State and local governments filed thousands of lawsuits against drug companies and wholesalers accused of fueling the crisis, resulting in a plethora of settlement deals. The largest to date is a $26 billion settlement that began paying out this year. As the funds arrive, some people say it’s reasonable for densely populated cities and counties to receive more, as they serve a greater number of residents. But others worry such an approach misses an opportunity to use that money to make a difference in rural communities that have been disproportionately affected for decades. “You could really diminish what is effectively generational, more than 20 years of harm in rural areas,” said Robert Pack, co-director of East Tennessee State University’s Addiction Science Center. Just because rural areas are less populated doesn’t mean it’s cheaper to provide health services there. Research suggests the per-person cost can be greater when counties can’t capitalize on economies of scale.

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