The largest civil trial in US history is scheduled to begin in a matter of days, placing those who manufactured, marketed, distributed, and distributed prescription painkillers. But those at the forefront of the opioid epidemic are already looking beyond the courtroom to the massive solution they hope will eventually solve the case.
Experts have little doubt that this would be the most complex payment the country has ever seen. It would require a lot from so many companies. And that would have to do a lot for so many people, starting with the 2 million Americans in prison.
A solution in the case known as Multidistrict Litigation 2804 would have many expensive pieces. The total cost can easily reach $ 100 billion.
It would need funding – potentially for years – addiction counseling and treatment for those who are ready to give it a try.
It would have to expand access to naloxone opioid reversal drug and underpin the development of new, more effective rescue medications, so that those who overdose have a chance to stay clean.
It could afford public drug abuse prevention campaigns, safe prescribing seminars for doctors, and drug abuse awareness programs for pharmacists.
It would probably include screening for drugs for pregnant women and treatment for children exposed to opioids in the womb.
It can fund family support groups for drug addiction and bereavement services for those left behind.
It would reimburse state and local health departments for the money they spent treating millions of victims.
This is not even an exhaustive list. And of course, there is no money that can bring back the 400,000 Americans who lost their lives to opioids.
Gail Box listens during the final arguments in Oklahoma's opioid lawsuit against Johnson & Johnson. His son, former University of Oklahoma football player Austin Box, died of a drug overdose in 2011.
(Sue Ogrocki / Associated Press)
A global settlement would require the consent of the approximately 35,000 plaintiffs in the case, as well as 348 pharmaceutical companies, popular pharmacies, professional medical associations and other individuals accused of fueling an epidemic of death and addiction.
US District Judge Dan Aaron Polster, who presides over the case in his Cleveland court, leaned on all sides to calm down before the jury selection began on Wednesday. It is much easier said than done.
To appreciate the magnitude of the challenge, consider the plan Oklahoma has devised to address the opioid crisis within its borders. The State has proposed an expansion of its opioid addiction treatment services, public awareness campaigns aimed at preventing addiction and proper drug disposal, and funding for non-opioid pain treatment programs, among other elements.
The projected cost of 20 years amounted to $ 17 billion – and this is for a state with only 1% of the US population and a 30% lower opioid overdose mortality rate than the national average.
"There are a million moving parts" in this case and its solution, said University of Georgia litigation expert Elizabeth Burch. "And as soon as you find out, it changes for you."
Leaders of the nation's largest cigarette companies are preparing to testify before Congress in 1994. The companies agreed to a landmark tobacco deal four years later.
(Johnn Duricka / Associated Press)
However complex the case of opioids is not completely unprecedented. Legal experts compare it with 1998 Master Settlement Agreement where seven tobacco companies have agreed to pay US states billions of dollars annually to make up for decades of tobacco-related health spending. Total of these payments over $ 126 billion so far – and will continue in perpetuity, reaching projected $ 246 billion by 2025. (The agreement also included provisions that drastically reduced the freedom of tobacco companies to market and advertise their products.)
A CDM 2804 deal would probably be much smaller, experts agree. Even at the current pinnacle of the opioid crisis, tobacco use kills 10 times more people in the US each year. And the opioid epidemic was brief compared to the wait for centuries of tobacco.
Still, Big Tobacco's humiliation can serve not only as a model for an opioid settlement, but also as a warning story. Free to spend resources as they see fit, many states have used their unexpected revenues to fill budget gaps and fund public works programs, such as improvements to schools and highways.
In the fiscal year ended September 30, The states raised $ 27.3 billion from settlement and tobacco taxes. But only $ 650 million will be spent on public health initiatives, such as programs to help people quit or prevent children from starting in the first place, according to a Campaign for Tobacco Free Kids count. This is no match for the $ 9.5 billion The tobacco industry spends on US marketing every year.
The biology of addiction makes this imbalance even worse. Most smokers need to quit at least eight times before quitting, according to the Centers for Disease Control and Prevention and the American Cancer Society. (A recent study said 30 abandonment attempts was a more realistic estimate.)
A woman takes her methadone dose at the Evergreen Treatment Services clinic in Hoquiam, Washington, where she is being treated for drug addiction. Health experts say a global deal with opioids would have to increase funding for drug treatment programs.
(David Goldman / Associated Press)
It is unlikely that getting people off opioids will be faster or easier, experts say. People with an addiction often take a long time to recognize their problem and, in any given year, only 2.1% of those in need of treatment really seek it out according to a national authority search by the federal Administration of Mental Health Services and Substance Abuse.
In addition, addiction treatment often fails even when using the most effective medications. The National Institute on Drug Abuse estimates that the relapse rate for recovering drug users falls between 40% and 60%.
Getting everyone involved in the opioid case to agree on the price of a deal will be quite challenging. Figuring out how to spend this money can take years.
Mike Moore, who helped broker the agreement on tobacco as Mississippi's attorney general, said an opioid deal should go beyond a single dollar figure and set aside funds for use in direct reversal of the epidemic.
"If you get just about every city and county in the United States and check it all out, that's great," said Moore, who now represents several counties and cities in MDL 2804 and separately in the states of Mississippi, Ohio, Louisiana, and Arkansas. . "But then what are they going to do with the opioid epidemic?"
Any deal would probably be Divided among the authors of the MDL 2804, based on three factors, according to Joe Rice, one of the case's leading advocates: the volume of opioid painkillers sold in each city, county, and state; the number of people in each jurisdiction who died of opioid-related overdoses; and the number at each location that reported a pill addiction.
As smaller settlements were hit in Oklahoma and elsewhere, skirmishes emerged over which government entities should decide how the money is used.
Many cities and counties intend to use settlement funds to launch drug prevention programs and build addiction treatment centers. Cuyahoga County leaders – one of two Ohio counties that first settled with some opioid drug makers – unveiled a $ 23 million plan last week to expand residential drug treatment, hiring drug recovery support coaches. camp and set up an opioid treatment program in his prison.
Cuyahoga County authorities plan to use their money to set up an opioid treatment program in the county jail above.
(Tony Dejak / Associated Press)
That leaves $ 14 million in cash for settlement. Moore and others fear that, after an initial flood of opioid treatment and prevention spending, the beneficiaries of the deal will use what remains to replenish the coffers exhausted by the opioid crisis or divert funds to other priorities.
"It's my biggest fear," he said.
Dr. Kathleen T. Brady, who chairs the executive committee of International Society of Addiction Medicine, said it would be a "shame" if opioid settlement funds were not used to deal with the crisis. Her wish list includes rebuilding and expanding the workforce providing addiction services, funding pain and addiction research, and training doctors in pain management and addiction treatment.
Few, if any, families who have lost their breadwinners, caregivers, loving grandparents, or promising children would likely receive a dime from an opioid settlement. People struggling with addiction will not be compensated for lost jobs, broken families or time spent in prison. And those who pay for addiction treatment will not be reimbursed for the money they have handed over – often – in an attempt to rescue a loved one from opioids.
Former addicts and people who have lost loved ones to drugs participate in an Overdose Awareness Day march in New York City. In all likelihood, a settlement of the CDM 2804 would not reimburse individuals for dependency treatment costs or other losses.
(Spencer Platt / Getty Images)
This is because any settlement fund would flow to the MDL 2804 plaintiffs or to the 49 states (all except Nebraska) that have joined forces to pursue those they say are responsible for the opioid epidemic. Virtually all of these authors are government entities. In principle, they could decide to use settlement funds to pay families or individuals for their problems. But this is something the tobacco settlement has never done, and no one in the case of opioids has considered this possibility …