Kentucky Turned $865,000 in Opioid Settlement Money Into a Lifeline for Five Counties. Arizona Has $1.2 Billion and Nothing Like It.

Jamie Madden grew up in the Kentucky mountains believing there was only one way to make a living. “I grew up with the impression that that’s how you paid your bills,” she says of the pill economy that ran through the hollers of eastern Kentucky a generation before her — the same economy that became her own addiction, and, years later, the reason she now works the front desk of a place called the Hub.

The Hub sits in Whitesburg, Kentucky, population 1,575, and it exists because of opioid settlement money — the billions that drug manufacturers, distributors, and pharmacy chains have been court-ordered to pay state and local governments for their role in flooding American communities with pain pills. Kentucky’s cut of the national $57.8 billion settlement is about $1 billion. The Hub’s cut, so far, is $865,000: $545,000 awarded in 2025, another $320,000 in April for a two-year reentry grant. With it, the Hub pays the salaries of people who run syringe services, staff a crisis line, and do reentry work for women coming out of jail — five rural counties’ worth of the kind of help that used to not exist at all.

Money that pays a peer support specialist’s rent does more for an overdose crisis than money that pays for a press conference.

Arizona’s opioid settlement fund is $1.215 billion over 18 years, with $1.194 billion already recovered as of this year’s $108.2 million Purdue Pharma tranche — roughly the same size as Kentucky’s, spread across a state with less than double Kentucky’s population and, per Arizona’s own public health researchers, a fentanyl crisis that is currently getting worse while the rest of the country’s gets better. If you want to know what $1 billion in opioid settlement money can build when it’s spent on people instead of institutions, the Hub is the answer. Arizona hasn’t built its version yet.

What $865,000 buys when it goes to people who’ve been there

The Hub isn’t a clinic in the way most people picture one. It’s a physical space in a town of under 1,600 people, in a stretch of Appalachia — Knott, Lee, Letcher, Owsley, and Perry counties — where the nearest hospital can be an hour’s drive on mountain roads. Its staff includes Becky Todd, a community health worker and peer support specialist who leads the Beattyville branch of the Hub and says plainly, “I could not have done it without this place.” It includes Amber McDaniel, who came to the Hub through AmeriCorps after a period she describes simply: “I didn’t know where to turn, didn’t know what to do.” It includes Hannah Stamper, staffing the Hub through Recovery Corps. None of them are imported experts. They are, by design, people who have already lived the thing the person walking in the door is currently living.

That’s not incidental — it’s the model. JoAnn Fraley, Kentucky River’s harm reduction program coordinator and the Hub’s initiative director, put the logic simply: “In order for anybody to sustain recovery, they have to have financial stability, they have to have transportation, and they have to have a home.” Recovery, in other words, is not a single clinical event you complete. It’s a set of logistics problems — a ride, a place to sleep, a job that doesn’t fire you for missing a Tuesday — and the Hub’s peer staff exist to solve those logistics problems in real time, because they’ve already solved them for themselves once.

Scott Lockard, the Kentucky River District’s public health director, has watched harm reduction programs rise and fall over 36 years in public health. He’s not equivocal about what he’s watching now: “I’ve been in public health for 36 years, and it’s one of the most effective interventions I’ve seen.” Lauren Carr, who advises the Kentucky Association of Counties on how member governments should spend their settlement dollars, frames the Hub as a template other counties can copy: “What jazzes me about it is it’s a community approach to harm reduction.”

Scott Lockard, the Kentucky River District’s public health director, has watched harm reduction programs rise and fall over 36 years in public health.

If you’ve ever sat across from a caseworker who read your file off a screen and never once looked like they’d lived any version of what you were describing, you already know why that matters. A peer specialist who’s been exactly where you are isn’t a nicer version of the same service. It’s a different service.

The ban that took 27 years to lift, and who finally lifted it

The Hub runs syringe services today because of a fight that started decades before Jamie Madden was born, and it’s worth knowing the shape of it, because Kentucky’s own delegation ended up on both sides of it.

In 1988, at the height of the AIDS crisis and led by Senator Jesse Helms, Congress banned the use of federal money for syringe exchange programs — the low-cost, high-evidence intervention that gives people who inject drugs clean equipment so they don’t contract or spread HIV and hepatitis C through shared needles. The ban held, almost unbroken, for the better part of three decades, even as the evidence that syringe access saves lives without increasing drug use piled up on one side of the ledger and nothing but moral discomfort sat on the other. President Obama lifted it briefly in 2009; Congress put it back in 2012.

