery who serves as West Virginia's drug czar; and Danny Bolner Jr., a person in recovery who lost his son to a fentanyl overdose and is raising his son’s daughter in Jefferson Parish, Louisiana. A majority vote determined which expenditures were appropriate. <br><br> The map depicts the percentage of money each sheriff spent on expenditures disapproved by the reviewers.

Note: The reviewers voted on the propriety of each expenditure based on their own views of the purpose of opioid settlement money. The rates of opioid-involved deaths are age-adjusted. Rates based on counts <5 were suppressed by the Louisiana Department of Health to protect privacy. "Opioid-involved deaths" include deaths in which opioids were present in the body and/or contributed to death, even if they were not the sole cause of death. <br> Sources: Settlement spending and reviewer opinions collected by Ñî¹óåú´«Ã½Ò•îl Health News, The Current, Gulf States Newsroom, and Verite News; opioid-involved death rates from the Louisiana Department of Health <br> Credit: Ñî¹óåú´«Ã½Ò•îl Health News' Lydia Zuraw and Aneri Pattani, The Current’s Alena Maschke, Gulf States Newsroom’s Drew Hawkins, and Verite News’ Katie Jane Fernelius

But taxpayer money may not cover everything sheriffs need, said , executive director of the Louisiana Sheriffs’ Association. “Our budgets are overloaded,” he said.

Complex investigations to dismantle drug trafficking syndicates can require advanced equipment, , a spokesperson for the East Baton Rouge Sheriff’s Office, wrote in a statement.

“While treatment and recovery services are indispensable components of addressing opioid addiction, they address the consequences of addiction after these drugs have already reached our community,” she wrote. “Law enforcement has a different, but equally essential, responsibility: preventing those deadly drugs from reaching potential victims in the first place.”

First Lt. Blake Tabor, a spokesperson for the Terrebonne sheriff’s office, similarly wrote, “Our role as a law enforcement agency is primarily focused on disrupting the criminal activity that fuels addiction in our community.” That effort complements other entities’ work in prevention, treatment, and recovery, he added.

The Bossier Parish Sheriff’s Office declined to comment.

Where Public Health Meets Public Safety

Not all sheriffs spent the money on enforcement.

Acadia Parish Sheriff directed all his settlement cash to provide treatment in jail. He said he hopes to break cycles of addiction and crime.

“I want people back into society, being productive,” he said.

Research shows for opioid use disorder behind bars and .

In St. Martin Parish, settlement funds helped launch a of officers that connects people with substance use disorders or related mental illness to treatment, said Chester Cedars, chief legal counsel for its sheriff’s office. Officers also try to coordinate support services for family members and assist with questions around paying for care.

“We’re not clinicians,” Cedars said, but we “serve as a broker” between people who need services and those who provide them.

, an addiction medicine doctor and the West Virginia drug czar, who was the third member of the review panel, said he loved the comprehensive nature of the program. Addiction “is a family issue,” he said. “Every time that phone rings, it’s a potential family crisis.”

It’s not a coincidence that these parishes earned top marks from the reviewers. Cedars is the former chair of the , and Gibson is the current chair. That’s the body meant to guide others on priority uses of settlement cash.

Cedars was clear that the St. Martin sheriff’s office was not using “one penny for any enforcement activity,” because that’s not what the settlement “intended to accomplish.”

Gibson was more hesitant, saying the legal guidelines are broad and “I’m not here to criticize anybody.”

He has advised about a dozen sheriffs who have reached out with questions, but he knows they’re not required to heed his guidance.

A from the Louisiana Legislative Auditor found that the task force has no teeth to enforce its recommendations.

If people want stronger guardrails on the opioid cash, state lawmakers need to enact new rules, Gibson said.

Stepping Up Oversight

The Louisiana state legislature in May calling for the legislative auditor to review how all parishes and sheriffs are handling their opioid settlement money and report to lawmakers prior to the 2027 legislative session.

State Sen. , a Republican who co-authored the resolution, said the goal is to shed light on where dollars are flowing, if jurisdictions are spending them at all, and which funded programs are effective.

With that information, Myers said, he and others could “absolutely” introduce bills “to tighten up how funding is spent.”

