“I was dumbfounded,” said Jesi, a retired executive. “How do you let this money sit there in a bank while people are dying?”

The Middleton example is hardly an anomaly. Less than 5 percent of the $50 million that Massachusetts communities received from the opioid settlements so far has been spent on addiction-related services and overdose prevention efforts, according to a Globe analysis of municipal spending reports.

More than 90 percent of the 247 communities that submitted financial reports to the state hadn’t spent a single penny in the fiscal year that ended June 30, 2023. That includes most of the largest cities, all hard hit by the overdose crisis: Boston, Cambridge, Springfield, and New Bedford, which each received more than $1 million in settlement funds.

The money has sat unused while the decades-long opioid epidemic has entered a perilous new phase — marked by the rapid spread of fentanyl and other toxic substances throughout the illicit drug supply. More than 3,500 people in Massachusetts have died from drug overdoses since municipalities began receiving payouts in July 2022 — the first of about $400 million that drug companies will pay to cities and towns in the state over the next 18 years.

(Another 98 cities and towns were not required to submit reports because they received payments of less than $35,000 a year.)

“It’s inexcusable,” said Senator John Velis, a Westfield Democrat and chair of the Senate’s Mental Health, Substance Use and Recovery committee. “This should be an ‘all-hands-on-deck’ moment. This is a public health crisis . . . and we need every dollar out there to minimize harm and save lives.”

Municipal officials and groups that monitor opioid settlements say the money is being held up by local disputes over competing priorities, accounting red tape, and protracted efforts to collect community input. While the legal settlements came with clear spending guidelines, some town and city officials said they were still unsure of how to spend the money effectively and equitably, given the complexity and persistence of addiction. Others said they were moving cautiously to gather ideas from residents, including treatment specialists and those with experience living with addiction, to make sure they are making the best decisions on their behalf.

Boston, which received $6 million as of December, announced plans late last month to use some of the money for supportive housing and for financial aid for residents who have lost loved ones to overdoses.

Dr. Bisola Ojikutu, executive director of the Boston Public Health Commission, said the city preferred a “very thoughtful, deliberative, and inclusive” approach that included a public survey and listening sessions in communities particularly hard hit by the opioid epidemic. The city expects to receive more than $1 million annually in settlement money through 2038.

“We will move as quickly as possible, but we’ll also be deliberative and make sure that we’re doing the right things with the money,” Ojikutu said.

The influx of opioid settlement money has been described by some public health experts as a once-in-a-generation opportunity to change how local governments address substance abuse and possibly even reverse the scourge of overdose deaths.

Yet the sluggish pace of spending is frustrating some lawmakers and families who have lost loved ones to overdoses and are demanding faster action. Some of the grieving families played a pivotal role in the legal cases that led to the multibillion-dollar settlements, and they have emerged as the most outspoken voices for dispersing the money more quickly.

“Those of us serving a life sentence of grief over the loss of our loved ones do not want that money sitting in a bank account,” said Cheryl Juaire, who lost two sons to fatal overdoses and lives in Marlborough, which has yet to spend more than $160,000 in settlement money.

Marc McGovern, a city councilor and vice mayor of Cambridge, said administrators have only themselves to blame for why his city has failed to spend $1.9 million in settlement funds. They spent too much time, he said, deliberating over whether to fund existing harm-reduction programs or to tackle broader issues such as the shortage of supportive housing for people with substance use disorder.

“There are a lot of ideas,” he said. “What we need is a sense of urgency.”

Cambridge so far has decided to use some of the money to buy a medical outreach van.

New Bedford’s Health Department has been meeting with public health officials across the state and is still working on “detailed, long-term action plans” for using the settlement funds to address the opioid crisis and its root causes, the city said. Lynn organized public focus groups and gave away gift cards to encourage residents to attend.

Not every city has been slow to act.

Worcester is among nearly a dozen that spent all their settlement money. Its initiatives include $500,000 on mobile crisis teams to respond to emergency calls involving substance use and mental health. Teams of purple-shirted social workers are dispatched in vans to crisis calls to help steer people to treatment programs and other services.

Other programs in Worcester include a new office of maternal health, which will provide support to pregnant or postpartum mothers struggling with substance use, and recovery counseling for people who are homeless or incarcerated. “It’s an awful epidemic . . . and we need programs in place that can be long-lasting and self-sustaining,” said Dr. Matilde “Mattie” Castiel, Worcester’s commissioner of health and human services.

Policy makers are determined to avoid the mistakes of the Big Tobacco settlement of 25 years ago, when much of the billions in payments to states plugged budget holes and funded public infrastructure projects instead of nicotine-prevention programs. Under the statewide opioid settlements, cities and towns must use the dollars on substance abuse prevention, treatment, and recovery programs, as well as harm-reduction strategies that seek to mitigate the deadly risk of using drugs.

Massachusetts expects to receive almost $1 billion over 18 years from settlements with opioid manufacturers and distributors. Of that, 40 percent is going to municipalities based on such factors as the number of opioid-related overdose deaths and US Drug Enforcement Agency data on the amount of opioids shipped into local communities. The remaining 60 percent goes into the state’s Opioid Recovery and Remediation Fund.

The payments do not include the settlement with Purdue Pharma, producer of OxyContin, which is undergoing court review.

The state has been far more decisive with its share, about $100 million thus far, funding three mobile programs for delivering methadone and addiction teams to consult at 15 hospitals, among other efforts.

The state Department of Public Health said it plans to sponsor a conference this spring to help municipalities better understand how to use the funds, including whether to team up with neighboring communities..

“Town government is picturesque and nice, but many towns are not large enough to have a public health function,” said David Rosenbloom, a professor of public health at Boston University and a member of a state advisory council on the Opioid Recovery and Remediation Fund. “Something like this [opioid epidemic] comes along and they don’t know how to respond.”

As for Jesi, the Middleton retiree turned his frustration over the unused settlement money into action. Since his visit to Town Hall, the retired executive organized a series of monthly meetings that involved the local Fire Department, public health nurses, and addiction treatment specialists. The town has since tapped about $8,000 of its settlement money to install opioid overdose “rescue kits” equipped with free Narcan in dozens of local restaurants, Dunkin’ shops, and public buildings throughout Middleton.

“Every parent who’s lost a child . . . wants to see that money out there saving lives,” said Jesi, after stopping at Middleton’s public library to check on one of the kits. “If we can save one life, then it’s worth every cent.”

Chris Serres can be reached at chris.serres@globe.com. Follow him @ChrisSerres.