Easing the Pain? Opioid Settlement Brings Valuable Funding to Fight Crisis
By Joey Berlin

The questions now are: How much money will Texas get? Where will it go? And how much can it help?

September 2019 brought what could become a major victory for the state’s handling of opioid addiction. Drugmaker Purdue Pharma – which faced thousands of lawsuits from cities and states, including Texas, for its role in the national opioid crisis – announced it had agreed to a settlement with 24 state attorneys general and other plaintiffs. The maker of OxyContin and other pain drugs says the agreement will provide more than $10 billion to address the epidemic.

With only the framework of a settlement in place at press time, how much each state and territory would receive hadn’t yet been decided. But a representative of the Texas attorney general’s office – which filed suit against Purdue in state court in May 2018 – expects the Lone Star State’s share to be “fairly significant.”

Texas physicians are greeting the news with a sense of opportunity, and they envision plenty of uses for the settlement money to help undo the havoc opioid proliferation has wrought within the state’s borders.

“The funds themselves won’t be enough to fix the problem,” said Sugar Land family physician Lindsay Botsford, MD. “But I do hope that it gets the attention to … [fund] things like medication-assisted therapy, to promoting recovery, and really just getting people the support to treat their addiction.”

Deceptive marketing allegations

A major August ruling out of Oklahoma served as an appetizer for news of the Purdue settlement agreement. (See “Texas Sues Johnson & Johnson,” page 25.) The lawsuit Texas filed against Purdue in a Travis County court in 2018 – one of more than 2,600 filed against the company – alleged the drugmaker violated the state’s consumer protection law in several ways, including:

• Misrepresenting or failing to adequately disclose the risk of opioid addiction;
• Misrepresenting the potential for opioid abuse;
• Misrepresenting opioids’ therapeutic benefits;
• Making false, unsubstantiated representations about the concept of “pseudoaddiction,” a term that represents drug-seeking behavior in patients whose pain allegedly had been ineffectively treated; and
• Misrepresenting the safety of using opioids to treat pain.

According to Texas’ suit, as Purdue launched OxyContin in the 1990s, the company “ramped up marketing efforts to health care providers, disseminating the message that pain was undertreated; that opioids were non-addictive; that patients deserved to be pain free; and that its opioids were superior to non-opioids for pain relief.”

The company’s “deceptive marketing campaign was fueled by greed and disregard for its consequences,” the suit said. “Even as the opioid crisis reached its zenith, Purdue continued to deceptively market prescription opioid products.”

On Sept. 15, Purdue Pharma filed for Chapter 11 bankruptcy and released a statement announcing it had agreed to the settlement, which at press time had yet to be finalized. Steve Miller, chairman of Purdue’s board of directors, said in the statement that the agreement “avoids wasting hundreds of millions of dollars and years on protracted litigation, and instead will provide billions of dollars and critical resources to communities across the country trying to cope with the opioid crisis.”

Purdue said key elements of the settlement included:

• Purdue’s owners contributing all of the company’s assets to “a trust or other entity established for the benefit of claimants and the American people;”
• Purdue creating a company that would be governed by a new board selected by the claimants in the lawsuit, and the company contributing “tens of millions of doses of opioid overdose reversal and addiction treatment medications at low or no cost,” and
• The Sackler family, which owns Purdue, contributing a minimum of $3 billion to the settlement funds.

Purdue Pharma admitted no wrongdoing as part of the settlement structure, which at press time more than 20 state attorneys general had rejected for not going far enough. A bankruptcy court filing for Purdue said, “It is important to note that no court to date has found that any of [Purdue’s] conduct caused any of the harms alleged.”

Paul Singer, chief of the consumer protection division of the Texas Attorney General’s Office, told Texas Medicine the amount the state receives depends on several factors.

“Given the strength of the claims that Texas and our sister states have as sovereign states in these cases, and given the way that the epidemic has hit Texas, and given frankly just the sheer size of Texas, I expect that our claim and our recovery is going to be a fairly significant piece of the overall pie,” he said.

Mr. Singer says despite any objectors to the settlement, it will be up to the bankruptcy judge to approve it.

Physicians weigh in

A possible influx of hundreds of millions of dollars earmarked for the opioid problem gives physicians measured hope. Brian Bruel, MD, president of the Texas Pain Society, says the money could help in many different ways, starting with boosting resources for those who are addicted to or dependent on the medications.

“That would probably include more resources in terms of No. 1, training more physicians on addiction therapy,” he said. “Not only the primary addictionologists, but also primary care physicians and other specialists who might encounter patients that are addicted and learning how to identify [them] that so they can get to the proper treatment.”

Pain physicians say Texas has a severe shortage of addictionologists. An April 2015 report by the North Texas Regional Extension Center, citing American Medical Association data, counted just 23 addiction psychiatrists in Texas and four other addiction medicine specialists.

“I practice in the Texas Medical Center, the largest medical center in the world, and there are very few options for my patients to seek addiction therapy,” Dr. Bruel said. “And I could just imagine in more rural Texas what’s going to happen to those patients. So having more competent, evidence-based programs to treat addiction is very important.”

In some cases, addicted patients also have psychological issues and need to develop a trust relationship with a mental health professional before they’re comfortable entering detox, Dr. Bruel adds.

“Sometimes, they have grief, they have PTSD [post-traumatic stress disorder], they have anxiety, they have depression on top of their addiction. If you’re not addressing those other psychologic issues, it’s going to be very, very difficult for them to buy into [going] to the addictionologist.”

Gatesville pain management physician Richard Hurley, MD, hopes the money can boost not only medication-assisted treatment and training in addiction medicine, but also help those without insurance coverage.

“The biggest problem I have in my practice is that [for] a patient who comes to me addicted to a particular substance, the only thing I have to offer them is Suboxone, which is approved by the FDA and by the state. I’ve been trained to use it. I’ve been using it for many years,” he said. “If this form of medication assistance does not help their addiction, I do not have an addictionologist remotely close enough for referral. I do have access to an inpatient drug rehab center, but frequently patients and families cannot afford it.”

From the state’s perspective, Mr. Singer says treatment is “top of the list” for using the money to best address the crisis, including “providing resources and support for physicians to be able to address the crisis that they see every day with their patients.

“That could include helping to supply medication-assisted treatment throughout the state. It can help [to] provide training and research and education for our physicians throughout the state,” he said. “All of this is on the table.”

Dr. Botsford hopes the publicity over the settlement will not detract attention from the development of drugs that remain helpful in treating pain.

“Physicians are starting to be part of the solution by ensuring that we prescribe the lowest amount to still help relieve pain,” she said. “The things that are going to change to really make a difference are better coverage for medication-assisted therapy; better coverage for therapies that we know work for chronic pain. This is physical therapy, this is non-opioid drugs, exercise, weight loss.

“These are all things that are fantastic, but are hard to do. They can be expensive, and they’re not well-covered by insurance at this point. I hope all of this just brings attention to the fact that we need to find better ways to treat people’s pain that doesn’t involve just giving them a prescription for an opioid pain medicine.”

Mr. Singer says Texas “remains a leader” in the multi-state effort to address the role drug manufacturers and distributors played in creating the opioid crisis. He says the state intends to “collect as much money as we can” to address the crisis and ensure the drug companies don’t do the same thing in the future.