In response to the opioid epidemic in the U.S., cities, counties, states, insurers, and medical groups filed more than 2,000 lawsuits seeking to hold pharmaceutical companies accountable for it. A tentative settlement is now on the horizon: according to news reports on Wednesday, Purdue Pharma will pay up to $12 billion over time and the Sackler family, which owns the company, will give up control of it.

Opinions abound on how this money should be spent.

In the midst of this discussion, we mustn’t miss the tragic reality that we are still losing 130 lives every day as a result of opioid overdoses.

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That’s why I, on behalf of five organizations representing physicians and experts on the front line of this crisis, urge that money garnered from the opioid settlement be used to directly combat the opioid crisis through three main approaches:

  • support for evidence-based treatment and prevention efforts
  • research focused on new approaches to treatment and prevention of opioid and other substance use disorders
  • improvement of training for practitioners in treatment of addiction and pain management

Treatment and prevention efforts desperately need financial support. Between 2009 and 2012, state budget cuts to mental health and addictions services amounted to $5 billion and have never recovered since. An abundance of evidence shows that these services actually make a difference. Numerous studies, for example, indicate that medications for addiction treatment significantly reduce the risk of overdose, relapse, and other health and social outcomes of opioid addiction.

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But partly due to lack of funding, only about 10% of the 2 million Americans with substance use disorders receive treatment for them. And while the federal government recently announced some funding for access to evidence-based treatment for individuals with opioid use disorders, it’s a short-term investment with an unclear future.

In spite of what we now know about treatment and its effectiveness, we can learn much more. Exciting advances in neuroscience have identified neural pathways underlying addictions and pain that can be used to develop new therapeutic interventions, but the pathway from basic discovery to everyday usage is costly. At a systems level, health services research can help transform and reshape the treatment system, making it more accessible and effective. And there is much more we can discover about preventing substance use disorder in the first place.

Most physicians and other health care providers receive only basic training in the prevention, recognition, and treatment of addiction and the care of pain. Lack of provider preparedness in these areas has been partially blamed for the limited response to the opioid crisis. Meanwhile, there is a dearth of qualified addiction treatment specialists. Funding from the opioid settlement should be dedicated toward extending the workforce capacity through additional addiction psychiatry and addiction medicine fellowships, as well as better training for health care providers in general on addiction and pain care.

The historic $246 billion Tobacco Master Settlement Agreement in 1998 was supposed to support treatment and prevention of smoking. But it mostly wound up covering state budget shortfalls, subsidizing tax cuts, and supporting general services. In fact, according to a report from the Campaign for Tobacco-Free Kids, 20 years after the settlement states had spent only 2.6% of the settlement revenue on smoking prevention and cessation programs.

It would be a shame not to use the opioid settlement to help the people who are living with this public health emergency across our country. The money from any forthcoming opioid settlement must be applied to the problem — to help victims of opioid and other substance use disorders through access to evidence-based care, research, and training.

Kathleen T. Brady, M.D., is professor of medicine and vice president for research at the Medical University of South Carolina, and president and chair of the International Society of Addiction Medicine’s executive committee. The views expressed here are shared by the American College of Academic Addiction Medicine, the American Academy of Addiction Psychiatry, the American Psychiatric Association, and the Association for Multidisciplinary Education and Research in Substance Use and Addiction.

The American Academy of Addiction Psychiatry does not accept funds from pharmaceutical companies to support its educational programming, scientific program, seminars, or print materials. In 2016, Biodelivery Sciences was among the exhibitors at the academy’s annual meeting in 2016, and Orexo was an exhibitor in 2018; both companies manufacture addiction treatments as well as opioid pain medications. The American Psychiatric Association receives funding from some pharmaceutical companies, including those that manufacture opioid analgesics, via advertising in its publications and at its meetings in the form of exhibits, sponsorships; or product theaters; those areas are segregated from the association’s educational activities. The other three organizations do not accept funding from manufacturers of opioid pain medications.

  • a clientilistic political system.
    the patients with substance use disorders are least represented as they have no resources nor the educations to organize for their representation.
    making the appropriation of the opioid funds transparent may help.
    more resources need to be allocated to long term outpatient treatment.

