Who Will Benefit from Opioid Settlement Money?

By SAM URETSKY

On August 26, Judge Thad Balkman issued a ruling fining Johnson & Johnson $572 million for its role in the Oklahoma’s opioid crisis. The state claimed that J&J’s marketing caused a public nuisance by increasing addiction and overdose deaths. According to the National Institute on Drug Abuse, “In 2017, there were 388 overdose deaths — involving opioids in Oklahoma — a rate of 10.2 deaths per 100,000 persons, compared to the national rate of 14.6 deaths per 100,000 persons.” NIDA also reported, “In 2017, Oklahoma providers wrote 88.1 opioid prescriptions for every 100 persons (Figure 2) – a 30% decline since 2012, when the rate was 127 opioid prescriptions per 100 persons (CDC). The rate of overdose deaths involving opioid prescriptions has also declined from 11.8 deaths per 100,000 persons in 2012, to 6.7 deaths per 100,000 persons in 2017.”

Last June, in a federal case, the drug maker Insys Therapeutics agreed to pay $225 million to settle federal criminal and civil charges that it illegally marketed fentanyl, and currently, attention has turned to the case against Purdue Pharma, which may be resolved for $10-12 billion. There may be as many as 2,000 lawsuits pending against the pharma companies, including over 100 lawsuits from Native American tribes. Ohio Attorney General Dave Yost is asking an appellate court to halt a case brought by two Ohio counties on the grounds that only the state has the legal authority to bring the claims.

The lawsuits have been aimed at drug manufacturers and distributors, as well as against chain pharmacies. There’s a lot of attention focused on misuse and marketing of narcotic analgesics, but the problem is hardly new. Back in 2009 the American Journal of Public Health published an excellent report, “The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy,” which stated, ”When Purdue Pharma introduced OxyContin in 1996, it was aggressively marketed and highly promoted. Sales grew from $48 million in 1996 to almost $1.1 billion in 2000. The high availability of OxyContin correlated with increased abuse, diversion, and addiction, and by 2004 OxyContin had become a leading drug of abuse in the United States.”

While the high rate of addiction and death represents a national crisis, it is important to deal with the problem with responsibility and intelligence. Experience with the money from the November 1998 he Master Settlement Agreement four major tobacco companies signed shows the way states may divert money from one purpose (health care expenses, smoking cessation programs) to capital projects and filling in budget deficits that should have been paid for from taxes. Tobacco companies covered their settlement expenses by raising prices, and states spent the money on routine expenses, so that the actual cost of the settlement, both in terms of health and costs, was limited to smokers.

The money that will be collected from the opioid settlements should be directed towards treatment and education, not to keep state taxes down.

While narcotic analgesics such as fentanyl and oxycodone are obviously dangerous, it’s important to assure that they’re available for people who need them, and that the hazards of non-prescription analgesics aren’t ignored. The Journal of the National Comprehensive Cancer Network (September 2010) reported, “The incidence of cancer is increasing worldwide. In 2000, approximately 11 million cases were diagnosed and approximately 7 million patients died of the disease. In 2030, approximately 27 million cases are expected worldwide, with an estimated 17 million cancer deaths annually. Overall, 75% of patients with cancer experience pain severe enough to require opioids. Many patients will present with pain as the first sign of cancer, and nearly two thirds are undertreated for this symptom.” There are other condition which cause long term severe pain, and these patients have a need for narcotic analgesics.

The alternatives to opioids are the non-prescription analgesics, aspirin, acetaminophen and the NSAIDS (naproxen and ibuprofen). The American Council on Science and Health has warned that the toxic dose of acetaminophen (Tylenol, APAP) is dangerously close to the toxic dose. A 2017 study (J Hepatol. 2017 Dec; 67(6):1324-133) notes “APAP toxicity dwarfs all other prescription drugs as a cause of acute liver failure in the US and Europe, but it is not regulated in any significant way.” The non-steroidal anti-inflammatory drugs, both prescription and non-prescription, can cause potentially fatal gastrointestinal ulcers, particularly in patients over the age of 65.

Two points seem significant. According to the Substance Abuse and Mental Health Services Administration National Survey on Drug Use and Health (2017) roughly 80% of people who misused narcotic analgesics got them first from a friend of relative. “Only 4.8% of people who misused prescription pain relievers in the past year indicated that they had bought the prescription pain relievers they had most recently misused from a drug dealer or other stranger.”

Another problem is that Purdue was able to represent the risk of addiction by cherry picking published studies. These publications may be legitimate and reflect the results of a well conducted study, but they lack the validity of a careful analysis of the published literature. Purdue relied on one study that concluded that addiction was extremely rare, but other studies showed addiction rates going into the 30s and even over 40%. Marketing was aimed at primary care physicians as least trained in pain management or addiction.

The phrase War on Drugs was first used by President Nixon in 1969. So far it seems as if the drugs are winning. There’s a great deal of information now available about how our efforts to control addiction and overdose went wrong. Now that the money will be available it’s time to do something right.

Sam Uretsky is a writer and pharmacist living in Louisville, Ky. Email sdu01@outlook.com.

From The Progressive Populist, October 1, 2019

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