After years of litigation to hold the pharmaceutical industry accountable for the deadly abuse of prescription painkillers, payments from what could amount to more than $50 billion in court settlements have started to flow to states and communities to address the nation’s continuing opioid crisis.

But though the payments come with stacks of guidance outlining core strategies for drug prevention and addiction treatment, the first wave of awards is setting off heated debates over the best use of the money, including the role that law enforcement should play in grappling with a public health disaster.

States and local governments are designating millions of dollars for overdose reversal drugs, addiction treatment medication, and wound care vans for people with infections from injecting drugs. But law enforcement departments are receiving opioid settlement money for policing resources like new cruisers, overtime pay for narcotics investigators, phone-hacking equipment, body scanners to detect drugs on inmates and restraint devices.

“I have a great deal of ambivalence towards the use of the opioid money for that purpose,” said Chester Cedars, chairman of Louisiana’s advisory opioid task force and president of St. Martin Parish. The state’s directives say only “law enforcement expenditures related to the opioid epidemic,” added Mr. Cedars, a retired prosecutor. “That is wide open as to what that exactly means.”

On Monday, 133 addiction medicine specialists, legal aid groups, street outreach groups and other organizations released a list of suggested priorities for the funds. Their recommendations include housing for people in recovery and expanding access to syringe exchange programs, personal use testing strips for fentanyl and xylazine, and medication that treats addiction.

They expressly stated that no funds “should be spent on law enforcement personnel, overtime or equipment.”

“Law enforcement already gets a lot of funding, and I’m sure they would say it’s never enough,” said Tricia Christensen, an author of the proposed priorities, who is the policy director at Community Education Group, which has been tracking opioid settlement money across Appalachia. But the opioid money, she said, “is really unique.”

Groups that monitor opioid settlements use various criteria to estimate the total payout. But even employing the most conservative tabulation, the final amount could well be north of $50 billion when pending lawsuits are resolved, notably the multibillion-dollar Purdue bankruptcy plan, which the Supreme Court temporarily paused last week.

At first glance, that looks like a fabulous trove of money. In reality, it will be parceled out over 18 years and is already dwarfed by the behemoth dimensions of the opioid crisis, now dominated by illicit fentanyl and other drugs.

The spectacle of states as well as thousands of cities, counties and towns all struggling to determine the most effective uses of these desperately needed funds is raising many questions.

Underlying the wrangling is a push for greater transparency in awarding the money and a determination not to repeat the mistakes of the Big Tobacco settlement 25 years ago. State governments have used most of the $246 billion from tobacco companies to plug budget holes and pay for other projects, and reserved relatively little to redress nicotine-related problems.

Now, states and local governments have committees to determine appropriate allocation of the opioid money. Sheriffs and police officials comprise less than a fifth of the members on those task forces, according to a recent analysis by KFF Health News, Johns Hopkins University and Shatterproof, a national nonprofit that focuses on addiction.

But public sentiment in many communities favors ridding the streets of drug dealers as a means of abating the crisis.

When Samuel Sanguedolce, the district attorney of Luzerne County in Pennsylvania, presented his budget to the County Council in November, he made a pitch for some of the county’s settlement money, about $3.4 million so far.

“With 10 more detectives, I could arrest those cases around the clock,” he said, referring to drug dealers. “I think this is a good way to use money that resulted from this opioid crisis to assist those detectives without putting it on the taxpayers.”

“And I’ve asked not just for detectives,” he continued. “But hiring people, of course, costs money, in the way that they need guns and vests and computers and cars.”

In many areas of the country, the lines between law enforcement and health care can be somewhat blurred: Police and sheriffs’ departments are also emergency responders, trained to administer overdose reversal drugs. Louisiana is dedicating 20 percent of its opioid money to parish sheriffs.

Sheriff K.P. Gibson of Acadia Parish, who represents sheriffs on Louisiana’s opioid task force, said that he intended to use the $100,000 his department is set to receive for “medical needs” of people in the jail, including various opioid treatments and counseling. The goal, he said, is to help inmates become “productive citizens within our community,” once they are released.

Public health officials and addiction treatment specialists are also concerned about another use of the money: grants for faith-based rehab programs that prohibit federally approved medications like Suboxone and methadone, which blunt cravings for opioids.

“I would be open to a faith-based cancer program, but not one that doesn’t let you take effective medicines to treat the cancer,” said Dr. Joshua Sharfstein, a professor at Johns Hopkins Bloomberg School of Public Health, which has released its own guidance principles for the settlement funds.

Throughout the years of negotiating opioid settlements, lawyers for states, tribes and local governments and those defending drug distributors, manufacturers and pharmacy chains struggled to avoid the pitfalls that emerged from the Big Tobacco litigation.

This time, local governments have struck agreements with state attorneys general over the allocation of the money. Legislatures are largely excluded from most of the funds.

Johns Hopkins praised Rock County, Wis., as a jurisdiction that strove to get a full picture of local needs for the money: It put together a working group to review evidence-based literature and conducted surveys and meetings to elicit community suggestions.