Louisiana Sheriffs Spent $4.7M in Opioid Settlement Cash on Items, Activities Deemed Unallowable in Other States

Six states — <a href="; target="_blank" style="color:#0071ce">California</a>, <a href="; target="_blank" style="color:#0071ce">Indiana</a>, <a href="; target="_blank" style="color:#0071ce">Kansas</a>, <a href="; target="_blank" style="color:#0071ce">Michigan</a>, <a href="; target="_blank" style="color:#0071ce">South Carolina</a>, and <a href="; target="_blank" style="color:#0071ce">Virginia</a> — have created lists of items and services that they say opioid settlement funds should not be spent on, including surveillance cameras and vehicles. Although Louisiana does not have its own "unallowable" list, the state's Opioid Abatement Task Force said it has shared other states' guidance with some sheriffs. Yet nearly 60% of the sheriffs' spending involves items found on such lists.

Note: Unallowable lists may not be legally binding in each state but are considered strong guidance. <br> Source: Data collection by Ñî¹óåú´«Ã½Ò•îl Health News, The Current, Gulf States Newsroom, and Verite News <br> Credit: Ñî¹óåú´«Ã½Ò•îl Health News' Lydia Zuraw and Aneri Pattani

Meanwhile, the Louisiana Opioid Abatement Task Force is trying to strengthen its oversight.

Curtis Nelson is executive counsel for the Louisiana Opioid Abatement Administration Corporation, a nonprofit that supports the task force. He said the body is seeking quotes from accountants to conduct ongoing forensic audits of parishes and sheriffs. The goal is to audit 10 to 15 entities annually, starting with those receiving the most money. If the audits turn up misuse, the task force could withhold future payments from those parishes or sheriffs, Nelson said.

The task force is also exploring creating its own unallowable list, like those in other states, Nelson said.

Louisiana Gov. Jeff Landry and Attorney General Liz Murrill did not respond to questions about whether they’d support an unallowable list or take other actions to address opioid settlement spending.

But many advocates are hopeful that an unallowable list could curb spending they found concerning.

“You’re keeping them on the track when you tell them what they can’t use it for,” said Bolner, the Jefferson Parish resident who lost his son to overdose and is raising his son’s daughter.

While he awaits greater oversight for sheriffs, Bolner plans to continue the work he’s been doing for years: distributing overdose reversal medications at schools, hospitals, and bars; participating in grief support groups with other families; and showing up at community events to raise awareness about addiction. He said he’ll keep speaking with sheriffs and parishes about what he considers the best use of settlement money.

“If I save one life, it’s accomplished,” he said.

Methodology

The Current’s Alena Maschke, Gulf States Newsroom’s Drew Hawkins, and Verite News’ Katie Jane Fernelius contributed to the database featured in this article.

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

“I’ve seen nurses get shoved, pushed, scratched. The biggest one is bitten,” said Dhooghe, who works at in Grand Blanc, Michigan.

The in healthcare has in states such as , , , , and , where Dhooghe and many of her co-workers have been on the picket line since Labor Day last year.

“People will question me and be like, ‘Why are you still working in a place if you’re treated like this?’” said Dhooghe, who gets by on strike benefits and working extra shifts at another hospital. The problem, she said, is that other hospitals aren’t any better. “It’s the same everywhere I go.”

In a statement, spokesperson Dana Jay acknowledged violence against healthcare workers is a “national epidemic” and said the health system’s efforts to address the problem include metal detectors, armed security officers trained to make “misdemeanor arrests,” and de-escalation training.

“We have zero tolerance for violence of any kind,” said Jay, asserting the strike is not about safety but is instead “simply an economic strike.”

Nationwide, hospital workers are seven times as likely to be injured on the job due to violent acts as members of the general working population, according to the available from the Bureau of Labor Statistics. The outcry over workplace violence in healthcare is pitting workers’ demands for better compensation and staffing against hospital operators pressured to cut costs.

‘A Powder Keg’

Violent outbursts are so common that they’ve been dramatized on the popular medical TV series . “Emergency rooms right now are like a powder keg,” said Rachel Odes, an assistant professor at the University of Wisconsin-Madison School of Nursing.

