INDIANAPOLIS, IN — Every official charged with spending opioid settlement money has been given the same instruction, and it sounds like wisdom: fund evidence-based practices. A new paper argues that almost no one who receives that instruction has been told what it actually means — and that the gap between the phrase and its reality is exactly where the next public debacle is taking shape.
The paper, “The Evidence Trap: What Opioid Settlement Recipients Need to Know About Evidence-Based Practice Before It’s Too Late,” is the second in a series on the evidentiary foundations of opioid abatement from the founding team of Essentrify, Inc. It was published this week.
Its central warning is direct: the tobacco settlement is remembered as a cautionary tale — billions spent, almost nothing proven — but the mechanism of that failure is widely misread. It did not fail because the money went to bad programs. It failed because no one built the means to know whether the good programs worked. The opioid settlement, the authors argue, is being handed the same opportunity to fail, this time wearing the language of evidence-based practice.
“Everyone remembers the tobacco settlement as money that vanished. What they miss is how it happened. It doesn’t happen because anyone funds bad programs. It happens because no one builds the means to know whether the good ones worked. We are watching that exact failure set up again — and this time it’s wearing the costume of ‘evidence-based practice.’”
The paper makes a series of arguments that cut against conventional wisdom.
An evidence-based program is a floor, not a ceiling. The research is clear that the specific named program a recipient funds explains only a modest part of whether people actually get better. Far more is carried by the person’s own circumstances, the relationship with those helping them, the skill of the provider, and whether anyone is engaged with the person and tracking their progress. “Requiring an evidence-based program is right,” the authors write. “Believing it is sufficient is the trap.”
There is a difference between evidence-based practice and evidence-based treatment — and the system rewards the wrong one. Evidence-based practice is best practice: research and guidance applied with skill and judgment, shaped to the individual. Evidence-based treatment is the fixed protocol — the cookie-cutter version that can be billed and audited. “One is a profession,” the paper states. “The other is a checklist.” Payers, reasonably pursuing accountability, reward the version they can administer — and quietly strip out the judgment and individual fit that actually drive outcomes.
The interventions that matter most are the ones treated as “soft.” Peer support, recovery housing, family engagement, and navigation act directly on the factors that carry most of the outcome — yet they are dismissed as the soft edge of the field rather than its core, largely because they don’t come with a registry entry and a fixed protocol.
The organizations doing the most important work have the least ability to prove it. The community programs delivering these high-value interventions typically have no research staff, no evaluation budget, and no spare hour.
“The binding constraint is bandwidth, not will or ability. We are asking three-person organizations to become research institutions on the side, and then blaming them when they can’t. The work is extraordinary. The capacity to document it was never provided.”
The result, the authors warn, is a structural trap: settlement money flows to exactly the right interventions, those interventions produce no evidence because the people delivering them have no capacity to generate it, and years later the absence of evidence is misread as the absence of impact — and the programs are cut.
The paper also points to a gap in the national record. A review of the available literature finds no systematic assessment of whether opioid settlement spending is actually aligned with evidence-based practice. The most comprehensive national tracking effort — led by Johns Hopkins with KFF and Shatterproof — states plainly that it did not evaluate program quality or alignment with evidence-based practice, only where the money was directed.
“We can tell the country where the money went, by category. What no one can yet tell you is whether any of it worked. The information needed to answer that question is not being captured — which means, right now, the question is unanswerable.”
The authors are careful to say the solution is not to fund fewer community programs, but to build the capacity to measure them — designed for organizations that have no spare bandwidth, rather than assumed to already exist.
“The difference between success and failure here will not be found in the list of what gets funded. It will be found in whether anyone can prove what changed. That is a question of method and of detail — the unglamorous work of measurement that the field has always treated as someone else’s problem.”
The paper draws on more than five years of work by its authors, beginning with research one co-author first circulated in 2020 — well before settlement funds began to flow — on the challenge of expressing evidence-based practice through real-world service delivery.
The authors disclose that they have a commercial interest in the problem the paper analyzes: Essentrify is developing infrastructure to help communities generate rigorous evidence from the kinds of interventions the paper describes. They state the interest plainly and argue the paper should be weighed on its merits regardless.
About Essentrify, Inc.
Essentrify, Inc. is building the Abatement Information Ecosystem — a platform designed to manage opioid settlement compliance and generate longitudinal evidence for community-based addiction interventions. Its founding team includes physicians, health-informatics researchers, and community-health and public-sector practitioners.
The full paper, “The Evidence Trap,” is available on this site. High-resolution graphics and the full paper are available on request.
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