In North Carolina, county governments receive 85 percent of the funds, which have reached nearly $161 million so far. Having signed onto the core principles worked up with the attorney general, the counties have great discretion in spending their allotments.

“When you look at who addresses the issues of the opioid epidemic, it’s addressed locally by E.M.S., social services and jails. Those are all county functions in North Carolina, so that’s why it made sense for them to get the bulk of the resources,” said Josh Stein, the North Carolina attorney general, who helped negotiate the national opioid settlements.

Each county is establishing its own priorities. Stanly County, he said, is setting up teams to reach people who have just survived overdoses, hoping to connect them with services. Mecklenburg County has directed some of its funding for post-recovery education and job-training programs.

Such uses can help to lift a community stricken by addiction, said Ms. Christensen, whose group monitors opioid settlements for 13 states. “I really subscribe to the idea that overdoses are often ‘deaths of despair’ — that the reason many folks spiral into chaotic drug use has a lot to do with what has happened to them and their lack of opportunities,” she said. “So how can we invest in the community to prevent that from happening generation after generation? That’s why I think community input is so important in this process.”

The groups that released the new set of priorities cited examples of promising use of the funds. Michigan’s plans include adding rooms in hospitals so that new mothers can stay with infants born with neonatal abstinence syndrome. Kentucky is giving $1 million to four legal aid groups to represent people with opioid-related cases.

“I was blown away by that,” said Shameka Parrish-Wright, executive director of VOCAL-KY, a community group that worked on the priorities documents. Ms. Parrish-Wright, a former candidate for Louisville mayor who had been addicted to drugs, homeless and incarcerated, added: “Those legal entities are really helpful in making sure we deal with paraphernalia charges and evictions. People coming out of treatment are sometimes discriminated against because of those charges and can’t get housing or jobs.”

VOCAL-KY has not applied for settlement money but works closely with groups that do. Its members attend meetings held by Kentucky’s opioid task force. “Knowing that Black and brown and poor white communities are dealing with it the worst, we pushed them to have another town hall in those communities,” Ms. Parrish-Wright said.

With Big Tobacco’s cautionary tale shadowing these debates, the issue of accountability looms. Who ensures that grantees spend their money appropriately? What sanctions will befall those who color outside the lines of their grants?

So far, the answers remain to be seen. Christine Minhee, a lawyer who runs the Opioid Settlement Tracker, which analyzes state approaches to spending the funds, noted that on that question, the voluminous legal agreements could be opaque.

“But between the lines, the settlement agreements themselves imply that the political process, rather than the courts, will bear the actual enforcement burden,” she said. “This means that the task of enforcing the spirit of the agreement — making sure that settlements are spent in ways that maximize lives saved — is left to the rest of us.”

Juliette Vasquez gave birth to her daughter in June with the help of Medicaid, which she said had covered the prenatal medications and checkups that kept her pregnancy on track.

But as she cradled her daughter, Imani, in southwest Houston one afternoon this month, she described her fear of going without the health insurance that helped her deliver her baby.

This month, Ms. Vasquez, 27, joined the growing ranks of Americans whose lives have been disrupted by the unwinding of a policy that barred states from removing people from Medicaid during the coronavirus pandemic in exchange for additional federal funding.

Since the policy lifted at the beginning of April, over half a million people in Texas have been dropped from the program, more than any other state has reported removing so far, according to KFF, a health policy research organization. Health experts and state advocacy groups say that many of those in Texas who have lost coverage are young mothers like Ms. Vasquez or children who have few alternatives, if any, for obtaining affordable insurance.

Ms. Vasquez said that she needed to stay healthy while breastfeeding and be able to see a doctor if she falls ill. “When you are taking care of someone else, it’s very different,” she said of needing health insurance as a new parent.

Enrollment in Medicaid, a joint federal-state health insurance program for low-income people, soared to record levels while the pandemic-era policy was in place, and the nation’s uninsured rate fell to a record low early this year. But since the so-called unwinding began, states have reported dropping more than 4.5 million people from Medicaid, according to KFF.

That number will climb in the coming months. The Congressional Budget Office has estimated that more than 15 million people will be dropped from Medicaid over a year and a half and that more than six million of them will end up uninsured.

While some people like Ms. Vasquez are losing their coverage because they no longer meet the eligibility criteria, many others are being dropped for procedural reasons, suggesting that some people may be losing their insurance even though they still qualify for it.

The upheaval is especially acute in Texas and nine other states that have not adopted the Affordable Care Act’s expansion of Medicaid, all of which have state governments either partly or fully controlled by Republicans. Under the health law, states can expand their Medicaid programs to cover adults who earn up to 138 percent of the federal poverty level, or about $41,000 for a family of four.

But in Texas, which had the highest uninsured rate of any state in 2021, the Medicaid program is far more restrictive. Many of those with coverage are children, pregnant women or people with disabilities.

The ongoing unwinding has renewed concerns about the so-called coverage gap, in which some people in states that have not expanded Medicaid have incomes that are too high for the program but too low for subsidized coverage through the Affordable Care Act’s marketplaces.