In hospitals, a combative or violent patient is known as a “.” Outbursts can be spontaneous and unpredictable, making some almost impossible to prevent. But research shows the increases when hospitals are understaffed or employees are insufficiently trained or experienced.

Mental health worker Andrew Kimball-Mirzaie said he got hurt in February 2024 at Butler Hospital in Providence, Rhode Island.

He’d been working at the private psychiatric hospital for about six weeks and said he hadn’t yet worked in the ER. He said he was sent there to “monitor” a man in his 20s who was waiting for an inpatient bed.

The patient was alone in a back room watching a Knicks basketball game on TV, he recalled. Kimball-Mirzaie said he got the patient a drink and a snack. They were watching the game when, suddenly, he said, the patient stood up and punched him in the face. He said the assault left him with a concussion and broken nose. His injuries were documented in the hospital’s.

“I understand that there is an inherent danger with the job,” Kimball-Mirzaie said. He doesn’t blame the patient, who was very ill at the time. “We should have had at least another staff member with us,” he said, “and I should have been adequately trained on the unit.”

The attack emboldened Kimball-Mirzaie to join some 700 other unionized Butler workers last spring and summer in a months-long strike, which forced the hospital to close . Service Employees International Union 1199 New England declared the strike a win.

Employees received wage increases that union leaders said would enable the hospital to attract and retain more staff. The hospital also agreed to provide financial support for workers violently injured on the job. And the hospital and union agreed to jointly fund a “time bank” to supplement workers’ compensation for injured workers who need more time to recover.

But five months later, a nurse supervisor at Butler had to call 911 because an unarmed patient in the hospital’s ER was assaulting staff. According to the police report, by the time police arrested the patient, he’d injured two nurses, a security guard, and a police officer.

“Butler recognizes the importance of being proactive in protecting those who provide care,” Mary Marran, Butler’s president and chief operating officer, said in a statement. She added that hospital leadership meets regularly with staff to review safety measures and “identify opportunities to strengthen protection for everyone.”

The patient was charged with four counts of , including against the two nurses.

The American Hospital Association has said punishment is key to preventing violence. It has been to make assaulting healthcare workers a that would carry in prison. At least , including and , have enacted similar laws. But workplace safety experts say there is no evidence that such laws have reduced the incidence of violence against healthcare workers.

Calls for ‘Safe Staffing’

Striking healthcare workers around the country often have demanded “safe staffing” instead of stronger punishments for patients who cause injuries.

The against healthcare workers has caught the attention of the , the accreditation organization for more than 80% of U.S. hospitals and health systems. The commission released national performance goals that and require hospitals to be and that staff be trained “to provide safe, quality care.”

But no federal law limits the number of patients in a nurse’s care across healthcare settings, despite the nation’s largest nurses union, National Nurses United, having pressed for a national standard . Hospitals must “safely staff all units” to enable nurses to “provide the care that patients need before they get agitated or disoriented,” said , lead industrial hygienist for .

Some states have passed their own staffing laws. Only has enacted broad mandatory nurse staffing ratios, which were associated with lower mortality rates and likely higher retention. Oregon enacted a staffing law, . Legislators in and have introduced similar bills, but they have failed to advance to floor votes.

The American Hospital Association opposes mandatory minimum nurse staffing ratios in hospitals, saying they would “remove real-time clinical judgment and flexibility,” , and potentially force some hospitals to turn away patients or delay care, spokesperson Colleen Kincaid said. And she pointed to California, whose for psychiatric hospitals reportedly in at least four counties.

“There are a lot of other things you can do to prevent workplace violence than just increasing staffing levels,” said , who was a deputy assistant secretary of labor for the Occupational Safety and Health Administration during the Obama administration and helped develop OSHA’s for healthcare and social service workers.

Barab said hospitals can, for example, train employees in de-escalation, install metal detectors, or have specially trained security guards on-site so staff don’t have to wait for police to arrive when an incident happens.

, a worker safety and health policy expert at Georgetown University, said the in congressional Republicans’ One Big Beautiful Bill Act will in the next few years.

When funding dries up, she said, “protecting workers is going to be the first thing that gets cut.”