What finally broke the ban wasn’t Washington deciding the evidence had become undeniable. It was an HIV outbreak in Scott County, Indiana in 2015 — rural, white, opioid-driven, close enough to home that it was no longer someone else’s epidemic. That same year, Kentucky’s Hal Rogers and Mitch McConnell, alongside West Virginia’s Shelley Moore Capito, helped write the partial repeal into a federal spending bill. The politicians whose own rural districts were about to need exactly this tool were the ones who finally got it unstuck.

We have watched a government decide that a cheap thing which keeps people alive sends the wrong message before. It took 27 years and an outbreak next door to reverse course once. The Hub, and the syringe services it now runs in five counties with settlement money, is downstream of that fight — proof that the intervention Congress once refused to fund is, once funded, exactly as effective as the evidence always said it would be.

Arizona has more money and a different model

Arizona is not doing nothing with its settlement money. In June, Attorney General Kris Mayes announced $10 million — $2 million each to the sheriff’s offices of Coconino, Mohave, Navajo, Pinal, and Yavapai counties — to expand coordinated reentry planning, the programs that are supposed to catch someone the moment they leave jail, before the highest-risk window for a fatal overdose closes. That’s a real use of the money, aimed at a real problem: people are dramatically more likely to die of an overdose in the weeks right after release than at almost any other point in their lives.

But notice the structure of it. The money moves from the Attorney General’s office to five sheriffs’ offices — institution to institution — rather than to a community organization staffed by people in recovery, the way Kentucky’s flows to the Hub. That’s not automatically the wrong choice. Reentry programs matter, and law enforcement agencies often run them well. It is, however, a fundamentally different theory of what settlement money is for, and Arizona’s own public health researchers are starting to ask whether the theory is working.

In June, Allan Williams, a PhD and public health researcher, published a report through the Arizona Public Health Association with a title that states its argument outright: Overdose Deaths Are Falling Nationwide — Why Is Arizona Moving in the Wrong Direction? While national overdose deaths fell roughly 14% from 2024 to 2025 — the third consecutive year of decline, per provisional CDC data that separately confirms Arizona is one of only three states (with New Mexico and Colorado) where deaths rose 10% or more over that same window — Arizona’s own numbers moved the other direction: from 2,531 deaths to 2,988, an 18% increase, with synthetic-opioid deaths up 33% and cocaine deaths up nearly 70%. “Nearly 3,000 Arizonans died from drug overdoses last year,” Williams writes. “Behind every number is a family, a workplace and a community.”

Williams’s report doesn’t call for less settlement spending. It calls for smarter spending — for the money to go toward naloxone and fentanyl test strip access, faster paths into treatment, and, specifically, toward “programs that can show measurable results.” That last phrase is the whole argument in miniature. Arizona has nearly as much settlement money as Kentucky. What it’s missing isn’t the dollars. It’s a Hub — a place you could point to, with names and salaries attached, and ask whether it’s working.

It’s a Hub — a place you could point to, with names and salaries attached, and ask whether it’s working.

The money is not the problem. Knowing what the money did is the problem.

If you have used, if you are trying to stop, if you have already stopped and started again — you already know that a phone number printed on a pamphlet is not the same as a person on the other end who has already stood exactly where you’re standing. That’s the entire difference between the Hub’s model and a line item in a sheriff’s budget. It’s not that reentry funding is wasteful. It’s that funding routed through institutions is legible to auditors and invisible to the person who needs to walk through a door at 2 a.m. and find someone who won’t flinch.

This is, not incidentally, the exact gap a navigation platform is built to close — not by replacing the Hub’s peer staff or Arizona’s sheriffs, but by making it possible to see, in something close to real time, whether either one is actually getting someone from crisis to care faster than they were a year ago. Kentucky’s settlement overseers can point to the Hub’s five counties and describe what changed. Arizona’s overdose numbers, moving the wrong direction while its settlement fund grows past $1.2 billion, suggest nobody yet can say the same for the state as a whole.

You don’t need $865,000 to borrow the part of the Hub’s model that actually works. If you’re a case manager or reentry coordinator reading this, the copyable piece isn’t the building — it’s the sequencing: pairing a peer specialist, even one, with a caseload before someone’s first post-release appointment lapses, rather than after. That’s a smaller bet than replicating a five-county hub, and it’s the bet Kentucky’s data suggests is doing the heavy lifting.

Arizona’s $1.215 billion hasn’t finished arriving — most of it, under the settlement’s own 18-year payout schedule, is still years from landing. That’s not a small mercy. It means the decision about what this money becomes is still open. Kentucky spent $865,000 and built five counties a place with Jamie Madden’s name on the front desk. Arizona has roughly a thousand times that much money on the way, and the state that calls itself the crisis’s ground zero still hasn’t decided what its version of the Hub looks like — or whether it’s willing to let the people who’ve lived it run the front desk.