“Do you guys tell anybody?”: Exploring allocation and implementation of opioid settlement funds and reduced access to health vending machines for people who use drugs

OBJECTIVE: This study examined how county-level decision-making shaped implementation and accessibility of an opioid-settlement-funded health vending machine (HVM) in California. METHOD: We conducted approximately 250 hours of ethnographic fieldwork and qualitative interviews with 17 HVM users. Using constructivist grounded theory, we analyzed the data to explore how structural and political dynamics influenced program awareness and engagement. RESULTS: Three themes emerged: (1) county leadership placed the HVM in a low-visibility location to minimize anticipated political and organizational backlash to harm reduction; (2) additional implementation decisions, including minimal signage and a high-barrier registration model further limited awareness and engagement; and (3) these overlapping barriers constrained participants' ability to obtain health supplies, undermining the intervention's ability to achieve its goals. CONCLUSIONS: Structural constraints, agency-level discretion, and fears of political and social backlash significantly reduced the effectiveness of an opioid-settlement-funded HVM. Even when funds are allocated for evidence-based strategies, implementation shaped by stigma or risk aversion may restrict access for people who use drugs. Transparent processes, accountability, and meaningful community involvement are essential to ensure settlement investments advance their goals of reducing overdose and infectious disease harms.