The $580 Million Question: How Baltimore Spends Its Opioid Settlements Will Define the Next Decade

Nearly $580 million.

That is how much Baltimore City has won in legal settlements against pharmaceutical companies, distributors, and pharmacies that manufactured, shipped, and sold the opioids that fueled the city’s overdose crisis — a crisis that has killed nearly 6,000 Baltimoreans in six years and still claims, on average, three lives every day.

The settlements represent one of the largest public health windfalls in Baltimore City history. They also represent a test: whether a city that has long struggled to sustain investments in its most distressed communities can deploy complex, multi-year funding streams in ways that actually change outcomes.

Where the Money Is Going

Baltimore’s plan, approved by City Council, calls for spending the settlement money over 15 years on four broad categories: harm reduction, treatment, education, and prevention. Those categories reflect a public health consensus on what actually reduces overdose deaths and helps people achieve long-term recovery.

The early disbursements suggest the city is moving in the right direction. In March 2025, the City Council approved more than $14 million in grants to community organizations focused on overdose response — needle exchanges, naloxone distribution, mobile treatment units, and low-barrier recovery programs. In separate action, the city directed $5 million over four years to Helping Up Mission, which operates large-scale emergency shelter and recovery programming for men.

By mid-2024, the city had secured approximately $90 million in settlements — a significant portion of the eventual total, which is expected to grow as additional cases resolve.

What Harm Reduction Means in Practice

“Harm reduction” is a term that generates political friction. In practice, it refers to a set of evidence-based interventions designed to keep people alive until they are ready for treatment: needle exchanges that prevent HIV and hepatitis C transmission, naloxone distribution that reverses opioid overdoses, fentanyl test strips that let people know whether their drug supply contains the synthetic opioid that has made every use more dangerous.

Behavioral Health System Baltimore, the agency that coordinates the city’s public behavioral health system, spends more than $52 million annually serving more than 107,000 people. That system existed before the settlements and will continue regardless of them. The settlement money is meant to augment it — to reach people the existing system isn’t reaching, in places it isn’t present, with services it currently can’t afford to provide.

The Accountability Problem

Large, multi-year public health funding streams are notoriously difficult to track. Baltimore’s opioid settlement spending plan calls for the money to flow through a dedicated fund, with annual reporting on outcomes. But annual reports describe what was spent and what was delivered — they rarely capture whether the spending changed the death rate in the neighborhoods where people are dying.

An investigation by The Baltimore Banner found that one treatment provider, PHA Healthcare, had been operating housing for patients in buildings where drug use was pervasive — nominally receiving public dollars for treatment while delivering conditions antithetical to recovery. The state ordered PHA to close. But the case illustrates the risk: in a system that depends on providers of varying quality and accountability, outcome tracking is essential and hard.

Who Needs to Be at the Table

The residents most affected by the opioid crisis — concentrated in high-poverty, predominantly Black neighborhoods on the west and east sides of Baltimore — have rarely had consistent representation in the decisions about how crisis funding gets spent. Harm reduction advocates have pushed, with partial success, for community advisory structures that include people with lived experience of addiction and recovery.

That representation matters practically: people who have navigated Baltimore’s treatment and recovery landscape know which programs work, which ones turn people away, and which conditions make recovery impossible regardless of what a program offers on paper.

The Long View

Baltimore’s overdose death rate fell in 2024-25 — a development the Banner reported with cautious optimism. That decline followed years of investment in naloxone distribution, medication-assisted treatment expansion, and street outreach, and it came before the bulk of settlement money arrived.

Whether the decline continues — and whether it reaches the neighborhoods where the crisis has been most concentrated — will depend on decisions made now about where the $580 million goes, who administers it, and how outcomes are measured. The Baltimore Neighborhood Indicators Alliance tracks overdose-related health indicators across the city’s 55 communities. Its Vital Signs data will provide one measure of whether the investment is working — or whether it is disappearing into the system without reaching the people it was meant to save.

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This article draws on reporting by The Baltimore Banner and data from Behavioral Health System Baltimore (bhsbaltimore.org) and the Baltimore Neighborhood Indicators Alliance (bniajfi.org).