“It’s going to lay bare the need for expansion, particularly when we see these very poor parents become uninsured and fall into the coverage gap and have nowhere to go,” said Joan Alker, the executive director of the Georgetown University Center for Children and Families.

Texas’ Medicaid program grew substantially during the pandemic when the state was barred from removing people from it. At the start of the unwinding, nearly six million Texans were enrolled in the program, or roughly one in five people in the state, up from nearly four million before the pandemic.

Now the program is shrinking significantly. Legacy Community Health, a network of clinics in and around Houston that offer low-cost health care to the uninsured, has been swamped in recent weeks by panicked parents whose children suddenly lost Medicaid coverage, said Adrian Buentello, a Legacy employee who helps patients with their health insurance eligibility forms.

“Moms are frantic,” he said. “They’re in distress. They want their child to have immunizations that are required, these annual exams that schools require.”

Texans are losing Medicaid for a variety of reasons. Some people now have incomes too high for their children to qualify, or they now earn too much to keep their own coverage. Some young adults have aged out of the program.

Some new mothers like Ms. Vasquez are losing coverage because they are two months out from having given birth, a stricter cutoff than in most states. Gov. Greg Abbott, a Republican, recently signed legislation extending postpartum coverage to a year, which would bring Texas in line with most of the country. But the new rule is not expected to go into effect until next year.

Kayla Montano, who gave birth in March, said she suffered from an umbilical hernia and pelvic pain from her pregnancy and was set to lose coverage at the end of this month, most likely falling into the coverage gap. A mother of three in Mission, Texas, Ms. Montano said she was working only part time so she could take care of her young children, a schedule that had left her ineligible to receive insurance from her employer.

“My health will be on hold until I start working full time again,” she said.

Health experts are particularly worried about the many Texans who are losing Medicaid coverage for procedural reasons, such as not returning paperwork to confirm their eligibility, even if they may still qualify for the program.

Of the 560,000 people whom Texas has reported removing from Medicaid during the first months of eligibility checks, about 450,000, or roughly 80 percent, were dropped for procedural reasons. Nationwide, in states where data is available, three-quarters of those who have lost Medicaid during the unwinding were removed from the program on procedural grounds, according to KFF.

In a statement, Tiffany Young, a spokeswoman for the Texas Health and Human Services Commission, which is overseeing the state’s unwinding process, said that Texas had prioritized conducting eligibility checks for those most likely to no longer be eligible for the program. She said the agency was using a range of tactics to try to reach people, including text messages, robocalls and community events.

Ms. Young said the first few months of eligibility checks had generally gone as expected, though she said the state was aware of some instances in which people had been wrongly removed from the program. “We’re working to reinstate coverage for those individuals as soon as possible,” she said.

Adrienne Lloyd, the health policy manager at the Texas branch of the Children’s Defense Fund, an advocacy group, said that because of its size and rural expanse, Texas was an especially difficult state for outreach to people whose coverage may be at risk.

Many rural residents lack steady internet access or nearby health department offices where they can seek help re-enrolling in Medicaid in person, Ms. Lloyd said, while a state hotline could have long wait times. Others, she said, might not be comfortable using technology to renew their coverage or could struggle to fill out paper forms.

The work required for those who do not enroll online or over the phone can be challenging. Early this month, Luz Amaya drove roughly 30 minutes to a branch of the Houston Food Bank for help filling out an application to re-enroll her children in Medicaid. Her arthritis had left her hands impaired, making the drive difficult, she said.

Ms. Amaya was among dozens of parents who visited the food bank for an event sponsored in part by the state that offered help with enrollment.

Ms. Amaya grew emotional at the event when she learned that her oldest daughter would soon age out of Medicaid and might no longer be able to get the therapy she needs. Ms. Amaya said she was there in part to confirm coverage for another daughter who needed therapy.

Another attendee, Mario Delgado, said he had come to re-enroll in Medicaid after he and his wife suddenly lost coverage around the beginning of the state’s unwinding. Both are disabled and cannot work, he said. With money tight, they have scraped together payments for medications.

His wife needs back surgery, he said, and he needs medication to keep up with his diabetes, which makes his hands swollen. “If you cry, the pain stays the same,” he said, describing the resignation they have felt struggling to afford health care.

He soon received good news. He and his wife were back on Medicaid. “I’ll sleep better,” he said as he exited the building into the scorching Texas summer heat.

Health experts have warned that many of those losing coverage in the unwinding may not realize their fate until they are informed by a health provider or billed for a medical service.

Perla Brown, the mother of a boy with autism, came to the food bank event soon after her son’s therapist told her that her child had lost Medicaid, she said. She soon discovered letters in the mail she had missed that had warned her of the imminent loss of his coverage. She said she was worried about paying the bill for the therapy appointment.

Ms. Vasquez, the new mother, said that having a child “just opens up your heart in a very different way.” She had learned to enjoy switching out her daughter’s blankets once they accrued too much spit. The way her daughter had learned to play on her stomach, she added, made her happy.

But the joy of her parenting, she said, had been dimmed by morbid thoughts about the consequences of losing her Medicaid. Health care, she said, “is always about the cost.”