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“They called me a ‘liability to the job site,’” Pugh said, recalling the words of his manager when a seizure cost him his last job at a fast-food restaurant in this western Montana city.

When the 46-year-old lost work in the past, his wife of 10 years covered their rent and he tended to their home until he found another job. But his wife died last year. Soon after, Pugh became homeless. His problem with alcohol became worse, which made managing his seizures more difficult.

“When she died, my whole base was depleted,” Pugh said.

Medicaid pays for the prescriptions that keep Pugh’s seizures at bay. The government-subsidized health coverage would also pay for an addiction treatment program that Pugh said he has tried to get into, but he was told there’s a waitlist.

Pugh’s goal has been to get healthy enough to work again. But he’s worried about being able to keep the Medicaid coverage he needs to get to that point.

Early Embrace of New Rules

In the spring, the federal government finalized regulations requiring millions of people who receive Medicaid benefits to prove they’re working, volunteering, or going to school to keep their coverage. States have until January to begin those checks. Montana, Arkansas, and Nebraska have already started implementing them.

The Trump administration’s federal work requirements exempt certain groups of people: those with disabilities, those older than 64, pregnant people and Native Americans, among others. To receive an exemption, anyone without a clear-cut qualification — such as through their age or disability status — will have to prove they’re too sick to work.

But the administration decided that being homeless isn’t a medical condition and can’t count as an automatic out from having to meet the new requirements. Many conservative policymakers support work requirements, and some states have attempted to implement such rules for years. At least four states — Montana, Arizona, Kentucky, and Utah — previously proposed policies that included homelessness as an exemption.

But federal officials have said that’s not allowed. In an email to Ñî¹óåú´«Ã½Ò•îl Health News, the Centers for Medicare & Medicaid Services declined to provide a comment on the record. But the agency confirmed that states must stick to the federal government’s list of exemptions. Homelessness in the U.S. increased by 27% from 2013 to 2025, from the Department of Housing and Urban Development. Last year, about 746,000 people .

Many, like Pugh, qualified for Medicaid, though the number of enrollees who are homeless is difficult to measure. In 2023, who received medical or behavioral health services through one of the nation’s roughly 300 programs were enrolled in Medicaid.

Jennifer Tolbert, deputy director of KFF’s Program on Medicaid and the Uninsured, said the federal regulations are a lot stricter than many states had expected, even those on board with work requirements. (KFF is a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News.)

“It took everyone by surprise,” Tolbert said.

Mehmet Oz, who leads CMS, touted the regulations as a “path to prosperity” during a press conference in June.

“We need to get people to try to work,” Oz said. In June, 25 mostly Democratic-led states over the regulations, arguing the medical frailty standard would be too hard for enrollees to meet — and for states to assess. The work requirements are projected to increase the number of uninsured people nationwide by by 2034, according to the Congressional Budget Office.

Most states will begin to implement the Medicaid work requirements in January. 

Montana plans to begin booting Medicaid enrollees from coverage this October if they can’t prove they’re in compliance with the work requirement.

“My Medicaid is still active, but when are they gonna cut that off from me?” Pugh said. “I can’t get employed. How am I supposed to survive?”

The differences between the states’ and federal government’s exemption lists don’t end with people who are homeless. In Montana, lawmakers also planned to excuse people fleeing domestic violence and caregivers of hospitalized family members — two other groups left off the federal exemption list.

“These are simply parties that, due to a number of conditions, cannot meet those requirements,” Republican state Rep. Ed Buttrey said in 2019 when the Montana Legislature passed its first Medicaid work requirement bill. Buttrey did not comment for this article.

Federal officials have said many people who are homeless could fall under another exemption, such as being too sick to work. But, like many states, Montana’s system to automatically conduct those checks through existing medical records isn’t ready, though health department spokesperson Jon Ebelt said it should be in place by October. Anyone not automatically exempted by the state would have 30 days to prove their case.

A Possible Exemption for Health

Pugh might qualify for a pass due to his seizures. But getting to doctor appointments the past year has been hard for him.

The anniversary of his wife’s death just passed. Typically, Pugh has to find a new place to sleep outside each night. One night while camping, Pugh lost his wallet and important documents. And with the addiction treatment centers that accept Medicaid patients overbooked, Pugh has had to rely on willpower to avoid drinking.