  • I am struck by what I believe are misleading statistics cited by anti-opioid zealots and I am concerned about the effect their opinions and actions are having on many patients struggling with chronic pain. The reason studies regarding safety and efficacy of opioids for long-term use in chronic pain are lacking is that such studies are fraught with methodological challenges and tend to be widely misinterpreted and misapplied. However, the relative lack of such studies does not imply opioids are ineffective. Anyone practicing pain management recognizes that opioids are vital for many chronic pain patients. Complicating all of this is the fact that pain itself is subjective. That does not mean it isn’t real to those experiencing it. Unfortunately, the subjective nature of pain enables individuals opposed to opioids to take advantage of this subjectivity and downplay its significance. The fact that pain cannot be measured objectively allows the portrayal of chronic pain patients in a negative light and the characterization of them as weak, addicted, and simply in need of finding other means to manage their pain. The majority of my patients on chronic opioids have exhausted every other available treatment option.

    I find it incomprehensible that some of my fellow physicians are doing tremendous harm to chronic pain patients under the pretext of protecting the public from the opioid crisis. I suggest that they and others of their mindset focus their efforts toward fighting the scourge of illicit street drugs including fentanyl and heroin, not attempt to limit access to opioids for legitimate pain patients. We are dealing with a heroin/fentanyl crisis, NOT a prescription drug crisis. I firmly believe and my experience dictates that individuals using prescription opioids for legitimate pain management purposes who are properly monitored are unlikely to become addicted. Studies bear this out.

    Pain specialists like myself routinely administer tools for stratifying an individual’s risk of opioid addiction and closely monitor patients for signs of aberrant behavior thereby further mitigating that risk. I firmly believe that prescription opioids have a major role to play in the management of chronic pain, both cancer and non-cancer. For many individuals, they are truly a life saver. What needs to be recognized is the fact that there is no drug available that is devoid of risk. In fact, the risk of NSAIDs including death due to bleeding, renal and hepatic toxicity and/or thromboembolic events seems to be ignored in this discussion. In the zeal to curb opioid related deaths, legitimate pain patients who are benefiting from these drugs and are using them appropriately and responsibly with positive results are being directly targeted. Forcing these individuals to taper below an arbitrary 90 MME dosage or off of opioids entirely and discouraging physicians from prescribing them for legitimate chronic pain patients is nothing short of barbaric and tantamount to torture.

    I have many patients under my care who lead productive and rewarding lives because their opioid regimens enable them to function at work, care for themselves and their families, and have quality of life that would be otherwise impossible for them. Because some individuals with chronic pain are able to manage without opioids does not mean all are. Because some may abuse prescription opioids does not mean all do. This “one size fits all” mentality under the guise of “evidence-based medicine” is increasingly harming patients and the entire medical profession.

    Another point. Death certificates do not differentiate suicides due to intractable, untreated or inadequately treated chronic pain from suicides in general. That is a hidden statistic that can be pointed to as an absence of evidence thereby implying these suicides are not occurring. I am convinced they are. That same flawed logic is being used to argue that the lack of evidence in support of opioids for long-term use means that opioids are not safe or effective for such use. Because the moon isn’t visible through the trees does not mean the moon doesn’t exist.

    Finally, the CDC Guidelines are being widely misapplied such that the CDC recently posted a media statement advising, “the recommendation statement does not suggest discontinuation of opioids already prescribed at higher dosages,” and, “policies that mandate hard limits conflict with the Guideline’s emphasis on individualized assessment of the benefits and risks of opioids given the specific circumstances and unique needs of each patient.” The problem for many of us practicing in pain medicine is that it is very difficult to undo the harm that has been done as a direct result of these Guidelines. Many insurance companies and state governments have imposed strict limits on opioid dosage. Medical boards and law enforcement agencies have been strictly interpreting these Guidelines and targeting physicians who treat chronic pain. This has had a chilling effect on many pain specialists and has caused many to abandon patients or refuse to accept new ones.

    As both an addiction medicine and pain medicine specialist, I am fully aware of the magnitude of the opioid crisis and the importance of doing all we can to curb it. It is a terrible tragedy. Our mission should be to fight a war against the disease of addiction, not a war against chronic pain patients. I am most certainly in favor of expending greater resources in that fight. However, our efforts must not be made at the expense of harming those among us who are most vulnerable – chronic pain patients and the physicians treating them.

  • The typical addict will pay out thousands in fines and judgements against them through the courts. Those same addicts will most likely never receive effective treatment because of the insane cost and general unavailability of effective treatment programs. This circle will continue, the addicts will die to be replaced by other addicts, all while unproven and unethical treatment programs will continue to fleece families trying desperately to save their loved ones. Tell me again who gets the money for these settlements?

