The recent proposal by the Sackler family to dispense with Purdue Pharma, its bankrupt manufacturer of addictive opioids such as Oxycontin, so it can become a “public trust” could be one of the best developments in the ongoing effort to address the current opioid crisis. Similar to the noteworthy tobacco settlement of the 1990s, this proposal could address numerous ongoing issues that consistently face individuals and institutions on the front lines of the crisis.
Rather than dismissing this as a way for those responsible for the crisis to avoid responsibility and consequences, we should take a step back and examine the proposal on its merits. The so-called Master Settlement Agreement of 1998 was a landmark agreement between Big Tobacco (Phillip Morris, R.J. Reynolds, Brown & Williamson, and Lorillard) and the attorneys general of 46 U.S. states to settle lawsuits primarily relating to health care costs the states were absorbing via Medicaid. The settlement funded numerous public health initiatives in perpetuity, amounting to a minimum of $206 billion over its first 25 years, and continues to this day.
One of the biggest obstacles to such a commonsense, utilitarian approach is the natural human desire to hold someone accountable for the hundreds of thousands of opioid-related deaths. With annual overdose deaths remaining above 70,000 per year (about two thirds involving opioids) in this country—and just showing signs of plateauing—the epidemic remains a true public health emergency.
The untold pain inflicted upon families and communities cannot be overstated, and culpability is important. So-called pill mills have been shut down, nearly all states have enacted restrictions on prescribing practices to make overprescribing much less possible, and rogue prescribers have been prosecuted and punished.
Nonetheless, ongoing efforts to address the situation require funding that is substantial and hard to come by with tight public budgets. Access to evidence-based treatment for substance use disorders remains difficult, with estimates still indicating that as a few as one in 10 people who need treatment receive it. For example, access to what is referred to as “medication-assisted treatment,” or MAT, utilizing medication such as naltrexone and suboxone, remains elusive for many addicted people; a single injection of the injected form of naltrexone can cost $1,000 or more.
Likewise, intensive outpatient (IOP) and residential treatment programs remain out of reach for far too many people with substance use disorders, including opioid use disorders in particular. Given the extent of the current crisis all communities should have such programs to provide the critical help needed by their residents. Shipping people away to far-off programs does not constitute best practice (we wouldn’t do this for a person with diabetes or cancer) and restricts the ability of family members to be involved in their loved ones’ care—an important element in support of long-term recovery.
Additionally, widespread access to naloxone, the lifesaving overdose response medication, is also less than ideal. Imagine a world where this medication is as prevalent as fire extinguishers or the seemingly ubiquitous automated external defibrillators (AEDs). These illustrate the societal responses that can occur when we take an issue seriously and devote resources to it.
Finally, ongoing public educations campaigns, similar to the Truth Initiative funded by the tobacco settlement, are needed to ensure that the opioid issue remains front and center in the public consciousness—and not simply as a phrase that is repeated and not understood. From television ads to infusion into school curricula, messages about the dangers of addiction and overdose, again focusing on opioids but extending to substance use in general, will be important in long-term societal change.
An infusion of funding that the creation of a public trust would provide would be critical in the implementation of a comprehensive response to the crisis and could accelerate the modest but encouraging progress being made through current efforts. In addition to legitimate consequences and penalties for those culpable, positive responses, informed by prior experience such as the Master Settlement Agreement in the tobacco precedent, should also be considered for implementation. It’s important to resist the urge to focus solely on punishing the individuals responsible for the opioid crisis and look forward to what this public trust could do to address this health care crisis.