“I’m taking it one day at a time,” he said.

A little over two hours north, in Kalispell, Dustin Goss, a case manager at a homeless shelter called Samaritan House, said Pugh’s experience reflects why he’s worried that people who qualify for an exemption will get tangled in bureaucratic tape.

“You can’t really worry about getting paperwork done when you don’t know where you’re eating today,” Goss said.

Cassidy Kipp, who heads Samaritan House, said once people find shelter and start to stabilize, they typically find work. But even then, meeting the new requirements can be challenging. Clients often start with temporary and informal jobs — such as cleaning out a storage unit — that don’t come with a pay stub, Kipp said. 

Kaitlyn Bosshardt, a social worker at Partnership Health Center, a health clinic in Missoula, has seen more people priced out of longtime rentals as housing costs outpace people’s paychecks. Meanwhile, affordable housing and rental aid are limited.

Partnership Health is one of roughly 1,400 health centers nationwide that receive federal funding to serve patients based on what they can afford — meaning even those who lose Medicaid can receive care. But organizations representing health centers have said if too many patients lose the coverage, some clinics won’t be able to fill the financial hole.

The other problem is that these clinics generally don’t provide specialty care.

One day in June, as temperatures hovered around 90,  Pugh visited Watershed Navigation Center, a refuge run by Partnership for people without steady housing to have a meal or see a doctor. His doctor, Atarah Sidey, told Pugh that the neurology clinic that managed his seizures had dismissed him from their care after he missed three appointments.

She referred Pugh to the other neurologist in town and talked about trying to find treatment for his addiction.

“It’s just that if I don’t make the effort at changing, it ain’t gonna happen and I’m gonna end up found on the side of the road somewhere,” Pugh told Sidey.

“You got this, though, Tywon,” she responded as Pugh nodded his head. “You can do this.”

Pugh has connected with a social worker for help keeping his Medicaid. By late July, he was waiting for space to open at a Missoula addiction treatment center and waiting on responses from two job applications.

In the hard moments, Pugh imagines his wife telling him to stay calm, that things will get better.

“I just don’t wanna lose hope in the meantime,” he said.

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BALTIMORE — In March in a McDonald’s parking lot off a busy street, mental health clinician Michala Williams met a 38-year-old woman in a car.

“So, you called the police for help?” Williams asked the woman, who was sobbing uncontrollably and said she sometimes thinks about harming herself.

She told Williams she has children ranging from age 2 to 22, she was dealing with health issues, and that her fiancé had recently been jailed. She felt so overwhelmed she couldn’t eat.

The woman, who asked not to be named so that she could freely discuss her mental health, explained she’d tried to get help the previous month by driving to the hospital but got pulled over on the way because her car registration had expired.

“I don’t care if I get pulled over,” she said. “But I was saying, ‘I don’t know what to do. I just want to go to the hospital.’”

The officer arrested her for acting erratically, so instead of going to the hospital she went to jail.

“I had to sit inside of a cold cell. I couldn’t use the bathroom or anything,” the woman said.

On the day she met Williams, she’d decided to call 911. The dispatcher recognized the woman didn’t need a police response but instead needed one of Baltimore’s mobile crisis teams, which send a clinician and a peer counselor to meet people in mental health distress.

By the end of an hourlong conversation, Williams set the woman up with referrals to a psychiatrist, a therapist, legal help, and a case manager to determine if her child with autism was eligible for government services.

“She’s been through a lot of trauma, and no one is going to deny that,” Williams said. “But I now have to take all of that and decide, ‘OK, here’s steps 1, 2, and 3,’ because we got to find a little bit of sliver of something to give her some hope that there’s help out here.”

For years, the mobile crisis teams, which are overseen by , a nonprofit that acts as the city’s mental health department, have diverted calls from police to mental health professionals. However, the units have a limited scope, focused on people in mental health crises.

Now Baltimore is tapping into some of the roughly $400 million from opioid-related legal settlements to build out a broader service to operate around the clock and respond to other kinds of crises when police aren’t needed.