  • I believe the illegal and recreational opioid users should be cut off, period. Just like I and many other legitimate pain patients were cut off cold turkey by our PPO’s from our sometimes over 2decadesvof prescribed opiate pain medications and other needed narcotic prescriptions without warning. It was either Pain Management or barely nothing in the form of hardly effective pain management with Tylenol 3.
    It’s horrid what hundreds of legitimate pain patients have been put through. It seems that all the government and advocates of the ‘war on opioids’ has done is subjugate the American citizen to it’s own agenda to punish all opioid users, legitimate or not. I know not why… but someone needs to bring the legitimacy of opioid as pain medications used by American law abiding citizens to ease their pain and suffering and destigmitizing of PPO’s to prescribe them as before the illegal, recreational users and THOSE doctors that prescribed (in Pain Management clinics) ruined it by taking advantage of big pharmacies greed. Whereby the American government seized it as a chance to take tried and true prescription, less costly pain management in favor of new, very costly, supposedly new wonder drugs that haven’t even been cleared totally by the FDA! It’s even worse if you use public aid, like Medicaid with SSI.
    Take a good look at the policies being brought into guidelines, misconstrued and misused by doctors to NOT prescribe previously used for decades by citizens who need them and never abused them.
    We are not In the Army Now, don’t lump us all together to solve the issue of illegal opiates and users and cut the legal, legitimate pain patients and their PPO’s alone!!!
    Thanks… GP

  • If the setttlement billions from Purdue Pharma do not get applied as perfectly suggested in this article, and instead go towards balancing state budgets and other non-opioid crisis related “quick fixes”, it would underscore to the whole world how corrupt America is. Americans need to hold their leaders accountable in every way, and their votes will speak volumes ……..

  • My father was a tobacco executive, years ago. I recall him telling me, prior to any of this, how good a settlement would be for tobacco. After which, the companies, would be left alone forever. Their profits wouldn’t change because they would just raise prices to meet the settlements. Also, he indicated that only a token amount would be used for tobacco cessation and the future moneys would be sold as annuities, for one time payments to the states for the benefit of the politicians, at the time of settlement.. He was correct on every count.

  • This was a mass-tort BigLaw Industry shell game from the get-go, whipping up a media hysteria using ignorant journalists who love a good ‘epidemic,’ using CDC officials who stepped out of their lane and had their ears bent by wealthy patrons of groups like PROP who enabled a coterie of academic psychiatrists to spin lies and fake stats into gold. That small group of ‘addiction’ specialists saw their chance to serve as trial expert consultants for cold cash, for research grants, for the makers of Suboxone. A perfect storm was created by using the disaster capitalism model, and everyone got a cut, from BigData sellers scraping our private medical data to sell and resell, to Stanford Pain who stays in the publishing spotlight running up grant tabs, now to states who will never use that money for their citizens, it will go to plug budget holes and for anything other than healthcare. Because trial attorneys cannot sue the Sinaloa Cartel! Daily, the criminal insurgency in Mexico sees slaughter and executions, kidnappings and shootouts, none of which is reported by the same media who seized on bogus stats that conflated illegal and legal poly-pharm ODs at the CDC! So the result is that OD deaths from illegal drugs skyrocketed, suicides from untreated chronic pain patients skyrocketed, ER visits from dumped pain refugee patients on Medicaid rose 50% in one state, 40% of patients taking pain meds for chronic incurable disease cannot find a GP in Michigan, and just wait until we see the new disability claims for the once productive who can no longer work because they cannot manage their diseases or injuries. This says nothing of veteran suicides, or those driven to the streets in search of relief. 115,500 Million citizens of the U.S are age 50 and older and the government continues to pursue prohibition of the treatment of pain instead of the illegal dope dealers in the streets, and it is doctors who are having their assets seized by law enforcement yet you spoke out too little too late. Forget it now, the damage is done, and it is the little guy who pays the price in a miserable punitive medical environment, while those law firms can have champagne toasts and state AGs will ponder who the next target will be.

  • Dr Brady’s essay brings to mind the sad waste of an opportunity that was the Tobacco Master Settlement Agreement. My state of Wisconsin, deeply in debt in 1998, gave up a $5.9B payout over twenty years in exchange for an immediate $1.59B by securitizing the settlement as bonds. Money that was to help people suffering from tobacco-related illnesses and addictions went to balancing the state budget, providing commissions and fees to the financial firms that issued the bonds, creating a fund to pay the bond interest, and a reserve fund. About $33M went to purchase anti-smoking ads or about 0.56% of the original settlement.

    Thanks for your essay and the work of your five organizations. I hope we learn from what happened last time.

  • Upon appeal there isn’t going to be a penny paid out to anyone other than the trial attorneys. Less, forks are now liable for making people fat, and hair brushes are liable for making people bald, etc. The entire suit is nothing more than a publicity stunt to, once again, make it look like someone is actually doing something.

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