Baltimore logged to 911 in 2024, but tens of thousands of them didn’t require traditional emergency services, like police, firefighters, or EMTs, according to , an expert in community safety at Georgetown Law.

Instead, the calls were about, for example, a homeless person who fell asleep in a store, a person who seemed confused in a public park, and someone who was yelling at passersby on the street.

Such calls “don’t require a badge, a gun, and handcuffs to resolve,” Duckett said.

Often those people end up in jail instead of getting the help they need, he said. A study that when a non-law enforcement team responded to 911 calls in Durham, North Carolina, it resulted in fewer arrests than when police responded — especially for callers who were Black, men, or ages 25-39. Police responses can also lead to trauma for that person or a less satisfactory outcome than another community service response would produce, Duckett said. The idea behind the Baltimore mobile crisis teams — and the new service — is to find out what people in crisis may need and how to connect them to those resources instead of arresting them.

From 2021 to 2025, Baltimore’s homicide rate decreased by 60%, setting records for the drop in violence. But at the same time, drug overdoses made national records, as about 1,000 people here each year from 2020 to 2023.

In 2018, Baltimore opted out of a global settlement that other jurisdictions made with opioid makers and distributors and instead sued them independently. As the opioid-related lawsuits were settled, city officials decided that the settlement awards it receives must be spent on drug-related harms — or on services that help prevent addiction, such as housing support, healthcare, and education.

One seeks to directly address overdoses by placing boxes of the overdose reversal drug naloxone at every subway stop. Expanding 911 services is part of a larger strategy to beef up city services, with $15 million in settlement funds allocated so far, according to Sara Whaley, Baltimore’s director of overdose response. Whaley hopes the expansion will help the city think differently about how it responds to residents in crisis — regardless of why they’re calling 911.

She views the calls as an opportunity to help solve a problem rather than be punitive. “What are the wraparound services and support that can help prevent them from being involved in this, in that emergency system?” she said.

For example, the person falling asleep in a store may need connection to community housing. The goal is to reduce violence, get people proper resources, and avoid the cycle of incarcerating people dealing with poverty, addiction, and mental health.

, executive director of the Health Lab at the University of Chicago, of services like these. She said they offer peace of mind for callers that “they’re going to be met with the right response at the right time.”

“We also see responders themselves feeling like they have a better toolbox in their ability to pursue actual resolution to these calls,” she said.

To expand its system, Baltimore looked to cities — including Durham — that have adopted similar models to reroute callers who don’t need emergency responders.

Durham’s diversion program is called the , or HEART. The program estimates it has diverted more than 12,000 calls in four years. It said police backup was needed for only 0.02% of those calls and that response times have improved for all types of 911 calls.

Durham has of the HEART calls, showing that nonpolice responders in Durham have helped with everything from finding housing for a woman fleeing domestic violence to setting up medical appointments for a homeless veteran.

In one case, a hotel manager called 911 asking for help finding a blind man housing for the night, since the hotel didn’t have accessible rooms available. The HEART responders booked him a room and the next day provided a ride to meet with an organization that could help secure housing.

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Nearly half of that money is , to be distributed by county commissioners and city councilors. The idea is that local leaders know their communities best and can do justice to these payouts, often described as “blood money” by people who’ve lost loved ones to an overdose.

But many local leaders have little to no training in addiction policy and may lack robust local health departments and policy guardrails to assist them.

That has resulted in spending decisions that many clinicians, researchers, and addiction recovery advocates say are unlikely to save lives or treat substance use disorders.

In New York, where is directly controlled by local governments, counties have spent tens of thousands of dollars on surveillance cameras, technology to help police access data on locked cellphones, and goggles that simulate being drunk, according to public records obtained by the nonprofit advocacy group and shared exclusively with Ñî¹óåú´«Ã½Ò•îl Health News. Though the purchases were likely legal, many people consider them a slap in the face because they don’t directly help people struggling with addiction or their families.

Without oversight, counties have the chance “to go rogue” with this money, said , director of drug policy at VOCAL-NY, an advocacy organization that is tracking settlement money as part of its mission to serve people affected by the war on drugs.

When advocates and families of overdose victims raise concerns to the various state agencies that could hold localities accountable, those agencies often punt to one another, Budnella and other local advocates said.

It feels “like the where it’s like everybody’s pointing at each other,” Budnella said. “Somebody needs to be able to have the stick and slam their hand on the table and be like, ‘You’re doing this wrong and this is the consequence.’”

The experience in New York provides a microcosm of regulators evading oversight responsibility nationwide while varied interests vie for the financial windfall.

Years of data collected by Ñî¹óåú´«Ã½Ò•îl Health News, the Johns Hopkins Bloomberg School of Public Health, and the addiction nonprofit Shatterproof have found that settlement money was spent on law enforcement gear, such as night-vision goggles and bulletproof vests; unproven prevention initiatives, such as a drug-awareness magician for kids; and budget stopgaps.

It’s unclear who should — or will — take action on such expenditures that many people harmed by the crisis consider questionable.

In each state, control of the money is split among various entities, creating a leadership vacuum. The federal government . Advocates and families who’ve lost loved ones have pushed for accountability but have limited power. A few states have passed new laws, but change is slow and uneven.

The require the majority of the money to be spent on “opioid remediation,” with . But the list is broad and open to interpretation. Further complicating the issue, many states — including New York — designate some portion of the settlement dollars as unrestricted, which allows for general spending.

Meanwhile, federal budget cuts have threatened addiction-related services and created more demand for funding. And though overdose deaths have decreased since , they still claim about 186 lives per day.

“We really are wasting this opportunity to use these funds to turn the epidemic around,” said , a Binghamton, New York, resident, whose 28-year-old son, Jeff Dugon, died of a heroin overdose in 2014.

He was a chef who loved to rib Pleus about her bad knife skills. She thinks of him and smiles every time she peels garlic the way he taught her. If the money could spare other families such heartache, that would give her solace.

“We need oversight,” said Pleus, who runs a nonprofit that is receiving opioid settlement cash from her county to serve people who use drugs and provide support groups for families.

In New York, there are three prime watchdog contenders: the Office of Addiction Services and Supports, the attorney general, and the comptroller.

The Lead State Agency

New York’s opioid settlement documents designate the as the “.”

It distributes a portion of settlement dollars via grants, according to recommendations from the state’s . It also has the power to “engage in oversight and audits of projects and programs” funded by settlement cash and “may withhold future funds” from local governments that do not comply with certain requirements, according to the agreement.

Agency spokesperson Jerry Gretzinger told Ñî¹óåú´«Ã½Ò•îl Health News the office has not yet exercised its power to withhold funds but understands its oversight role.

“OASAS has a duty to ensure these funds are used responsibly and strategically to build programs that will have a lasting impact in reversing this crisis,” Gretzinger wrote in a statement.

The office is currently auditing 19 local governments’ use of the money to ensure compliance with “reporting and recordkeeping requirements,” he said. However, that may not encompass the broader question of whether money was spent on appropriate uses, which many advocates want addressed.

Some people are frustrated with the narrow role OASAS has carved out.

For example, required local governments for the first time to publicly report how they spent settlement money. OASAS on its site. But it does not review the accuracy or detail of that data, instead relying on “the information as it is provided” by localities, Gretzinger said.

“That doesn’t feel like oversight,” said , a deputy director at the Legal Action Center, which obtained public records about local spending in New York.

Members of the state’s Opioid Settlement Fund Advisory Board have also to provide more data and evaluation of how dollars are being used. But at a , OASAS Commissioner Chinazo Cunningham deflected.

“OASAS has no oversight over these portions of dollars,” she said of the 46% of settlement money that goes directly to counties and cities. “In terms of what kind of data each county collects,” she added, “we cannot dictate exactly what that information is.”

Click for Examples of spending decisions Local Spending That’s Fueling Calls for Oversight in New York

To uncover how opioid settlement cash is being spent, the nonprofit advocacy group filed public records requests with 56 New York counties and New York City, all of which are to disburse as they see fit.

Many of the responses showed spending on addiction treatment, recovery, and prevention initiatives that researchers and clinicians agree are a good use of money. Others surfaced questionable expenditures.

, for example, showed $150,000 in settlement cash directed to “Sheriff Jail” with no further description. The county did not respond to repeated inquiries for more details.

Sullivan County spent more than $30,000 on Cellebrite technology, used to extract data from cellphones, and more than $37,000 on Tasers. Though county officials didn’t respond to requests for comment, explained that those purchases came from unrestricted funds.

Such justifications rankle some families affected by the crisis, who say even if there aren’t legal restrictions on those dollars, there should be moral ones.

“Anything that is not directly tied to people who are struggling with opioid addiction or the loss of someone is a poor use of funds,” said , who lost a son to an overdose and now runs a nonprofit aimed at helping families dealing with addiction. Her organization has received settlement funds from Broome County, New York.

Records also revealed that many jurisdictions have yet to spend a significant portion of their money — a other .

Local officials say thoughtful planning takes time. But some advocates suspect ulterior motives. Millions of settlement dollars in bank accounts can generate sizable interest.

In March, it came to light that Nassau County had in interest accrued from unused opioid settlement funds to the county’s general fund, where it could be used for any purpose. County officials didn’t respond to requests for comment. The money was following public backlash.

Advocates suspect such attempts are happening elsewhere but are difficult to identify within complex budgeting documents.

It feels like “it’s up to us all — the organizers, the advocates, the service providers” — to be constantly watching, said , director of drug policy at the advocacy organization VOCAL-NY. “It’s frustrating.”

That’s why state agencies are being called on to step into an oversight role.

The Top Law Enforcement Officer

New York has been one of the leading national voices on prosecuting pharmaceutical companies that fueled the overdose crisis. Her office has issued on the topic, touting her role in securing billions of opioid settlement dollars for the state.

But when asked about the attorney general’s role in ensuring this windfall is spent appropriately, her office passed the buck to other agencies.

“While our partners in state and local governments distribute and oversee these funds, we will continue our work to hold accountable the companies responsible for fueling the spread of addictions and overdoses,” spokesperson Grant Fox wrote in a statement.

That stance contrasts starkly with many people’s views of the office’s responsibility.

A state senator, a member of the opioid settlement advisory board, and several advocates named the attorney general’s office as a key enforcement entity.

“The money is here because of their efforts,” said Democratic state , who chairs the committee on alcoholism and substance use disorders and has introduced of related to settlement funds. “I believe it is under the Office of the Attorney General to enforce.”

Budnella, the advocate with VOCAL-NY, agreed, saying, “It would be a shame for all of their work that they have done to secure all this funding for it to be misspent.”

Attorneys general in and have taken more active roles, issuing lists of ways opioid settlement money cannot be spent. The lists include many law enforcement expenditures that have raised concerns for advocates in New York.

James’ office did not respond to a specific question about whether she’d consider creating a similar list.

The Fiscal Watchdog

Some people have suggested that the state comptroller, as a steward of New York’s finances, could play an oversight role, perhaps by conducting or requiring audits.

Early this year, the Reason Foundation, a libertarian think tank, that would create audit requirements for organizations receiving settlement cash. The blueprint suggests recipients of more than $1 million in opioid settlements be required to undergo an independent review of financial statements and transaction testing to determine whether funds were used for their intended purpose. Smaller grantees, receiving less than $1 million, could simply provide an unaudited accounting of the funds.

It’s “not telling states what is and what isn’t an appropriate use,” said , a co-author of the Reason Foundation plan. “We’re simply trying to ensure recipients follow through with their promises.”

No state has adopted the model law yet. But the office of New York told Ñî¹óåú´«Ã½Ò•îl Health News it is already conducting an audit.

The process, which began in February, “is looking at OASAS’ oversight” of the opioid settlement money, said spokesperson Mary Mueller. It includes settlement money controlled by the state and local governments.

Mueller said any future enforcement action “will depend on the results of our current work and our ongoing monitoring.”

The office is following in the footsteps of comptrollers and auditors in , , and , Tennessee, who have taken action on settlement cash.

These initial steps have given some advocates and researchers hope for the future of opioid settlement dollars, which are expected to flow for more than a decade.

“We’re already years in and we’ve seen the craziest stories” of this money and a , said , a co-author of the Reason Foundation’s model law. “If we can prevent that at least a little and have these funds be a bit more focused, I don’t think it’s too late.”

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .